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Five percent or more of provider claims contain errors. The error percentage can add up to significant improper payments from data entry mistakes, incorrect coding of claims or other errors. In light of successful government healthcare claims recovery audit contractor programs, commercial payers are also interested in establishing similar programs.

CGI is a leading provider of recovery audit services to government and commercial organizations. Since 1990, we have used our strong combination of subject matter expertise, knowledgeable personnel and solutions to identify claims that have been inappropriately paid to providers. We offer a comprehensive approach to identify errors and provide accurate claims reimbursement. Our CGI ProperPay solution and services have enabled clients to achieve substantial results, with more than $2.8 billion recovered.

CGI leverages our public and private sector experience in claims auditing and recovery to provide a robust audit, recovery and provider education solution. We deliver provider outreach, data and program analytics, value-based healthcare program management and data consolidation and integration services.

Recovery audit scope

Our audit scope covers all provider types with a focus on payment issues that have a high rate of error and yield a return on investment. Examples include:

  • Inpatient auditing – CGI inpatient auditing identifies inpatient claims for medical necessity review, as well as those with potential coding and billing errors. We screen inpatient claims for potential upcoding, diagnosis sequencing errors, place of service issues and Diagnosis Related Grouping (DRG) creep.
  • Outpatient auditing – CGI hospital outpatient auditing identifies hospital outpatient coding errors. Outpatient claims are screened for coding errors and inappropriate coding, unbundling and case rate violations, medically unlikely edits, as well as documentation, payment window and contractual issues.
  • Professional auditing – CGI professional auditing identifies and corrects improper CPT-4 coding to eliminate inappropriate billing and revenue optimization of professional claims. Our process includes Medicare’s Medically Unlikely Edits (MUEs) and National Correct Coding Initiative (NCCI) edits.
  • Allied health – CGI customizes edits for all types of allied health claims data to identify claims that have potential billing discrepancies such as upcoding, unbundling of charges, duplicate payments, policy violations, duplicate charges across various providers, date of death and others.

CGI’s team of specialized healthcare professionals brings more than 25 years of experience in analyzing and auditing Medicare, Medicaid, managed care and private insurance medical and pharmacy data. Our team includes clinicians, pharmacists, health information management professionals, fraud investigators, CPAs and IT experts.