Recovery and audit yield

The current period against the four before it. Every figure is computed from the claims in the batch.

Overpayment identified per period

$15,288.93 this period across 7 findings

Nov

Dec

Jan

Feb

Mar

Hit rate by selection method

Share of reviewed claims where a finding was identified, and what each criterion actually selects on — a hit rate you cannot act on is a number, not a measure.

Drug and biologic spend 1 of 2 · 50%

Physician-administered drugs above the per-claim drug threshold · $1,344.96 identified

Advanced imaging review 1 of 3 · 33%

MRI, CT, PET and nuclear studies, including repeats within 90 days · $254.18 identified

DRG severity tier review 2 of 4 · 50%

Admissions whose payment rests on a single MCC or CC · $9,528.92 identified

E/M level distribution 1 of 3 · 33%

Providers billing level 4 and 5 visits above their specialty distribution · $4,089.23 identified

Cost threshold 0 of 2 · 0%

Paid above the cost-review threshold for the line of business

Bundling and duplicate rules 2 of 5 · 40%

The same code repeated, or a component billed alongside the panel that contains it · $71.64 identified

Random sample (control) 0 of 6 · 0%

Unselected control group — what the hit rate is measured against

The random control sample is the line the others are measured against. Every finding in this batch came from a targeted criterion; the control group found nothing, which is what makes the targeted rates mean something.

Yield by clinical and cost class

Cost threshold $500.00

Class	Claims	Share of batch	Paid	Findings	Identified
Advanced imaging MRI, CT, PET and nuclear studies	3	12%	$762.87	1	$254.18
Drug and biologic Physician-administered drugs on the medical benefit	2	8%	$11,153.61	1	$1,344.96
Inpatient admissions Institutional claims priced by DRG	8	32%	$70,167.31	2	$9,528.92
Above the cost threshold Paid above $500.00	12	48%	$86,113.80	4	$14,963.11
Up-coded Billed at a higher level, severity or unit count than the record supports	5	20%	—	5	$15,030.82

A claim can sit in more than one class, so the rows overlap and do not sum to the batch. Every figure is computed from the claims.

Auditor throughput

Team	Claims reviewed	Findings confirmed	Overturned on dispute	Avg review time
Professional claims audit	6	2	0 of 4	18m 40s
Facility audit	4	1	1 of 3	26m 10s
Lab and ancillary	2	0	0 of 1	9m 25s