Protect Reimbursement with an Audit Defense Program


Payers audit hospital accounts to reduce or recapture reimbursements. Are these audits always valid? No. That’s why Hospitals ask RSource to help defend reimbursements. We protect reimbursements by overturning audit findings and reduce future audits by providing feedback on documentation and process improvements.

With the increase in audits (DRG, Charge, RAC), hospitals need to protect their interests now more than ever. Our experienced audit team is your tactical and technical advantage, with over 20 years’ experience on both the provider and payer sides. The RSource team includes:

  • • Nurses (RNs, LPNs, and RNs that are certified coders) defending audits through persuasive, medically supported arguments that draw from InterQual, MCG (formerly Millimans), coding, billing, and payer guidelines
  • • Physicians successfully resolving ALJ hearings and peer-to-peer reviews
  • • Attorneys experienced with complex payers demands and creating reasoned arguments
  • • Coders certified and current with all coding changes

Pre-Payment and Post-Payment Audits

  • • DRG and ED Downgrade Audits
  • • Overutilization of E/M Codes
  • • Line-Item Charges not supported in MR’s
  • • Up-coding/Using wrong codes
  • • RAC
  • • Audits related to COVID-19

Underpayment/Clinical Validation Denials

  • • Clinical documentation not supported
  • • Level of care downgraded
  • • Interpretations of Contracts and Policies
  • • DRG validation

RSource’s program will triage every account and for appeals, we research and write “conscious” appeals (i.e. readmission, DRG downgrades, charge outlier audits) rebutting payers’ dispute rationale — not just defending based on a general argument, or from a medical necessity perspective. When RSource agrees with findings, we will provide clear analysis, feedback, and training to help staff reduce future audits.

A Comprehensive Program Ensures Improvement

  • • No more missing audit documentation request deadlines
  • • Improved audit results
  • • Analysis and feedback that documents improvements you can make in both your processes and documentation for reducing future audits and ensuring proper payment
  • • Medicare guideline compliance (i.e., NCCI, Observation/IP, CC44, NCD/LCD, Medical Necessity, E&M, Medicare CoP)
  • • Business process re-engineering and continuous process improvement (revenue integrity, utilization review, denials management)
  • • CDI education and recommendations (i.e., Medicare billing guidelines, payer medical policies, LCD/NCD, national coding guidelines)

Let RSource be your first line of defense against audits.