CareReview / Solutions / Payment Integrity
Clinical Validation That Protects Plan Spend
Specialty-matched clinical review that catches inappropriate payments after the claim is paid — applying the same clinical rigor used in utilization review to claims accuracy.
Clinical Validation That Protects Plan Spend
Specialty-matched clinical review that catches inappropriate payments after the claim is paid — applying the same clinical rigor used in utilization review to claims accuracy.
Most payment integrity programs run on claims-system logic — rules engines, edits, and pattern-matching that catch what's codeable but miss what's clinical. CareReview applies specialty-matched physician and coder review to claims accuracy, validating that services were coded correctly, medically necessary, and paid appropriately, informed by the same clinical judgment we bring to utilization review.
Payment Integrity is program-level. We validate claims accuracy and identify inappropriate payments across your post-pay claims. For clinical validation of individual high-dollar bills, see Specialty Bill Review.
Core Payment Integrity Services
Retrospective Claims Review
Independent review of paid claims to confirm coding accuracy, medical necessity, and appropriate payment — going beyond claims-system rules to clinical judgment on complex, high-cost claims.
Coding & Medical Necessity Validation
Specialty-matched physicians and certified coders evaluate documentation against clinical guidelines and coding standards, identifying inappropriate payments claims-system logic alone would miss.
Findings Documentation via Stradix®
Every finding is documented and tracked in Stradix®, integrating payment integrity results with case history for a clear, defensible record.
Why CareReview for Payment Integrity
- Clinical review, not claims-system logic — specialty-matched physicians and coders evaluate the claims that rules engines flag but can't resolve.
- The same clinical rigor used in utilization review, applied to claims accuracy.
- Independent, documented findings that reduce provider abrasion and appeal risk, rather than automated denials.
- Stradix® integration ties every finding to full case documentation for a complete audit trail.