Approximately 95% of hospital admissions are in-network. Therefore, it is essential that primary and stop-loss payers have the right tools to navigate the complex demands of the in-network environment to affect the best financial and quality outcomes for special cases.


Health Claim Review® uses 4 distinct methods to help our clients achieve inpatient cost savings.  These methods may be used alone or in combination to meet case needs and customer requirements. In patient bill review techniques may be applied to outpatient  facility repricing as well.


- Line Charge Verification

- Physician Specialist Utilization & Quality Audit

- Usual & Customary Repricing

- DRG Medical Record Validation



  • DRG (Diagnosis-Related Group) Validation

  • Inpatient Hospital Line/Charge Verification Audit

  •  Itemized Bill Hospital Inpatient Repricing

  • Neonatal Intensive Care Reviews

  •  MD Specialist-Specific Quality and Utilization Review

  •  Foreign Medical Claim Review

  •  Air Ambulance Necessity & Repricing

  •  High Cost Medical Implant Repricing

  •  Medicare Advantage Plan Customized Reviews

  •  Skilled Nursing Care Facility Review

  •  Home Health Care Medical Necessity

  •  Emergency Room Care Evaluation and Audit

  •  Outpatient Office Visit Review (E + M Level coding)

  • Outpatient Surgery Center Repricing

  • DME (Durable Medical Equipment) Review

  • U.S. Hospital Cost + Care Management for Foreign Payers

  • Travel Health Insurance + Medical Assistance Company Review Services

  • Captive Insurance Medical Plan Support

  • Stop Loss, MGU, and Reinsurance Custom Reviews

  • Medicare Reference Based Pricing (DRG, APC, ASC, RUG, HIPPS)