We may review paid claims to help ensure payment integrity. If reviewing all medical records for a procedure would burden you, we may select a statistically valid random sample (SVRS) or smaller subset of the SVRS. This gives an estimate of the proportion of claims that we paid in error. The estimated proportion, or error rate, can be projected across all claims to determine overpayment. You may appeal the initial findings. If we only used a subset of the SVRS, you can supply the all of the medical records in the SVRS. If you want a more complete audit, we can select a larger sample and re-estimate the error rate.
Please handle overpayment disputes as outlined in this guide and in your provider agreement.