What is the process used by payers to review claims before they are processed known as?

The process used by payers to review claims before processing is referred to as a prepayment audit. This is a critical step in the claims management system, as it allows payers to assess the validity and accuracy of claims prior to making any payments. Prepayment audits can help prevent fraudulent claims and ensure that the services billed meet the necessary criteria for reimbursement according to the payer’s guidelines. The audit evaluates factors such as coding accuracy, documentation sufficiency, and compliance with payer policies, ultimately aiming to reduce the risk of incorrect payments leading to financial losses.

This process differs from other types of reviews in that it occurs before payment is made, allowing issues to be addressed proactively. In contrast, post-payment reviews examine claims after they have been paid, which may lead to adjustments or recoupments if errors are discovered. Quality assurance reviews focus on evaluating the overall quality of care provided, rather than the specifics of claim processing. Prepaid audits are not a recognized term in this context, which further delineates the unique function of prepayment audits in the claims review process.