Medical Claims
Medical Claims Verification
Independent verification of relevant medical information to assist in assessing claims and establishing factual circumstances.
Overview
What this service covers
A medical claim rests on documents produced by third parties: invoices, discharge summaries, referral notes and attendance records. Verification confirms that those documents describe something that actually happened, at the facility named, to the person named.
The enquiry is factual and administrative. We confirm attendance, treatment and documentation against records held by the provider, to the extent the provider is able and permitted to confirm them. We do not review clinical judgement.
Typical situations
When You May Need This Service
Invoiced treatment cannot be confirmed from the file
The documentation is present, but nothing independently corroborates the attendance or the treatment billed.
The facility is unfamiliar
The named provider needs to be confirmed as existing, operating, and offering the services billed.
Documents appear inconsistent
Dates, reference numbers, letterheads or signatures do not align across the submitted paperwork.
The same provider recurs across claims
A facility or practitioner appears repeatedly in a pattern that warrants independent confirmation.
Scope
What We Investigate
The enquiries below are the ones most often required. Scope is agreed for each instruction, so a file only carries the work it actually needs.
- Treatment verification
- Facility verification
- Medical attendance enquiries
- Record-related verification
- Claim circumstance verification
Methodology
Our Approach
Each instruction follows the same sequence, so findings can be traced back to how they were established.
Document review
Submitted invoices, summaries and referral records are read for internal consistency and completeness.
Facility confirmation
The named facility is confirmed as operating, and its location and stated scope of service are verified.
Attendance enquiry
Attendance and treatment are confirmed with the provider, so far as the provider is able and permitted to confirm them.
Reporting
What was confirmed, what was not, and what the provider declined or could not confirm are each recorded separately.
Output
What You Receive
Reporting is the product. Every instruction closes with a written record that sets out what was established and on what basis.
Verification report
A clear statement of which elements of the claim were independently confirmed and which were not.
Facility findings
Confirmation of the existence, location and stated scope of service of the provider.
Document observations
Any inconsistencies identified in the submitted paperwork, described factually.
Explicit limitations
Where confidentiality or provider policy limited the enquiry, that is stated rather than left implied.
Related
Related Services
Insurance Investigations
Independent investigations into insurance claims and related circumstances, helping insurers establish facts, verify information and understand the circumstances surrounding a claim.
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Fraud Detection & Prevention
Investigative support for identifying inconsistencies, suspicious circumstances and indicators that may require further examination.
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Due Diligence & Background Checks
Structured enquiries designed to help organizations verify individuals, businesses and relevant background information before making important decisions.
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Questions
Frequently Asked
If your question is not answered here, our team can usually give you a direct answer before you commit to anything.
No. That is a matter for a medical professional. We verify factual and documentary matters: that attendance occurred, that the facility exists, and that records support what has been billed.
Providers are entitled to protect patient information. Where a provider declines, we record that fact and the reason given rather than drawing an inference from it.
Confirmation is sought through proper channels. Where consent or authority is needed for a particular enquiry, we tell you before that enquiry is attempted.
Yes. Facility and attendance enquiries are carried out wherever the provider is located.
Talk to us about Medical Claims Verification
Tell us what needs to be established. Our team will confirm scope, turnaround and reporting requirements before any work begins.