Who is responsible for retrospectively reviewing claims submission and payment trends?

The responsibility for retrospectively reviewing claims submission and payment trends primarily falls on providers and payers. Providers are involved in submitting claims for services rendered to patients and need to ensure that their billing practices are accurate, compliant with regulations, and reflect the services provided. By reviewing claims submissions, they can identify trends in billing, understand denial rates, and make necessary adjustments to their coding and documentation practices.

Payers, such as insurance companies, also play a crucial role in this process as they review the claims submitted to them. They analyze payment trends to manage their resources effectively and assess the appropriateness of the claims based on their coverage guidelines. By jointly reviewing these trends, both providers and payers can improve the overall healthcare billing process, leading to a more efficient system in terms of claims reimbursement and healthcare delivery.

In contrast, audit managers have a more specialized role that pertains to overseeing audits and ensuring compliance rather than directly conducting retrospective reviews of claims submission trends. Insurance regulatory bodies focus on establishing guidelines and overseeing compliance rather than direct reviews of specific claims. Patients and families are not typically involved in the review process of claims submission and payment trends as they are more focused on their medical care and related costs. Thus, the collaborative responsibility of providers and payers accurately reflects the