Zero-Balance Audit and Payment Compliance Review Services

The vendor required to provide zero-balance audit and payment compliance review services to identify and recover lost or underpaid revenue by validating payments received from commercial and governmental payers against contracted terms.
- Operational and compliance standards:
•    Possess the ability to transmit and store data in accordance with university it and cybersecurity policies. 
•    Employ staff who are fully trained in payer contract interpretation, reimbursement methodologies, and claim adjudication logic. 
•    Provide documentation of staff credentials and training programs ensuring audit personnel are qualified to perform complex payment analyses. 
•    Demonstrate the ability to interface with epic or equivalent EHR and billing systems for data extraction and claim reconciliation. 
•    Maintain a dedicated compliance officer or department responsible for regulatory oversight and internal quality assurance.
- Technical and reporting capabilities:
•    Utilize proprietary or advanced audit software capable of modeling payer contract terms and identifying underpayments at detailed CPT, DRG, or contract-line levels. 
•    Produce comprehensive reports summarizing audit outcomes, underpayment findings, payer trends, and financial recovery metrics. 
•    Provide data transparency that allows agency to validate findings independently. 
•    Offer configurable reporting dashboards or data exports compatible with university analytics systems.
- Performance and service requirements:
•    Commit to defined turnaround times for audit completion, reporting, and payer recovery actions. 
•    Provide a clear escalation process for unresolved claims or payer disputes. 
•    Maintain open communication channels with agency billing and finance departments, including routine progress meetings and milestone reviews.
- Reporting and communication requirements:
1. Regular reporting cadence:
•    Provide monthly summary reports detailing audit progress, underpayment findings, recoveries obtained, payer trends, and outstanding issues. 
•    Provide ad hoc reports upon request for leadership review, payer escalations, or compliance validation. 
•    Supply weekly status updates or dashboards to agency project leadership outlining claims under review, pending recoveries, and aging of active items.
2. Report content:
•    Provide monthly summary reports detailing audit progress, underpayment findings, recoveries obtained, payer trends, and outstanding issues. 
•    Provide ad hoc reports upon request for leadership review, payer escalations, or compliance validation. 
•    Supply weekly status updates or dashboards to agency project leadership outlining claims under review, pending recoveries, and aging of active items.
3. Access and data acquisition:
•    Obtain access to all claims with a zero-balance within the defined 12-month review period, including both hospital-based and professional claims.
4. Payment verification and modeling: 
•    Enter payer contract terms into the vendor’s software or analytical platform to model expected payments and compare these to actual payments received.
5. Chronological audit review: 
•    Conduct the review in chronological order, beginning with the oldest claims, to ensure comprehensive coverage of the eligible audit period.
6. Contingency-based compensation:
•    The university will remit an agreed-upon contingency fee to the awarded proposer based on verified recoveries.
•    No payment shall be made for unverified findings or nonrecoverable claims.