Medical Bill Review Services
Finding Medical Bill Review services are essential for risk managers. In other words, it is applicable to property and casualty, auto insurance, and health insurance companies. Our medical bill review cost reduction solutions ensure accurate repricing. To clarify this maximizes savings, and allows clients to make intelligent payment decisions. We provide:
- Credit balance and overpayment intelligence, NCQA and URAC Standards
- Payment integrity and provider CAQH overview information
- Cost containment, including discovery and cost avoidance
- Coordination of Benefits (COB) medical bill review, including Medicare Secondary Payer Act (MSPA) analysis where Medicare has paid primary but should recover from Non-Group Health Plans (NGHPSs) who should be primary payers. These include ERISA self-insured plans, property and casualty, and other payers
- Subrogation services review
- Pharmacy audit compliance
- Out of Network (OON) reviews
See note (1)
How does Bill Review Work and What are the Possible Weaknesses in this Approach?
Here is an example. Firstly, assume that an insured employee is injured in a motor vehicle accident. The insured employee refuses ambulance transportation at the scene, walks back to their car, and drives home. Three days later, the employee visits an orthopedic spine surgeon with a complaint of back pain. The orthopedic spine surgeon performs an MRI and notices that the patient has herniated disc, protruding into the vertebral canal and pinching the spinal cord, causing pain.
Second, the employee undergoes spine surgery and has a discectomy performed. A discectomy is the most common surgery used for a herniated disc in the lumbar region. In this procedure, the portion of the disc that is causing the pressure on the nerve root is removed. The surgeon access the disc through an incision in the back. The patient goes to an out-of-network facility: the hospital bills $250,000, an amount it does not expect to receive.
Subsequently, a medical bill review is conducted, and the bill is negotiated down to $50,000, netting a savings of $200,000. The charge for the bill review is a percentage of the savings. A twenty percent charge (30%), which results in a fee for the bill review analysis would be $60,000. Net savings after fees is 66%.
Another scenario: assume that the injured party is taken by an ambulance to the hospital. A hospital lien is filed and the orthopedic bills, emergency evaluation, and management and diagnostic images are part of the lien. Plaintiffs’ personal-injury attorneys at times send a “letter of protection”to healthcare providers, in lieu of payment, to provide an assurance that there will be a future payment from the proceeds of any recovery from the alleged tortfeasor who caused the injuries. For example, in the Texas jurisdiction, see Advantage Physical Therapy, Inc. v. Cruse, 165 S.W.3d 21, 24–25 (Tex. App.—Houston [14th Dist.] 2005, no pet.).
Third, what if the bill or hospital lien is not successfully negotiated? This can be a weakness in bill review services. Litigation-ready bill review assists companies in securing the lowest reasonable market rates based on usual customary and reasonable charges where no collateral source may be used.. See below.
Full Spectrum Litigation Ready Bill Review with Expert Witness Testimony
Personal injury cases that go to litigation may be limited by a collateral source rule. This depends on the jurisdiction. To clarify, this means that evidence of what insurance pays cannot be part of the opinion regarding the medical bill review. Usual customary and reasonable charges in the community can provide litigation-ready information. For example, certified expert witness testimony can help prepare liability, property, and casualty insurers and insurance defense law firms for a spectrum of possible outcomes. Our Integrated Medical Bill Review and Risk Management capabilities are focused on both accurate determinations of the value of medical care and risk reduction.
Medical specialty experience in Medical Bill Reviews
Orthopedic Surgery - spine subspecialty
- Orthopedic Surgery - hand subspecialty
Pain Management, including prescribing and cost of Controlled Substances
Physical Medicine and Rehabilitation
Emergency Medicine and Trauma
- Cardiology - invasive and Cardiology - non-invasive
General, Pediatric, and Transplant Surgery
Internal Medicine and Osteopathic Medicine
Data, Regulations, Technology, Economics, Experts in Paper to Electronic and litigation support
That is to say that, our Medical Bill Review programs utilize :
- Data and coding integrity checks
- Audits for adherence to Industry Standard data
- In-network and out of network (OON, also known as non-par or non-participating providers) agreements as well as State Standards for out of network payments
- Emergency physician and EMTALA standards for out of network reimbursement
- Patient/chart clinical documentation audits when needed by our Certified Professional Medical Auditor (CPMA) team. Audits can be helpful to detect upcoding or lack of documentation for medically necessary care
- Audits for supporting documentation including chart reviews
- Cloud electronic technology with payer and electronic health record integration
- Backed by expert opinions
- National and regional pricing data, adjusted for Industry Standard wage indices
- The Medicare Secondary Payer Act requires that Non-Group Health Plans (NGHPs) report Ongoing Responsibility for Medicals (ORM) and Total Payment Obligation to Claimant (TPOC). We use industry-Standard Electronic Data Interchange (EDI) and data collection strategies to make determinations as to whether an insured of a property and casualty no-fault insurer, self-insured ERISA plan, worker's compensation insured are also Medicare beneficiaries, which would trigger responsible reporting entity (RRE) under the MMSEA Section 111 reporting requirements.
- See program offerings for more information
Return on Investment
Furthermore, Return on Investment of Medical Bill Reviews at $10 to $70 per $1 in medical bill review fees. Additional potentially higher returns for chart reviews, audits, and claims analytics including de-duplication.
To elaborate, data integrity is the first crucial step in our bill review process. We ensure data accuracy through redundancy, automated scrubbing, dynamic logic, and manual intervention as appropriate.
Complete Solution from Review, Repricing, and Expert Witness Litigation Consulting
Above all, our national and local experts review charges and insurance payment data for:
- Outpatient ICD-10 diagnosis and medical procedures using diagnosis, CPT and HCPCS coded procedures
- Inpatient hospital bills including DRG validation
- Ambulatory surgery centers including facility fees
To emphasize accuracy, we use data quality checks. This means that we can evaluate clinical documentation and coverage policies. With diagnosis and procedure data, we review medically necessary care. Our analytics helps maximize savings.
Most important are our people. Our medical bill review team includes physicians, RNs, medical coders, and experts affirmed by Federal and State Judges. If negotiations are inconclusive, we can give testimony as to reasonable and customary charges in court.
We are experts in Medicare billing standards and CMS medical bill review procedures. We are experts in independent bill review (IBR) for workers' compensation.
Medical Bill Review Program Offerings
|Medical coding review which includes checks for unbundling. We check modifiers, place of service appropriateness and National Correct Coding Initiative (NCCI) edits
|Claim scrubbing and adjudication simulations
|Payor policy reviews
|Medical bill repricing
|Automatic fee schedule and adjustments required by Medicare Administrative Contractor (MAC) jurisdiction or State statutes
|Usual, customary and reasonable review
|In-network and out of network considerations
|Analytics to detect duplicate bill detection with high accuracy
|Fraud detection (especially when chart reviews are performed as part of the scope)
|Medical Specialty bill reviews
|HIPAA Security Rule compliant cloud-based electronic portal for medical bill approval and reports access
|Out of network settlement platform
(1) These services are provided for our non-litigation clients. See expert witness services for litigation-related matters. We do not request, nor do we accept a percentage of the savings when testifying as an expert.