Medical Bill Review

Bills are shared with our team and are subjected to manifold quality assurance by a Certified coding team. Charges are reviewed using relevant conventions and industry standards. Each receipt is reviewed for possible repetition of charges, non-billable charges, data entry errors producing inappropriate charges, unbundling of codes and relatedness of procedures to the diagnosis.

Financial Review:

Line by line inspection of the bill is performed to establish incorrect charges.

Clinical Review:

Assessment of medical documents to ensure services essentially rendered and those services were billed appropriately.

Examination applies fee schedules, billing rules and other appropriate review criteria, and is a retrospective review of paid claims for appropriateness of

  • Billing
  • Medical Necessity
  • Benefit Coverage
  • Program Compliance

In performing the review, it is established that the services paid were

  • Ordered
  • Rendered
  • Billed accurately
  • Medically necessary
  • Performed in the correct setting
  • In adherence to the policies and guidelines

Frequent finding of the assessment includes, but not limited to

  • Duplicate billing
  • Misplaced or scrawled records
  • inaccurate coding
  • Billing for chronic conditions without records to hold need
  • Billing for services that are not enclosed benefits
  • Lack of credentials to support the necessity
  • Billing under a different TIN
  • Capture unbilled stuff
  • Mistreatment of modifiers
  • Disallowed billing
  • Billing a secondary with no primary

A higher level of evaluation evolves by flagging the bill for

  • Dates of service
  • Bill Type
  • A line of trade (WC, Auto No-Fault, Liability etc)
  • State
  • Provider (Group, Individual)
  • Diagnosis code and Service code
  • Claim, Claimant, Client
  • Per bill and Per claim maximum.