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.
Line by line inspection of the bill is performed to establish incorrect charges.
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
- Medical Necessity
- Benefit Coverage
- Program Compliance
In performing the review, it is established that the services paid were
- 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)
- Provider (Group, Individual)
- Diagnosis code and Service code
- Claim, Claimant, Client
- Per bill and Per claim maximum.