Healthcare Solutions uses a combination of technology along with highly trained medical analysts and nurses to review workers’ compensation and auto liability medical bills. Our bill review programs can be integrated with our PPO networks or provided on a stand-alone basis. Through the automation of clinical judgment, the bill review system achieves maximum savings by:
- Combining National Coverage Capabilities. Healthcare Solutions applies a fee schedule and billing ground rules, as set forth by the state, to capture the greatest discounts for our clients. As the premier vendor of reimbursement schedules in the market, Healthcare Solutions’ software ensures compliance through frequent updates with state regulations and fees on a 30-day cycle.
- Using a Usual and Customary (U&C) Database in states where no fee schedule exists. The Healthcare Solutions system contains modules for medical, dental, outpatient facilities, inpatient facilities, anesthesia and Medicare’s Resource-Based Relative Value Scale (RBRVS) physician fee schedule, with the percentile of reimbursement customized to a client’s specifications or the industry standard. Currently, this system has more than 700 million current, unique and continuously updated provider charge records, with 1,500 private-0sector health care companies.
- Applying National Coding Parameters of the American Medical Association (AMA) and the National Correct Coding Initiative (NCCI) along with managed care benchmarks to further enhance results.
- Detecting Improper Billing Practices such as coding, code “unbundling” and undocumented charges and billing for incidental procedures combined with a complex CPT and ICD-9. This guarantees provider bills that are only for claims within the scope of the related injury or accident.
- Detecting duplicates on the claim -- not only “true duplicates” but also when concurrent care is implemented.
- Integrating all utilization review decisions into the bill review process to disallow charges for medically unnecessary or unrelated services. Integration with Healthcare Solutions’ managed care module (QRIS) ensures reimbursement is made only for items approved in the treatment plan and allows for auto-adjudication of pre-authorized records.
- Securing reductions for out-of-network services. Healthcare Solutions’ out-of-network management program ensures that bills are paid at a favorable rate and provides payers full visibility into services rendered across an entire book of business.
With over 70 custom reports, Healthcare Solutions has the ability to track everything from treatment benchmarking to client return on investment. In addition, on behalf of its clients, Healthcare Solutions provides state reporting where it is required.
Benefits of the Medical Bill Review Program include:
- Identification of over-utilization and unnecessary care
- Timely turnaround of bills
- Historical database for provider treatment patterns
Contact a Healthcare Solutions representative to learn more about our Medical Bill Review Program.
