Bill Review Service
Overview:
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
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