HOSPITAL BILL AUDIT
Considine & Associates HealthClaim Review® is a URAC-accredited Independent Review Organization that provides hospital and medical bill audit and negotiation for ERISA groups, TPAs, MGUs, stop loss carriers, and reinsurers. We have over 26 years of experience auditing, pricing, and negotiating large dollar hospital claims. We charge on a custom flat fee basis, not percentage of savings.
We use multiple methodologies to achieve savings on hospital bills:
Our physician consultant panel, evaluates hospital claims from utilization, quality and cost effectiveness vantage points. We use only US-licensed, practicing, board-certified physician specialists. Utilization review of the medical record post-discharge and pre-payment, often reveals inappropriate network approval of length of stay and/or level of care. Poor clinical outcomes are analyzed to determine if they were preventable and significant. MD narrative summaries are highly detailed, chronological day-by-day outlines 5 to 25 pages in length. Such thorough hospital bill reviews are extremely difficult to overcome and lead to enhanced claims outcomes. Our review physicians are also available to do peer-to-peer calls with treating physicians or hospital chiefs of staff on medical issues. It is best to use a medical review company that has its own internal physician specialist consultant panel to audit hospital bills, rather than a vendor with a Medical Director who has limited specialist physician consultant support.
PHYSICIAN SPECIALIST REVIEW
Each line of the itemized bill is performed by an RN CCFA (Certified Clinical Financial Auditor). Identification of unbundled services, incorrect item count, inappropriate drug charges, and incorrect coding are essential when doing medical bill auditing. Additionally, board-certified physician specialists analyze medical necessity of each line of the itemized bill, including major abuse areas of laboratory, respiratory therapy and physical and occupational therapy. Line Charge Audit and Physician Specialist review are the two cornerstones of successful hospital bill auditing, that consistently produce savings in-network. Findings in these two areas can lead to reconsideration of the entire claim, including individual charges for specific goods and services.
LINE CHARGE VERIFICATION
Using commercial non-Medicare data, is still an important benchmark in inpatient claims review, even when 95% of admissions are in-network. Facilities will lower prices for expensive medical devices, especially if there are significant hospital billing audit and medical billing audit findings on the Physician and Line Charge audits. U&C repricing also uncovers pricing anomalies such as different charge amounts for the same item. Exposure of grossly inflated individual charges is still of value, even in the presence of network discounts.
USUAL & CUSTOMARY REPRICING (U&C)
Utilized for clients with a reference-based Medicare reimbursement structure. We utilize our many years of working with Medicare Advantage plans to bring Medicare pricing expertise to ERISA plans and their reinsurers. Unlike many reference-based pricing approaches, review of the complete medical record at the physician specialist level is essential. Principal Diagnosis determines 95% of DRG selection; when incorrect, it leads to wrong (higher) DRG reimbursement. Reference-based pricing approaches must include an analysis of correct DRG assignment to avoid inappropriate DRG upcoding by hospitals. In our experience the hospital-billed DRG is wrong 30-35% of the time.
DRG MEDICAL RECORD VALIDATION
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Review of the complete medical record and itemized bill is the gold standard.
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The use of multiple review methods to audit medical bills simultaneously achieves durable outcomes.
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Solid audit findings precede successful negotiations.
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Physician Specialists who are board certified and practicing are best suited to do intensive inpatient reviews.
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Paying a vendor on a flat fee basis is more cost-effective than percentage of savings.
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It is essential to involve the payers in the negotiation process along with the review company, for timely results and improved communication.
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We work on an individual case-by-case basis without extended obligation for future reviews.
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After seeing both the UB-04 and itemized bill, we can tell you exactly what it will cost to do the review, before medical records are obtained.
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We are always available to do pre-screening of cases.