Medical Bill Review

Review of medical records to ensure that services were actually rendered and those services were billed appropriately. Service applies fee schedules, billing rules and other appropriate review criteria, and is a retrospective review of paid claims for appropriateness of

• Billing
• Medical Necessity
• Program Compliance
• Benefit Coverage

• Services paid were ordered
• Services paid were rendered
• Services paid were billed properly
• Services paid were medically necessary
• Services paid were performed in the appropriate setting
• Services paid adhere to policies and guidelines

• Issues related to coding errors
• Issues related to program compliance
• Issues related to unbundling
• Other possible errors

• Duplicate billing
• Missing or illegible records
• Incorrect coding
• Billing for chronic conditions without documentation to support need
• Billing for services that are not covered benefits
• Lack of documentation to support necessity
• Billing under another TIN
• Capture unbilled items
• Misuse of modifiers
• Ineligible billing
• Billing a secondary without the primary
• Non-standard Lab List

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