The HealthCare Industry Back Offfice

Medical Bill Review

Overview:
Bills are submitted to RapidCare Solutions and are subject to multiple quality assurance checks by CPC team. Charges are reviewed using applicable regulations and industry standards and accept RACD. Each bill is reviewed for possible duplication of charges, non-billable charges, unbundling of codes, data entry errors producing inappropriate charges, relatedness of procedures to the diagnosis etc.

Financial Review:
Line by line audit of the bill is performed to determine incorrect charges found.

Clinical 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

In performing the review, it is verified that

  • 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

In performing Bill review, tasks include but not limited to reviewing

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

Common findings include but not limited to

  • 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

A higher level of review evolves by flagging the bill for

  • 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