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Bill Review

Retrospective Utilization Review

The last opportunity an insurer has to capture savings on medical bill charges is in repricing. It is the responsibility of the managed care organization to evaluate the level of service as well as medical necessity then determine the appropriate reimbursement to the provider. Injury Care utilizes advanced bill review software as well as experienced bill review staff to make sure that the provider’s procedure coding is consistent with the medical reporting and that all services that are billed are appropriately supported. Explanation of Benefits (EOBs) or Explanation of Review (EOR) are generated for each bill repriced which allows the insurer or TPA documentation as to what was allowed or denied. It also provides the medical provider a written determination with full explanation of the payment.

The medical bill review includes identification of the proper use of modifiers to ensure that all surgical procedures are properly “bundled” and that any “unbundling” is denied with proper explanation and reference. In states where there is a state mandated fee schedule such as Utah or Nevada, another level of savings is to reduce the billed charges to the state fee schedule. Proper application of the state fee schedule alone can reduce allowances by approximately 50% off the physician charges. “Network” discounts below the state fee schedule are available through Injury Care resulting in additional savings.

It should always be cost effective to use a bill review service. We also make sure that the bill review staff is available to speak directly with the insurer or TPA to allow regular communication and optimize service to clients and providers.

NCCI Medical Data Call reporting is also an option available for Injury Care clients.