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Medical

Claims Review

Specializing in reviewing Medical Claims for overcharges.

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A simple audit may reduce your annual payout by 8% to 12% or more

Most hospitals have successfully created a fast turnaround time for payment from insurance companies that prohibits anyone from looking into all the non-billable services camouflaged by the UB-04 summary bill. This is resulting in millions of dollars being wasted in our healthcare system

 

Due to the complexity of medical guidelines, it would be recommended to perform a comprehensive provider audit.

 

Which  includes:

  • Determine compliance with both the contract terms and plan provisions 

  • Evaluate accuracy of provider billings and highlight overpayments 

  • Assess for potentially abusive or fraudulent claims per provider profiting, by evaluating subscriber claim history and other analytical techniques 

  • Determine if charges on the itemized statement are corroborated by the medical record documentation 

  • Evaluate charges for conformance with federal billing regulations that govern inpatient/outpatient billing compliance  

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Potential Indicators of 

overcharges

Double Billing

 

Health care providers tend to charge twice for the services they rendered to patients

Unbundling 
 

Procedures or lab test that instead of being billed with one code are billed with a bunch of separate codes to obtain more money

Upcoding 
 

Involves upcoding to obtain higher reimbursement than one is entitled. Providers use higher paying code to fraudulently reflect that of a more expensive procedure

Ancillary Charges

 

Items that are billed that should already be included in cost of hospital stay or surgical procedure

Phantom Billing
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Billing for services that were never rendered to patients 

Code Jamming

 

Laboratories inserting or jamming fake diagnostic codes to get coverage

Stop Loss Prevention

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By lowering claims cost and working closely with your stop loss provider, NLB has effectively reduced future stop loss premiums

Auditing Technique

  • Requires the UB-04 and the Itemized Bill, medical records are needed when charges warrant 

  • Can be done within a time frame to meet payment guidelines and assure access to network discounts 

  • Audits are performed, allowing access to mass volume of guidelines, resources, and documentation 

  • Our staff has an in-depth expertise in compliance billing as it relates to Federal Billing Regulations, CCI, and AMA coding guidelines as well as accurate medical record documentation

  • Should also perform "Fair and Reasonable" pricing analysis on out-of-network billings  

 

 

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