Specialty and Negotiation Services
Our AuditEdge™ program encompasses both specialty bill review and negotiations for high dollar medical bills on workers’ compensation, liability, and group health claims.
Specialty Bill Review is a thorough, line-by-line review of all charges to ensure the charges are related to the accepted diagnoses, appropriately documented, and appropriate and billable per AMA guidelines. This is very important in stop-loss cases in Texas and for all states for those services not covered by a fee guideline with an established reimbursement amount. Assuming the provider has billed appropriately, not taking the extra step to examine the detailed charges can result in millions of additional dollars in medical claim expense.
In addition, the Negotiation component of AuditEdge™ is a valuable tool and enhancement to any bill review program. Our negotiations are based on a preliminary, line-by-line review (Specialty Bill Review). We can confirm treatment is appropriate through our Peer Review and ODG unit services. With this preliminary review as the basis for the negotiation, we are able to achieve exceptional savings for our clients. Many clients refer lien cases to us as well as cases that are in dispute or litigation cases to us. We are often able to secure signed agreements and avoid the dispute and litigation process. This saves the substantial cost associated with this. Providers have added incentives to settle with a negotiation at this point to avoid the legal expenses as well. All negotiated arrangements are secured in writing and this is provided to our clients along with an EOB noting the disposition and the provider’s agreement. This indicates the provider’s agreement and ensures that there will be no basis for appeal. These services are performed in-house by our technical staff. These are not contracted or outsourced services.
Liability Bill Review Summary
This snapshot enables the client to quickly peruse each provider’s total bill, total dollar amount unnecessary/unrelated to the claim, total usual and customary reductions and the payment recommended. This is especially beneficial to a claim when a peer review has been completed and the charges or reductions reflect the opinion of the reviewer.