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Medical Bill Review
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Savings By Claims Examination GlobalCare’s Medical Bill Review program evaluates surgical, medical, hospital and pharmacy bills to help eliminate unwarranted charges. Our Medical Bill Review provides payers with an opportunity to perform a financial and clinical review on both primary network and secondary network medical claims. Skilled professionals perform a line-by-line reconciliation of the itemized billing and the entire medical record when applicable identifying:
Our program seamlessly integrates with GlobalCare’s workflow management to provide an efficient and supplemental means to realize additional savings to Preferred Provider Organization (PPO) contracted discounts. Upon request and in accordance with the plan document, GlobalCare will adjust appropriate charges to reasonable and customary. Payers receive itemized reports with corresponding adjustment rationale. In the event a full medical review is warranted, the clinical panel utilizes their medical expertise to review medical claims and identify cost reductions to provide unparalleled convenience and savings. We maximize medical savings for both large dollar primary network and secondary network medical claims. Medical Bill Review seamlessly integrates with GlobalCare’s workflow management to provide an efficient and supplemental means to realize additional savings to Preferred Provider Organization (PPO) contracted discounts. Unparalleled Performance
Features: Medical Bill Review services delivers two levels of review
GlobalCare Advantages
FREQUENTLY ASKED QUESTIONS1. What types of claims do you conduct a Medical Bill Review on? Both primary network and secondary network physician or facility medical claims with a threshold value of $25,000 or greater are candidates for Medical Bill Review. 2. What types of charges are reviewed to obtain savings? Identification of inconsistencies, billing errors, duplicate charges and unbundled charges. Undocumented medical claims, unnecessary medical claims and claims with excessive charges are reviewed by our clinician panel for accuracy and are comparatively evaluated against reasonable and customary fees. Examples of billing inconsistencies would be:
3. Do you guarantee Medical Bill Review performance? Typically our success rates for negotiating claims under the Medical Bill Review program are nearly 100% with discounts (incremental to PPO savings) ranging from 10% to 22% of the claim value. Savings are accompanied by a detailed report of the review findings with reason codes. A signed statement of agreement from the physician or facility supports all Medical Bill Review claims that secure a discount. The historical success rate on settling appeals has been 100%. 4. Do you conduct a Medical Bill Review on all large dollar claims? GlobalCare conducts Medical Bill Review for primary network or secondary network claims that typically are $25,000 or greater in billed amount. The threshold can be established at any reasonable value based upon consultation with the payer. For primary network claims, Medical Bill Review provides supplemental savings on a claim that has been re-priced under the primary network guidelines. For secondary network medical claims, our model utilizes a proprietary network assignment routine to re-price claims through contracted discounts with a selected PPO network. Claims not assigned to a PPO network for discounted savings would be processed under the Medical Bill Review program. 5. What is the process to conduct a Medical Bill Review? Claims that meet the established threshold criteria are flagged by our system and prescreened for a Review. The assessment is reported to the payer, and upon approval GlobalCare will proceed with the bill review. When additional savings are obtained a detailed report documenting line by line the identified adjustments with assigned reason codes will be provided to the payer supplemental to the PPO discount. letter and report to submit to the payer with the payment and Explanation of Payment. In the event of a Clinical Bill Review, the payer denies the claim for additional information and requests medical records from the provider. The provider submits medical records to payer who forwards them to GlobalCare for processing under the Clinical Bill Review Program. A clinical panel reviews the medical records in detail, examines the charts for undocumented medical services, clinically assesses the need and use of medical procedures, and compares the charges for excess to standards. The provider of services is then contacted to review and discuss the medical services rendered and the clinical panel resolves the claim with a signed agreement from the provider of services for additional savings. Documentation required includes original UB92 or HCFA 1500 claim, itemized billing, entire medical record, copy of EOB/EOP (showing claim was denied for medical records), patient liability and, for primary network claims, a re-pricing summary. 6. What is the average turn-around time for Medical Bill Review? A pre-screening and assessment will be reported to the payer within 48 hours. A Reasonable and Customary Review will be returned in 5 – 7 business days. Clinical Bill Reviews can last from 10 to 25 calendar days after receipt of the medical record. This is to allow time for our clinical panel to review and resolve with the provider of services greater discounted savings. Clinical Bill Reviews adjust the “clock” for timely adjudication and payment while the claim has been denied or pended awaiting additional documentation. 7. What are the fees associated with Medical Bill Review? GlobalCare offers contingency pricing with fees paid only if savings are obtained. Fees are calculated on a percentage of claim dollar savings. GlobalCare Simply More
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