Physician Bill Review
31% of US healthcare spending is attributable to care received in the hospital according to statistics from the American Medical Association. Hospital admissions are usually due to worsening of ongoing medical issues, traumatic events, and unforeseeable occurrences for your plan participants.
Our comprehensive Physician Bill Review helps ensure your plan participants receive the necessary clinical care but at a fair and reasonable rate commensurate with that clinical care as well as industry coding standards such as ICD-10 (International Classification of Diseases, 10th Edition), procedure codes, and DRGs (Diagnosis-Related Groups).
Your Challenge
Over 90% of hospital admissions are in-network. Charges for such events are often significant and could result in overpayment by the health plan if left unchecked. Out-of-network admissions demand similar scrutiny. Hence, stop-loss payers, plan sponsors, and their brokers must have the right tools to navigate the complex demands of the in-network environment to affect the best financial and quality outcomes for such events.
Our Solution
We achieve savings on in-patient hospital care for our clients in two ways:
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Hospital Bill Review: This occurs at various stages, including pre-bill review (before submission to payers) and post-payment audits to identify and rectify any errors and discrepancies. The goals of these reviews are to verify that the charges on the hospital bill are legitimate and appropriate and reflect the actual services and resources provided during the patient's stay in the hospital.
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DRG Audit: These are conducted post-payment to assess the accuracy of DRG assignments and address any coding or documentation errors retrospectively. DRG validation has a direct impact on reimbursement. The goal is to enhance the accuracy of DRG assignments, support fair reimbursement, ensure regulatory compliance, and promote transparency in healthcare coding and billing practices. Regular DRG validation processes are essential for maintaining the integrity of healthcare data and financial transactions.
Our review includes:
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Physician Expertise in Utilization Review & Quality Audit
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Line Charge Verification
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Usual & Customary Repricing
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DRG Medical Record Validation
Why Choose Us?
Our comprehensive review is designed to assist you with:
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Negotiating fair and reasonable rates with the provider or payer for the billed charges.
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Recovery of overpaid charges backed by industry standards and physician findings that are defendable and evidence-based.
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Ensure fair and equitable reimbursement.
Leverage Our Expertise Today!
Transform your benefits strategy. Empower your clients. Amplify your results. Discover tailored solutions for Brokers and TPAs in the self-funded arena.
Amwins Health & Employee Benefits Consulting has the solutions to help you gain and retain clients.
