Negotiation Experts
Bills for services often create challenges for providers and payors. Charges can be quickly and easily remedied where both parties can feel a fair and reasonable solution was reached. Appeals and litigation drive costs and delay payment. Developing fair and reasonable rates is a skill few have.
Having years of negotiation, litigation, adjudication, coding and compliance experience gives us the ability to easily give valid reductions and rates based on industry standards and applicable rules and regulations. We facilitate multimillion-dollar settlements for past and future claims. We obtain savings that others miss and write agreements that reduce or eliminate litigation. Access to unique UCR databases also provides an extra layer of savings not easily obtainable through traditional networks.
Specializing in workers compensation, automobile, and bodily injury cases, we break down large bills to what should be paid. Claimants with limited policies can have their insurance dollars stretched on their first and third party benefits.
Medical Code Review
In this highly litigious insurance environment, having expert certifications is essential to show proper coding and reimbursements to arbitrators and judges that would otherwise just side with the provider. By producing expert reports, we have successfully changed the net opinions of arbitrators, which caused shifts with governing regulations. Our certifications raise the bar as judges and arbitrators are given a thorough analysis of complicated coding scenarios with supporting documentation that is often irrefutable.
Having the most experienced coders is essential in the insurance adjudication industry. We have a team of certified coders that can produce expert analysis, reporting, and automation for maximum savings in highly complicated specialties. Coders that specialize in difficult surgeries can save payors millions by appropriately applying nationally accepted rules, edits, and other bundling or surgical regulations. We have business partnerships with companies that also offer expert analysis of specialty services, surgical implants, pharmacy solutions, and durable medical equipment.
Complex Bill Adjudication & Automation
Many billing scenarios can easily be identified through the implementation of internal adjudication rules built directly in your bill processing system. By using technology and automation, we can identify common and unusual coding errors or scenarios that should not be paid. Bill Review Solutions, LLC can accommodate your adjudication needs by using technology to expedite handling and reduce manual processes. We will develop rules based on your level of aggressiveness. You have the option to implement automated rules alone but we recommend you include manual review. Not all bills can be adjudicated with rules as documentation requires review to ensure compliance with coding regulations. Our professional coders compare operative reports, facility charges, and itemized bills with National standards to allow only payable codes at reasonable or regulated prices.
We have nurse and coding auditors that can review your most complicated provider or facility bills. A thorough analysis is essential to not pay for inclusive or bundled charges. Our coding and regulatory expertise also applies the most relevant fee structures to allowed charges so you only pay what you are obligated to pay.
Litigation Defense Strategies
Developing coding and reimbursement strategies is one part of this puzzle. The presentation of these positions requires the expertise of legal professionals that can support these opinions with authoritative and governing rules and statutes. Having relationships with attorneys in the industry that specialize in medical coding, insurance reimbursement and contracts gives you the tools to properly defend positions.
Many of our positions or methodologies are unique yet win and have changed the insurance environment. We have influenced legislators and the Department of Insurance to implement coding recommendations and adjudication procedures. These changes impacted the entire insurance community and reduced waste. We have successfully challenged and beat the most aggressive providers and attorneys in the industry!
Network Auditing
Who is watching your networks? Our relationships with expert attorneys that write and challenge PPOs can identify obligatory provisions and specific exclusions that are often overlooked. What does your contract actually say? Having a PPO does not necessarily insulate you from litigation and often creates more challenges than you would expect. Contracts with providers may conflict with the obligations or provisions made with payors. These highly technical matters often result in loss of savings or inconsistent payments.
We recommend contracts be reviewed, especially when part of litigation and to audit PPO reductions to verify whether all reductions you are paying fees on are collectible. Our simple analysis and reverse engineering identified erroneous charges that would otherwise go unnoticed.