Medical Bill Meditation - Medical Bills Making You Sick


DRG Validation

1. What size bills can we submit for DRG validation?

We prescreen all hospital in-patient claims that are paid on a DRG methodology regardless of the itemized charge amount.

2. Is there a fee for DRG prescreening?

No, DRG prescreening is performed free of charge.

3. Can DRG claims be prescreened prior to payment adjudication?

Yes, DRG claims can be prescreened prior to payment adjudication. Within 48 hours clients are notified of which claims are selected for DRG validation. DRG claims post payment may also be reviewed for validation.

4. Is the DRG staff AHIMA credentialed?

Yes, all members of the DRG staff are AHIMA credentialed. The staff are Certified Coding Specialists and several members are also Registered Health Information Administrators. The DRG staff has over 45 years of validating DRG's & coding experience.

5. Are medical records requested for DRG validation?

Yes, medical records are requested for selected cases for DRG validation. If there is a high volume of DRG claims for validation, the review audit is performed on site at the hospital.

6. Briefly explain the DRG validation process?

The medical record is reviewed to verify the ICD9 diagnosis and procedure codes for correct DRG assignment. The Certified Coding Specialist utilizes client customized DRG coding software to ensure that the selection of the correct principal diagnosis/procedure reflects the clinical findings in the medical record. The hospital is contacted with detailed correspondence regarding the adjusted DRG assignment. The hospital representative signs the DRG finalization form agreeing to the DRG adjustment.

7. Is medical record confidentiality maintained?

All of our staff are required to sign Privacy agreements to maintain the confidentiality of the medical record/client information.

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Claim Negotiation Services

1. What type bills do you accept?

We accept all out of network claims $50 and greater for all provider bill types including hospital inpatient and outpatient, physician, pharmacy, home health, ancillary facilities, and outpatient surgery centers.

2. Do you accept paid claims?

No. Most negotiations are based on prompt receipt of payment. If the claim has been paid, other options are available through the audit services department.

3. What is your turnaround time for claims?

Most claims are completed in less than 72 hours.

4. How do we submit claims to HCM?

HCFA 1500s, UB92s, or client screen prints for claims can be faxed or electronically submitted for negotiations. If claims are submitted electronically the minimum threshold of $500 may be lowered.

5. Who negotiates the discounts?

All negotiation staff members have prior management/supervisory experience in the healthcare setting or are experienced registered nurses. Each negotiator has at least 10 years experience in healthcare cost containment strategies.

6. Does HCM look for potential errors on bills prior to negotiating?

Yes. All claims are reviewed for potential errors and/or aberrant billing.

7. Is the confidentiality of the information submitted to you maintained?

Yes, it is. All staff members sign confidentiality agreements and HCM will be fully HIPAA compliant.

8. Will we have balance billing issues?

No. Signed off agreements are obtained from the providers for all prompt pay reductions.

9. Do you perform usual and customary reviews for physician claims?

Yes. The Analyzer performs an audit that is based upon accepted industry standards. Our software uses a comprehensive database that contains claims coding edits consistent with the CPT Physician Current Terminology Manual.

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Hospital Bill Auditing

1. Is there a fee for prescreening?

No, prescreening is performed free of charge

2. What information is necessary for prescreening?

Generally, prescreening can be completed with the information included on a UB92. This can be sent by mail, email, fax, or electronic submission in our format or as a data dump that HCM will then format.

3. What size bills can we submit for hospital bill audit prescreening?

We prescreen all hospital bills of $5,000 and higher.

4. Most of our claims have PPO or HMO discounts. Can these claims be audited?

Absolutely. Any claim paid by a % off of charges methodology can be audited. The majority of claims we audit have already received some type of discount. However, that discount is not as great as you may think since there could be significant overcharges on the bill.

5. Some states, such as Texas, have government regulations dictating a strict time frame for claim payment or penalties are applied. Can these claims be audited once paid?

It is not necessary to withhold any payment pending an audit. The majority of claims we audit have 100% of the payer's liability paid. Most hospital's audit policies require 90% to 100% of the charges be paid prior to audit.

6. Are medical records requested for audit?

With very few exceptions, audits are done onsite at the hospital. This ensures all documentation available at the time of audit can be presented by the facility and discrepancies can be resolved in a timely manner. This usually results in a signed agreement received on the day of audit. This method also adheres to the hospital's policies and procedures thus maintaining a respected professional relationship between HCM, the hospital, and the payer.

7. Who performs the audits?

Our auditors are nurses with extensive clinical experience and an average of 9 years of audit experience, most of it with HealthDataInsights.

8. Is confidentiality maintained?

All of our auditors are required to sign confidentiality agreements and HIPAA addendums. In addition, our HIPAA compliance officer is on schedule to ensure HCM is HIPAA compliant

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2. What is the average discount?

Discounts vary by state, however, nationally our experience reflects average savings of 24% on inpatient hospital claims, 17% on outpatient hospital claims and 26% on professional services. Nationally dental discounts average 31%.

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