Medical billing is complicated and fraught with opportunities to make honest mistakes. But this complicated process also lends itself to fraud and abuse. Here are just a few examples:
- A TPA missed a $10,530 overcharge for a semi-private room that was billed as an ICU room...over $2,000 per day difference.
- A 56-year old male goes into the hospital for a hip replacement; the itemized statement shows newborn blood tests and a crib mobile.
- $90 charge for a 70-cent I.V. and $12 for a mucous recovery system (which was a box of tissues).
- Charges for ordinary supplies (towels and sheets) that should be included in the room charges.
- An optometrist offered free eye exams to nursing home patients and staff. Using patient information obtained by offering this "free service" the optometrist generated additional, fictitious billings to Medicare.
- According to OIG's web site for April 2004, a podiatriast and two billing clerks in New York were sentenced for their roles in a scheme to defraud the Government and private insurers. The podiatrist was sentenced for submitting claims for services that were either upcoded, not rendered, or were medically unncecessary. The two billing clerks who, at the direction of the office manager, submitted claims that they knew were fradulent were also sentenced.
- In December 2003, the OIG reported the conviction of a Utah nurse practitioner who submitted false claims for services she provided from 1994 until 2001. During that timeframe, the nurse submitted claims for services she provided using the names and personal identificaion numbers of physicians not associated with the clinic.
Whether you are a healthcare or an estate planning attorney, we can save your clients time and money. We have the expertise to review medical records, billing statements, and insurance EOB's related to your cases. Our experienced reviewers scrutinize every line of your client's medical bills, paying particular attention to items that are non-compliant with federal and state billing guidelines, local medical review policies and correct coding initiatives. We provide a comprehensive, 70-point review.
We review bills from all medical specialties including but not limited to hospital based physicians. We review any claims including workers' compensation, motor vehicle accidents, medical malpractice, nursing home neglect, and medical bills charges to the estate of deceased patients.
Once we have completed our review, we will provide a detailed, draft report that provides documentation of all medical billing concerns identified by our reviewers. Included but not limited will be to:
- Verify that all charges are supported by appropriate documentation in the medical record.
- Compare the billed charges to the Centers for Medicare & Medicaid Services for Diagnostic Related Groups and/or Ambulatory Patient Classifications.
- Verify that all billed charges are in compliance with federal and state regulations and guidelines governing inpatient and outpatient billing procedures.
- Verify that all billed charges are in accordance with the applicable insurance company's local medical review policy.
- Verify that all billed charges are in line with the geographical conversion factor for the applicable area.
- Compare billed charges to local HIAA data for usual and customary.
- Verify that all billed items and services are in compliance with correct coding initiatives.
Medical Bill Review Services, Inc. will then work with you or your designee to prepare a final report that will meet your documentation requirements for submission in court.
Pricing plans include hourly rates and/or contingency based on dollars recovered or saved.
If you are interested in receiving additional information about our services, please e-mail us at firstname.lastname@example.org or call us at 615-783-1707; toll free 866-615-1400.