The Benefits of Private Medical Bill Review Services

By: David San Filippo, Ph.D. – 05/05/04

Medical bill review services can save your customers money and create a new revenue stream for your company. If you are a managed care or case management company and you are looking for a new revenue stream, you may be able to enter into the medical bill review business with little overhead or set-up costs.

All workers' compensation claims organizations and some group health and PIP claims organizations are doing some kind of medical bill review to reduce medical claims to fee schedules, managed care savings, and PPO rates. Some are providing this service in-house and many are out-sourcing it to other organizations that perform medical bill review services. These services are generally paid for by assessing the customer a per line rate, a per bill rate, or a percentage of savings along with a percentage of savings on PPO savings. The pricing for these services by the bill review service providers allows for considerable flexibility for small to medium size cost containment/case management companies to provide a quality service at a reduced rate from what the client has been accustomed to paying for these services.

The basic costs associated with offering Bill Review services are the adjudication software, the fee schedules, staffing, and the work space, computer, and telephonic support for the bill review staff.

The efficiency and the efficacy of the review of medical bills are dependent on quality review personnel and a comprehensive medical bill review system. The medical bill review information system should be able to adjudicate medical bills to prevailing medical fee schedules, medical plans, multiple PPO network discounts, and other user-defined discounts. The system should also be able to interface with pre-certification data and be able to import and export data to and from clients and governmental agencies. The reporting capability should be robust enough to provide sufficient reports to the clients to manage their business, manage claimants' medical care, and monitor the quality and timeliness of the work of the bill review staff.

Medical bill review services should be performed by qualified individuals who are familiar with medical terminology, ICD-9 and CPT codes, and general medical treatment practices. Medical Bill Reviewers perform the majority of their work reading and keying in data from medical bills submitted for payment to claims organizations. An average Medical Bill Reviewer can process 85-100 medical bills per work day, depending on the efficiencies of the medical bill review information system used by the Reviewer and the Reviewer's proficiency. The printing of the Explanation of Reviews, batching of the bills and the Explanation of Reviews, performing quality assurance reviews of the bills processed, and responding to medical providers inquiries regarding adjudication of their bills occupy approximately 15% of Medical Bill Reviewers' time.

Companies such as Lutz-San Filippo provide private-label medical bill review services for companies that want to offer medical bill review services to their customers under their name but do not want to invest in the infrastructure that is required to staff and support a medical bill review department. Private-label medical bill review companies can be the transparent bill review service department for your company, keeping your company name and logo before your customer and the ability to offer your customers a new cost containment service.

For more information regarding private-label medical bill review services you can contact David San Filippo at 407-571-2488 or PBR@L-SF.com.