Physician Bill Review

A physician bill review is a “tool” used to facilitate the adjudication, settlement or resolution of a medical bill or claim. AMBR’s physician bill review assures that the claims professional has the necessary data to demonstrate that their payment decisions are accurately based on appropriate pricing, acceptable billing practices, industry guidelines and relevant state regulations.

AMBR’s clientele consists of Personal and Commercial lines Insurance Companies, Worker’s Compensation Carriers, Health Insurers, Governmental Agencies/Entities, Third Party Administrators, and a variety of other payers of health care services.

Key Benefits

 Easy to use, defensible reports and Explanations of Review

 24-hour turn around time

 Available for all 50 states

 Compliant with all state fee schedules

 Provides a sound basis for evaluating the fair price of medical care

Each physician’s bill is reviewed for the following:

• Fee Schedule Review – Ensures that medical bills are compliant with the most current state-mandated Personal Injury Protection and Workers Compensation fee schedules, administrative rules and regulations.
• UC&R Review – UC&R is an industry-generic acronym for Usual, Customary and Reasonable. The UC&R component consists of a national database containing data from actual provider services performed throughout the United States. It enables our clients to assess whether a provider’s charge for a procedure is reasonable when compared to charges from other providers rendering the same type of service, in the same geographical region. The data is accurate to the 95th percentile level of confidence.
• Drug and Supply Charges – All drugs and supplies are reviewed based on the manufacturer’s average wholesale price, plus a reasonable markup.
• Rarity – Our Rarity feature identifies procedures that are rarely performed for the reported diagnosis. All medical services are reviewed to ensure that they are appropriate for the condition being treated.
• Utilization Review – Utilization is an important part of the cost-containment formula. This component confirms that the duration of care and the number of visits being rendered to a patient is appropriate for the given diagnosis.
• Compliance with CPT Guidelines – The Physician’s Current Procedural Terminology (CPT) is published annually by the American Medical Association. AMBR will ensure that provider billings adhere to the billing practices and guidelines established by the CPT.
• Bundling/Unbundling – This edit ensures that a provider is not billing separately for several services that would normally be combined in a single procedure.
• Elimination of Duplicate Billing – AMBR’s software maintains a history of all medical bills entered under a specific claim/file number. This allows us to detect duplicate charges in the same bill, on previous bills reviewed by AMBR, or other providers treating the same patient.

How It Works

The claims professional submits a cover sheet along with the medical billing statements to be reviewed.  Each case is handled individually by an auditing professional to assure accuracy and compliance to strict quality guidelines. When the case is approved for release, a report is generated that will explain any item on the bill that was impacted by the review process. In most cases the auditor will return the completed review to the claims professional within 24 hours. The auditor is available to assist with any further clarification or assistance required to help finalize the claim resolution process.