Medata’s Complex Bill Review Unit analyzes complex or difficult bills that are flagged by CORE and our expert users to augment the analysis, achieving a comprehensive examination of these bills.  All reviews are supported by thorough research.  The reimbursement recommendation is produced and backed by our team of experienced analysts.  Bills generally flagged for this high level category of review are:

• Inpatient Hospital Bills
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    • DRG Grouper Verification
    • Outpatient Surgery Audits
    • Line Level Audits
    • Implants

• Level of Service Reviews
  • • Determining a Reasonable Level of Service – Medata uses the historical experience of medical provider billings (more than 400 million bills) distributed throughout the United States.  Each submitted Evaluation and Management service can have its corresponding level of service evaluated for reasonableness, when compared to the traditional service submitted for the ICD-9 diagnostic code.
    • Appropriate Level of Service – Verifies that the provider’s submitted service level is appropriate after review of the reports and notes.

• RARITY – Medata’s thirty-four years of medical bill review experience and analysis of hundreds of millions of actual medical bills have afforded us the ability to statistically compare the historical incidence of a service or procedure code against the submitted ICD-9 diagnosis.  Service codes that rarely occur are flagged for injury relatedness and substantiation of medical necessity.

• HEAT – Medata’s proprietary protocol governing heat-related physical therapy treatments performed when the patient’s soft-tissue injury progresses from the acute phase to the chronic phase.

• Over Utilization
  • • Reasonable number of Visits for the Diagnosis
    • Reasonable duration of Care for the Diagnosis
    • Reasonable total charges for a Claim for the Diagnosis

• Client Established Business Rules

Bills for both in-network and out-of-network are reviewed consistently utilizing the following criteria and recommendations and are supported (both regulatory and legally) by an experienced team of review analysts using advanced technology.  All complex bills receive the same professional analysis which includes the following along with Medata’s proprietary databases compiled over years of accumulating medical data.

• • • Duplicate Checking
    • State Fee Schedule Value
    • State Fee Schedule Ground Rules
    • Prevailing Billing Parameters
    • Unbundling/Rebundling
    • CCI
    • Proprietary Unbundling Edits

• Physician Specialty Review Panel – Includes specialists in the fields of Orthopedics, Neurology, Internal Medicine, Anesthesiology, Chiropractic, and Physical Therapy.