Medical Cost Analysis Including UCR
Expert Medical Billing Reviews for Legal and Insurance Cases
Medical experts play an important role in the process of medical billing for litigation purposes. A bill payment needs to be reviewed by a medical expert in order to be deemed reasonable in a customary fulfillment for that payment. Payable bills that are related to an accident or cause of event, require charges that are necessary, reasonable and accurate. From a financial perspective, the charges need to be identified as usual and customary. There are two parts to a medical audit and bill review: the clinical aspect and the financial review.
KTA Ensures Accurate and Reasonable Medical Charges
The Clinical Aspect:
During a medical audit and bill review, our medical experts evaluate medical records and, when appropriate, examine the individual. They determine which diagnoses are related to the injury or exposure, assess the treatment provided, and compare it to what is considered medically reasonable based on established standards and professional medical judgment. The questions that medical experts are seeking to answer include:
- Are the particular diagnoses being treated, and are they related to the injury or exposure?
- How much treatment is reasonable, and how long should it continue?
- What is the connection between treatment, injury and exposure?
The Financial Review:
The financial review that takes place during a medical audit and bill review involves two separate aspects: looking at what is usual, customary and reasonable charges (UCR) and looking at auditing errors and financial review.
- UCR Analysis:
The US government healthcare website defines UCR as “the amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service.” By looking at geographic region, specialty, diagnoses, the prevailing and accepted charges and what is actually being done in terms of payment, medical experts are able to determine a UCR during the medical audit and bill review. There are many published standards, reference guides and physician reference guides to help with this process.
- Auditing Errors and Financial Review:
Auditing errors typically occur in 80-85% of cases. Common billing errors include duplicate charges, double billing for the same service, incorrect billing codes, inaccurate charges, and unbundling (billing separately for services that should be grouped together). To complete a thorough financial analysis, our medical experts review inpatient and outpatient hospital records, itemized bills, Explanation of Benefits (EOB) statements, and other relevant documentation to identify billing discrepancies and determine whether the charges are reasonable and accurate.
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Medical Bill Review
In this video, Dr. Kevin Trangle explains medical billing and the involvement of medical experts in performing an audit and medical bill review.
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