Services

Medical Bill Review

Optimizing Your Network for Greater Savings

CareWorks Managed Care Service’s superior technology and experience ensure that your custom bill review solution maximizes network penetration and savings. The cornerstone of the savings and efficiencies we deliver is PPO Fusion, our network optimization technology.We analyze your claims, bills and geography and match them to our 70+ networks to create an optimized network model. Your claims always start in the network where your best opportunity for savings is available. Plus, your data and our networks are updated quarterly to keep your matrix of networks most beneficial to your bottom line. This approach means that you receive the:

  • Greatest discounts – 60-65% of bills are caught for optimized savings
  • Greatest penetration – up to 80%
  • Fastest turnaround – most bills returned in 48-72 hours
What We Offer:
  • Rigorous Bill Review
  • Custom Bill Review Solutions
  • We Bring It All Together

CareWorks’ rigorous bill review starts with the application of the appropriate fee schedule / UCR and utilization review audits and edits completed by CareWorks Nurse Auditors and Certified Coders to ensure maximum negotiated discounts are applied to each bill.  Our experts’ firsthand knowledge of provider billing practices and techniques  combined with our processes, innovative technology, robust databases, and unique analysis methodologies enable our Nurse Auditors and Certified Coders to apply rules that prevent overpayment of inappropriate medical charges such as duplicate bills and charges, unbundling, up-coding and medical coding mistakes.

We also negotiate Out-of-Network bills and have a dedicated team that focuses on large hospital bills to maximize savings and minimize disputes.

Network penetration and savings are at the heart of our custom bill review solutions, but they are just the beginning.  We offer a comprehensive, end-to-end solution that includes:

  • Service Bureau
    • A virtual mailroom for bill intake/scanning
    • KFI/Data Entry
  • Fee Schedule and Rules Application
    • Multiple levels of auditing
    • RN Complex Bill Code Review
  • PPO Fusion Network Optimization
  • Electronic payment issuance

Our flexible approach also means that we can apply only the components you need to round out your overall process.

Adjusters and risk managers can easily access, review and approve bills  through our Zebra user interface. Zebra’s custom dashboard tool provides full-time transparent communication about what’s happening with your bills and claims, including:

  • Savings by type/category of bill, state and network
  • Calendar view of billing activity on each claim to track treatment and providers and to understand treatment patterns
  • Ability to custom filter, sort and analyze data
  • Real-time status of every bill in the system

At CareWorks, we start with an effective bill review process.  Then we add superior technology, expertise and innovation to provide a customized and comprehensive bill review solution that:

  • Simplifies your in-house workflow
  • Accesses the most efficient and cost-effective networks
  • Maximizes savings
  • Pay bills correctly and on time
  • Communicates efficiently with providers to resolve questions or disputes
  • Gives you easy access to all your data for full transparency and better management
  • Turn-around time

Our Services

CareWorks delivers the widest array of services, customizable to fit each client.

  • Access to multiple, tiered, global and specialty PPO networks
  • Client and state-specific network selection based on historical experience and analytics
  • Access to multiple out-of-network specialty review groups, including binding out-of-network negotiations
  • Online adjuster approval of bills
  • Flexible auto-approval options
  • Private labeling
    • Toll-free provider assistance line
    • Proprietary medical bill review and auditing, including:
      • Fee schedule and rules adjudication
      • Level 1 auditing of bills with simple fee schedules and rules to validate data entry and suspected duplicate validation
      • Level 2 auditing including RN review of complex medical bills
  • Multiple, time-saving electronic options, Including:
    • Data capture from the bill into the bill review system through mailroom outsource/claim indexing services
    • Image and e-bill receipt
    • Extensive reporting tools
    • Comprehensive status and outcome reports
    • Direct analysis of bottom-line savings
    • Duplicate detection on new and transferred history
    • Automated payment capabilities
      • Electronic fund transfers
      • virtual card solution (sending payments directly to providers via their credit card system)
      • eChecks/online checks

A truly effective managed care solution

Our comprehensive array of managed care services deliver the right results for our clients and their injured workers.

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