MEDICAL BILL ANALYSIS AND REVIEW
A method and business technique for reviewing medical service provider bills, recalculating and providing payment recommendation to a paying party for the bills. The method includes analyzing medical bills and determining erroneous and inappropriate charges on bills. The method provides a payment recommendation using multiple databases and sophisticated mathematical modeling that includes one or more of the following: a medical service provider's actual cost of delivering the medical services provided; the average profit-margin of that provider, an average profit margin of comparable medical providers in an area, other industry-specific profit-margin benchmarks; an average acceptable payment by medical service providers in the area for comparable services; payment rates negotiated by large health insurers and managed care organizations; and other industry benchmarks for reasonable payment for comparable services.
1 . A computerized medical billing review system for reviewing and recalculating a previously provided medical bill for a medical service/medical supply charge, the medical service/medical supply charge being generated by a medical service provider in a geographical region, the system comprising:
a data input device configured for entering information from the previously provided medical bill;
a computer system readable data storage medium configured to store the information from the previously provided medical bill;
a computer system being electronically coupled to the computer system readable data storage medium; and
a plurality of instructions stored on the computer system readable data storage medium wherein the instructions are configured to cause the computer system to:
identify erroneous medical service/medical supply charge from the previously provided medical bill;
calculate an estimated cost of the medical service/medical supply charge based on one or more of the identified erroneous medical service/medical supply charge being excluded from the previously provided medical bill;
determine whether the previously provided medical bill includes one or more medical service cost/medical supply charge making it eligible for performance of a substantive analysis based on predetermined criteria;
when it is determined that the previously provided medical bill is not eligible for performance of a substantive analysis then initiate informing a reimbursing party;
when it is determined that the medical bill is eligible for performance of the substantive analysis, then perform the substantive analysis of the medical service/medical supply charge on the information from the previously provided medical bill, the substantive analysis utilizing updated data from a plurality of data bases including:
a) a jurisdiction specific legal and regulatory requirements data base;
b) an industry reference data base including data from previously calculated costs of providing the medical service/medical supply charge by comparable medical service providers in the geographical region; and
c) a database containing a compilation of mathematical analysis results of geographical region specific and medical procedure specific data from previously analyzed medical bills;
determine a recalculated cost for the medical service/medical supply charge provided by the medical service provider based on a comparison with the information from the previously provided medical bill with the results of the substantive analysis and the estimated cost when the previously provided medical bill is determined to be eligible for the substantive analysis; and
provide a payment recommendation for the previously provided medical bill based upon the recalculated cost.
2 . A computerized medical billing review system for reviewing and recalculating a previously provided medical bill for a medical service/medical supply charge, the medical service/medical supply charge being generated by a medical service provider in a geographical region, the system comprising:
a data input device configured for entering information from the previously provided medical bill;
a computer system readable data storage medium configured to store the information from the previously provided medical bill;
a computer system being electronically coupled to the computer system readable data storage medium; and
a plurality of instructions stored on the computer system readable data storage medium wherein the instructions are configured to cause the computer system to:
determine whether the previously provided medical bill includes one or more medical service cost/medical supply charge making it eligible for performance of a substantive analysis based on predetermined criteria;
when it is determined that the previously provided medical bill is not eligible for performance of a substantive analysis then initiate informing a reimbursing party;
when it is determined that the medical bill is eligible for performance of the substantive analysis, then perform the substantive analysis of the medical service/medical supply charge on the information from the previously provided medical bill, the substantive analysis utilizing updated data from a plurality of data bases including:
a) a jurisdiction specific legal and regulatory requirements data base;
b) an industry reference data base including data from previously calculated costs of providing the medical service/medical supply charge by comparable medical service providers in the geographical region; and
c) a database containing a compilation of mathematical analysis results of geographical region specific and medical procedure specific data from previously analyzed medical bills;
determine a recalculated cost for the medical service/medical supply charge provided by the medical service provider based on a comparison with the information from the previously provided medical bill with the results of the substantive analysis when the previously provided medical bill is determined to be eligible for the substantive analysis; and
provide a payment recommendation for the previously provided medical bill based upon the recalculated cost.
3 . The computerized medical billing review system of claim 2 , wherein the plurality of instructions stored on the computer system readable data storage medium are further configured to cause the computer system to:
identify erroneous medical service/medical supply charge from the previously provided medical bill; and
calculate an estimated cost of the medical service/medical supply charge based on one or more of the identified erroneous medical service/medical supply charge being excluded from the previously provided medical bill; and
determine the recalculated cost for the medical service/medical supply charge provided by the medical service provider based on both a comparison with the information from the previously provided medical bill with the results of the substantive analysis when the previously provided medical bill is determined to be eligible for the substantive analysis and the estimated cost.