Medical Claim Review

The Key to Controlling Costs

When it comes to hospital bills, if you've been billed, it's a safe bet that you've been overcharged. As was reported in the Wall Street Journal, over 95% of all hospital bills contain errors. Of these errors, 85% are in favor of the hospital. Each year payers reimburse hospitals billions of dollars for services that were never rendered.

The AkesoCare Difference

Most TPAs have invested significant amounts of money incorporating claims auditing software into claims systems. This has been very successful in detecting those situations that can be identified from a UB or HCFA claim form. AkesoCare’s claim review takes it a step further by examining the details behind the UB or HCFA. We review all medical records to assure that all the services billed were actually delivered and delivered in the quantities billed.

AkesoCare reviews:

  • Physician orders against actual services billed
  • Medication administration log to assure prescribed meds were administered AND the dosage billed matches the dosage administered
  • Operative reports if the supply/implant charges are excessive
  • Each service for appropriateness/medical necessity
  • Experimental/investigational treatment review
  • Chemotherapy/radiation therapy protocols and audit
  • Pharmaceutical regimen appropriateness
  • ER reports for accident details when Motor Vehicle Accident (MVA) or other accidents involved to determine plan liability and/or subrogatable issues

AkesoCare recommends that all claims between $20,000 - $50,000 be evaluated for review potential. We also recommend that all claims over $50,000 be subject to a full claim review. We only charge a fee when savings are realized. If we cannot deliver actual savings to you and your client, there is no charge!

The Bottom Line:

AkesoCare takes the claim review process deeper than an automated claims process could undertake. Our auditors review the details found in the support documentation to the UB and HCFA claim forms to assure that you and your clients only pay for the services that were actually rendered.

AkesoCare Medical Review Success Stories:

Success #1:

  • $130,000 Claim; terminal cancer; patient initially admitted with shock and disorientation
  • Hospitalization for 18 days; including 2 surgeries
  • No apparent problems with UB or itemization
  • After medical record review, discovered patient had fallen in hospital while unsupervised
  • Fall directly led to $119,000 of charges
  • Based upon AkesoCare review, it was recommended that payer reimburse facility $11,000
  • Audit Savings:  $119,000

Success #2:

  • $128,000 claim; Pneumonia admission
  • Seven day LOS
  • Of the claim, $114,000 were pharmacy charges
  • No apparent problems with UB or itemization
  • After review, discovered error in the facility’s pharmaceutical database resulting in overcharge
  • Actual pharmacy charges should have been $14,000
  • Based upon AkesoCare review, it was recommended that payer reimburse facility $28,000
  • Audit Savings:  $100,000