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Audit and Negotiation

Audit

Repatriation Medical Management delivers a custom and comprehensive auditing process that is transparent to our clients. We scrutinize the prices being charged by the hospital and medical provider by comparing the prices to what is considered customary to Medicare, Worker’s Compensation and UCR (Usual, Customary and Reasonable).  We hold healthcare providers accountable to deliver medical bills that are accurate and fair.

Medical Records Review


The general rule of thumb provides that the greater the amount in charges, the more room for inconsistencies between the patient's medical record and final medical bill. Repatriation Medical Management has developed a program that records procedures and treatments based on daily reports provided by hospital case management, thus reducing the auditing process.  During the utilization and care management phase, Repatriation Medical Management will request a summary of charges on day 3, 5, and 10 of the hospital stay.  At this time, we verify charges:


  • Services were delivered by the institution in compliance with the physician's plan of treatment.*
  • Services are documented in health or other appropriate records as having been rendered to the employee.
  • Charges are report on the final bill correctly.


We see no reason why a member should pay higher rates than what an insurance company would pay.


Billing Error Review


RMM's clinical team performs a detailed, line-by-line analysis for the following errors:

  • Non-procedural or medical related items that should not be billed to an patient
  • Double billing (compare charges to the medical records)
  • Mismatched coding*
  • Unbundled charges
  • Upcoding
  • Unsupported or undocumented charges
  • Hospital Acquired Infections


*Claims are scrubbed to ensure that treatment codes are matched with the diagnosis related code (DRG).  In appropriate situations, staff may provide supplies or follow procedures that are in accordance with established institutional policies, procedures include items that are not documented in a medical record but are reference in medical or clinical policies.


Reasonable and Customary Review


Unfortunately, there is no universal standard for determining usual and customary pricing for hospitals.  RMM utilizes numerous sources such as national hospital pricing indexes, industry publications, charge master data, and CMS data.


Provider Sign-Off


RMM reviews the claim for overcharges and errors and presents the results to the provider prior to reimbursement.  All negotiations are secured with a signed agreement by the provider, which precludes patient balance billing and a risk of appeal. 

Negotiation

Whenever possible, Repatriation Medical Management will ask for a Worker’s Compensation Rate in advance of any procedure or service.  Sometimes circumstances make it difficult, or impossible, to negotiate medical bills in advance.


Repatriation Medical Management will look up the fair market price for care that is received.  This is the amount that providers regularly accept from insurance companies as payment in full, and the amount that we will aim for in the negotiation phase.