Review Audit and Credit (RAC)
Paying medical bills at fee schedule rates without reviewing the bill for coding errors, and abusive and fraudulent billing is a costly mistake. Historical billing abuse patterns seen under DRG-based inpatient fee schedules or an outpatient CPT code-based fee indicate that some health care providers may inflate reimbursement with coding that exaggerates the complexity of the services actually provided.
The Qmedtrix methodology combines mathematical algorithms, standardized medical billing rules, accepted medical billing practices and historical payer and provider data to track and evaluate the level of charges and appropriateness in coding, and evidence of abusive billing patterns. These patterns can be used to identify potential overpayments.
BillChek reviews the treatment and diagnostic services listed on a medical bill and flags DRG and CPT codes prone to billing errors, fraud, and abuse. Any errors, fraud, and abuse that have resulted in overpayment of medical charges reimbursed under fee schedule rates are eligible for a credit against future payments issued to the same provider. The savings is defined as the difference between the original amount paid and overpayment identified by BillChek.
Concurrent review of pre-payment bills not only allows Qmedtrix to identify errors and abusive billing patterns in the current bill, but also to apply any outstanding credits towards a provider’s future bills that are open for taking the credit. This service is available for Inpatient bills in California, Texas, Colorado and Georgia.