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Bill Review Software

Xybion Health’s flexible, rules-based bill review engine  with the power of our unique, web-based platform will ensure best-in-class accuracy and turnaround time. The software platform is integrated in real-time with the latest fee schedules,  state-specific rules, clinical best practice guidelines and EDI connectivity to provider networks.

Bill Review Platform

 

Xybion Health’s Bill Review Offering includes:

  • Fee schedule values
  • Out of network negotiation
  • PPOs, MPNs and other specialty network connections
  • Client specific business rules
  • Standard and custom reporting, data analytics and business intelligence
  • Accept bills in multiple formats (fax, mail, electronic)

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More than a fee scheduler

The configuration of the bill review system is a consultative process. Our experience is that many clients have a broad range of claims philosophies and that while state legislatures and state regulators make rules, occasionally the state courts differ when litigation occurs. Many aspects of medical bill adjudication are option driven with almost infinite possibilities for custom configuration.

  • Appropriateness of care – That is, does the treatment or service match the diagnosis? Also, the system reviews for whether a particular type of provider is allowed to invoice for the service billed. Example – A Registered Physical Therapist may not bill for a physician office visit.
  • Unbundling – On occasion, a provider will invoice separately for a service or supply that was billed under a “global” code. Since the supply or service was already allowed under a previous billing the “unbundled” code should be denied.
  • Duplicate billing – We will identify and deny payment for services or supplies that duplicate previous charges.
    Utilization Review – While payment may not be denied based solely upon over utilization, a warning may appear on the EOB when treatment exceeds that which other patients with the same injury have received. This warning alerts both the provider and the adjuster to potential over treatment and requests objective documentation from the provider.
  • Level of Service – Many times providers will submit billing for a level of service that does not correlate to the severity of the injury. For example when the diagnosis of sprains and strains of the neck (ICD-9 847.0) is submitted along with a high level of service (CPT 99215) the service would be reviewed as 99214 or 99213. The service 99215 requires a diagnosis that carries a high level of medical decision-making and a high risk of death or permanent disability and is therefore inappropriate.

MBR Process

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