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Tools for the delivery of integrated health care
Continually soaring medical costs have made it absolutely necessary to
verify the necessity of treatment and the accuracy of medical bills
before payment is made.
• PrimeCare Health Services Group Inc.
utilizes a knowledge-based system which provides a cost-effective
approach to electronic medical billing review for insurance companies,
state agencies, third party administrators and
self-insured/self-administered companies. With PCHSGI Bill Review, we
have taken the best elements of many previous bill review products and
combined them into a powerful, new and easy-to-use system.
• Data Entry and Bill Review Program: The Data
Entry and Bill Review components are the heart of the PCHSGI Bill Review
system. These components include standard features that review for
unbundling of procedure codes, duplicate billings, compliance with
standard billing practices and appropriate levels of service. PCHSGI Bill
Review stores the patient's medical bill history, has complete
reporting capabilities and can transfer information to or from any
existing claims system.
• National UCR Database: This feature verifies
that your company is paying the appropriate amount for medical
procedures by using a national database of "reasonable and customary"
charges for medical services for those services that don't fall within
the standard medical fee guidelines according to each state.
• Fee Schedules: State-mandated fee schedules are
updated regularly so bills reviewed in designated fee schedule states
are up to date, including facility bills, DRG's, per diem and PPO
contracted rates that are at or below fee schedules.
• Utilization of Services: Alerts adjusters when
the duration of care or the number of visits billed exceeds the level
that appears to be reasonable when compared to other claimants with the
same diagnosis.
• Levels of Service: This component ensures that the treatment received by the patient is appropriate for the specific diagnosis.
• Treatment Evaluation: The treatment evaluation verifies that a certain procedure is appropriate when used with a specific diagnosis.
• Drugs and Supplies: This feature compares drug
and supply charges to the manufacturer's wholesale price and verifies
the suitability of a drug for the diagnosis.
• Additional Features: In addition to these
review elements, the PCHSGI Bill Review system is provided with the
following review capabilities: Bundling of unbundled procedures, level
of service review, appropriateness of service rendered, follow-up days
and many more features.
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