40+ Years’ Experience: Provider Bill and Medical Bill Auditing, Hospital-Based and Office-Based

Medical Practice Bill Auditing

Obtain audit services that go far beyond standard medical bill auditing—re-pricing and unbundling software programs and achieving audit results that are medically valid and defensible. PPS proprietary auditing procedures extend further:

• We detect and address all areas of potential errors, including coding errors, unbundling, code upgrading, fee schedule non-compliance, R&C excessive billing, and fraud.
• Specialists perform all audits and directly oversee the fee schedule auditing programs.
• In addition to accessing the latest technology and resources for fee-schedules and coding principles, PPS auditors apply extensive CPT and ICD-9-CM experience and a high level of clinical expertise to each audit, insuring a more accurate medical and financial outcome than would be available with auditing software alone.
• To prevent balance billing or disputes with the client or insured, we also finalize each audit with the provider after reaching full agreement on the medical or coding issues applicable to the bill, as well as the amount to be paid.

Provider Bill Auditing

PLATINUM Physician Services, Inc. has 40 years of auditing experience with insurance carriers, TPAs and self-insureds. Our process is different because we focus on the clinical as well as coding aspects of each bill. We audit bills in worker’s compensation, auto no-fault and bodily injury, liability and litigation, health insurance, fraud and S.I.U. claims. Typical provider bill auditing findings include:

• Undocumented or unsupported charges
• Billing for unrelated charges
• Billing for non-certified treatment
• Level of care/length of stay issues
• Medical necessity issues
• Unbundled charges
• Duplicated services or charges
• Coding and billing calculation errors
• Applicable state fee schedule compliance
• Billing above R&C or contracted rate
• Availability of discount in addition to audit findings

Our proprietary auditing procedures detect and address all areas of potential errors. In addition to accessing the most up-to-date resources for fee schedules and coding principles:

• PPS auditors apply extensive CPT and ICD-9-CM experience and a high level of clinical expertise to each audit, insuring a more accurate medical and financial outcome than would be available with auditing software alone.
• Reviews and audits are completed on a timely basis to in order to preserve applicable PPO or other fee discounting arrangements.
• To prevent balance billing or disputes with the client or insured, we also finalize each audit with the provider after reaching full agreement on the medical or coding issues applicable to the bill, as well as the amount to be paid.

Forensic Practice Auditing

Working in conjunction with the review team, PLATINUM Physician Services, Inc. can provide targeted medical bill auditing to help identify and document excessive or fraudulent provider billing. Our qualified auditors utilize real world experience and widely accepted resources in analyzing specific billing trends with certain providers. We can also conduct audits at the provider’s location, where we can evaluate the clinical setting to determine whether the billed treatment was actually rendered and whether the office or clinic is qualified and has the actual staff and equipment to render the treatment.

Targeted Areas for Auditing include:

• Excessive billing or treatment
• Medical coding maximization
• Inappropriate diagnostic codes
• Causality issues
• Billing above R&C
• Multiple modalities and testing on every visit
• Lack of medical documentation
• Repetitive "boilerplate" medical reports
• Billing out of specialty

PPS audits are finalized with a detailed report, listing all findings and recommending appropriate levels of payment for services actually rendered and related to the claim.