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Medical Bill Review Services

Bill review services entail an in depth audit of the health care provider bills through application of various fee schedule and usual and customary rates. In addition, the reduction based on Preferred Provider Organization (PPO) contracts or pre-negotiated rates are generated to maximize potential savings. Our staff is well trained and extensively exposed to different state guidelines and jurisdictions. Coupled with user-friendly software and decision management tools, our operations are extremely comprehensive and cost effective to ensure that savings are continually optimized. With our advanced software program, our staff has the capability to recognize even the subtlest inappropriate billing practices and loopholes. Unlike any other traditional bill review environment, our company utilizes published and reputable screening guidelines to effectively review unnecessary and over-utilization of services.

Mail-In Process

Onsite Bill Review

Supplemental Workforce

Non-Subscriber Re-Pricing

Retrospective Review Services

In an attempt to strike the balance between cost and quality of health care, the emphasis of reviewing services that have already been rendered continues to increase. In some states, the preclusion of many services from the pre-certification programs yield high costs on unnecessary services. Appropriate treatment patterns and nationally accepted medical standards are utilized to achieve the highest quality of medical service while minimizing cost. These key components have been implemented and initiated in an effort to reduce over-utilization of medical services. With this process, providers are highly encouraged to present treatment plans on a voluntary basis prior to rendering the service.


Complex Review Services

Our process allows the channeling of comprehensive bills for a thorough physician and/or nurse review based solely on medical necessity. The integration of our professionals consistently produces evidence-based medicine that positively impacts return to work objectives.


Utilization Management Services

One of the most effective tools available to ensure patients receive quality and necessary treatment is through a rigorous prospective program. Aside from our physicians' medical training and experience, determinations are based on nationally accepted medical standards. The collaborative effort in our Utilization Management team accounts for the highest standards of delivering necessary and appropriate care while containing cost yielding overall satisfaction from all parties involved.


Medical Administrative Services

Independent Medical Examination (IME)

Required Medical Evaluation (RME)

Designated Doctor Examination (DDE-Texas only)

Peer Review

Prospective Review for Medical Examination (PRME)

Functional Capacity Evaluation (FCE)

With minimal access to your bill review software and claimant file, we can easily fill out the appropriate forms on your behalf, send these forms to the appropriate state office, copy, process the records timely and track it to ensure that we are meeting the necessary guidelines. With IME/RMEs and FCEs, we can even set up the appointments for you and handle every correspondence via certified mail. We can even enter the results of the physician's evaluation in your software application to ensure seamless communication among Third Party Audit providers.

"Physician Executive Summary"... the Common Denominator for our Medical Administrative Services

Every record we send has the "RSL stamp", which seals the fact that we have sent a quality file for a physician's evaluation. In addition to the tedious task of file preparation, we take time to summarize all pertinent medical activities that have been performed to a claimant: Referrals and physician consultations, diagnostic tests, surgical procedure, physical therapy visits, prescriptions, Durable Medical Equipments (DMEs) whenever applicable. We understand the benefits of arranging reports sequentially. We realize the importance of file completeness. We pay attention to details. After all, the provider's report is as good as what we give them!


Levels of Disputes Services (Texas Only)

Medical Dispute Resolution Services

Medical Dispute Resolution is a program for prospective, concurrent and retrospective review and resolution of a dispute regarding health care treatment and services. With the changes that took effect on January 1, 2002 regarding Medical Dispute Resolution, our skilled personnel can process fee disputes that involves any of the following:

• Health care provider dispute of a carrier reduction or denial
• Employee reimbursement dispute
• Carrier refund
• Provider refund

Independent Review Organization Services

Any need for a resolution that involves prospective necessity (requires the review of the medical necessity of health care that requires pre-certification/pre-authorization or concurrent review) or retrospective necessity (review of the medical necessity of health care already rendered), is escalated to the Independent Review Organization (IRO) level. Because of the critical nature of the medical necessity being disputed, RSL meticulously reviews the claimant's record to include important documentation such as reports from IMEs/RMEs, DDEs, Peer Review, forms filed on claim disputes, pre-certifications/pre-authorizations to name a few. We factor in time sensitivity so that we also request for a check payment to include with our files prior to sending the record to the IRO.

Decision and Order Services

The Decision and Order resulting from the appeals process that involves compensability, medical necessity and medical fee disputes can be very tedious. At the RSL Group, we can perform retrospective payment based on the results of the hearing's Decision and Order. We understand the financial impact of non-compliance and its intricacies that is why we only have experts assigned to this specialized service to ensure that we act on these decisions timely. Our alliance with Hoffman Kelley guarantees that all documents stemming from Decision and Orders are responded to within legal parameters.


Compliance & Practices

With a trained workforce, we can easily identify areas that may potentially be a Compliance and Practices issue. Our extensive experience in bill review takes you to a level where your bills are processed according to state guidelines. This allows you to steer free from unnecessary fines, which translates to more bottom line savings. It also sets the stage for a successful onsite state audit. The importance of bill review can never be underestimated when it comes to Compliance & Practices. At the RSL Group, we do it right in the "front end" to make sure that you are in conformity with the rules and regulations.


Customized Services

What can we help you with? Our services can be tailored to your needs. Ask us how we have helped our clients.


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