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FREQUENTLY ASKED QUESTIONS

CLASSIFICATION,
EDITS, & AUDIT

Medical claims and bills are riddled with errors.  WellRithms' CEA scrubs each bills to ensure accuracy.

  • What percentage of medical bills contain errors?
    90% of medical bills contain errors (Becker's Hospital Review).
  • How does WellRithms detect medical billing errors and what processes prevent these errors from influencing reimbursement recommendations?
    WellRithms has built classification algorithms into its proprietary software so that the errors outlined above are detected and corrected prior to a physician review of the medical records. Furthermore, standard industry accepted edits, such a CCI (Correct Coding Initiative), are applied prior to repricing. If an individual provider is known for a specific type of upcoding, this will be flagged in our system for all future bills and repriced appropriately. Our algorithms are architected to find questionable, abusive, and fraudulent charges and is continually tuned and updated to catch and flag suspicious charges for physician review.
  • What are some examples of errors that WellRithms commonly identifies?
    WellRithms has found one of the most common errors on a bill is inaccurate Place of Service (POS). Misidentifying an Ambulatory Surgery Center (ASC) as a hospital, or a doctor’s office as a surgery center, can greatly influence the reimbursement. WellRithms has found this to be the most common error on a bill. It is important to understand that repricing a claim through a PPO, RBP, or another cost containment strategy will not identify this error thus resulting in significant overpayment. Another common error is found through a disparity between the medical records and the billing statement: Services added that were never performed Implant devices billed that were never used Severity levels that have been inflated Bundled codes billed separately (sometimes on an entirely separate bill to fly under the radar) Services billed that are not medically appropriate for the diagnosis and procedures provided Grossly inflated provider charges/costs in comparison to what they have reported to the government Suspicious charges Drug choices and costs Supplies used and costs Implant appropriateness and costs Excessive charges in surgery
  • Who is reviewing my medical bill today?
    If WellRithms is not reviewing your bills, likely no one. While state fee schedules and traditional bill review systems are designed to identify clinical edits, unbundling tricks, and medically unlikely edits, they are not equipped to anticipate creative billing schemes. Comprehensive bill review is not viewed as an essential component of claims processing or PPO network reductions. Nurses may review certain cases, looking at the overall diagnosis and treatment, but this only scratches the surface on the amount of errors, abusive billing practices, and fraudulent activity that can be buried in a bill. The validity of charges is paramount to any defense of the bill and significantly influences any balance billing.

SUSTAINABLE CLAIM
& BILL PRICING

In addition to errors on medical bills, charges are often inflated.  WellRithms' repricing methodology is fair for providers and payers. 

  • What percentage of medical bills contain errors?
    90% of medical bills contain errors (Becker's Hospital Review).
  • How does WellRithms detect medical billing errors and what processes prevent these errors from influencing reimbursement recommendations?
    WellRithms has built classification algorithms into its proprietary software so that the errors outlined above are detected and corrected prior to a physician review of the medical records. Furthermore, standard industry accepted edits, such a CCI (Correct Coding Initiative), are applied prior to repricing. If an individual provider is known for a specific type of upcoding, this will be flagged in our system for all future bills and repriced appropriately. Our algorithms are architected to find questionable, abusive, and fraudulent charges and is continually tuned and updated to catch and flag suspicious charges for physician review.
  • What are some examples of errors that WellRithms commonly identifies?
    WellRithms has found one of the most common errors on a bill is inaccurate Place of Service (POS). Misidentifying an Ambulatory Surgery Center (ASC) as a hospital, or a doctor’s office as a surgery center, can greatly influence the reimbursement. WellRithms has found this to be the most common error on a bill. It is important to understand that repricing a claim through a PPO, RBP, or another cost containment strategy will not identify this error thus resulting in significant overpayment. Another common error is found through a disparity between the medical records and the billing statement: Services added that were never performed Implant devices billed that were never used Severity levels that have been inflated Bundled codes billed separately (sometimes on an entirely separate bill to fly under the radar) Services billed that are not medically appropriate for the diagnosis and procedures provided Grossly inflated provider charges/costs in comparison to what they have reported to the government Suspicious charges Drug choices and costs Supplies used and costs Implant appropriateness and costs Excessive charges in surgery
  • Who is reviewing my medical bill today?
    If WellRithms is not reviewing your bills, likely no one. While state fee schedules and traditional bill review systems are designed to identify clinical edits, unbundling tricks, and medically unlikely edits, they are not equipped to anticipate creative billing schemes. Comprehensive bill review is not viewed as an essential component of claims processing or PPO network reductions. Nurses may review certain cases, looking at the overall diagnosis and treatment, but this only scratches the surface on the amount of errors, abusive billing practices, and fraudulent activity that can be buried in a bill. The validity of charges is paramount to any defense of the bill and significantly influences any balance billing.

SHIELD INDEMNIFICATION

WellRithms Shield is designed to indemnify our clients from claims and bills that significantly impact their budget.  

  • What percentage of medical bills contain errors?
    90% of medical bills contain errors (Becker's Hospital Review).
  • How does WellRithms detect medical billing errors and what processes prevent these errors from influencing reimbursement recommendations?
    WellRithms has built classification algorithms into its proprietary software so that the errors outlined above are detected and corrected prior to a physician review of the medical records. Furthermore, standard industry accepted edits, such a CCI (Correct Coding Initiative), are applied prior to repricing. If an individual provider is known for a specific type of upcoding, this will be flagged in our system for all future bills and repriced appropriately. Our algorithms are architected to find questionable, abusive, and fraudulent charges and is continually tuned and updated to catch and flag suspicious charges for physician review.
  • What are some examples of errors that WellRithms commonly identifies?
    WellRithms has found one of the most common errors on a bill is inaccurate Place of Service (POS). Misidentifying an Ambulatory Surgery Center (ASC) as a hospital, or a doctor’s office as a surgery center, can greatly influence the reimbursement. WellRithms has found this to be the most common error on a bill. It is important to understand that repricing a claim through a PPO, RBP, or another cost containment strategy will not identify this error thus resulting in significant overpayment. Another common error is found through a disparity between the medical records and the billing statement: Services added that were never performed Implant devices billed that were never used Severity levels that have been inflated Bundled codes billed separately (sometimes on an entirely separate bill to fly under the radar) Services billed that are not medically appropriate for the diagnosis and procedures provided Grossly inflated provider charges/costs in comparison to what they have reported to the government Suspicious charges Drug choices and costs Supplies used and costs Implant appropriateness and costs Excessive charges in surgery
  • Who is reviewing my medical bill today?
    If WellRithms is not reviewing your bills, likely no one. While state fee schedules and traditional bill review systems are designed to identify clinical edits, unbundling tricks, and medically unlikely edits, they are not equipped to anticipate creative billing schemes. Comprehensive bill review is not viewed as an essential component of claims processing or PPO network reductions. Nurses may review certain cases, looking at the overall diagnosis and treatment, but this only scratches the surface on the amount of errors, abusive billing practices, and fraudulent activity that can be buried in a bill. The validity of charges is paramount to any defense of the bill and significantly influences any balance billing.
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