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A number of years ago, PMG instituted medical bill review and utilization review services at our clients' request. Unsatisfied with current industry offerings, they asked that we build a process that would: (1) provide accurate and reliable adjudication of bills; (2) maintain a turn-around time of five days or less; (3) carry out coding and documentation reviews on each bill; (4) eliminate duplicate, overlapping or excessive payments; (5) provide data and standards for continuous utilization reviews; (6) minimize provider appeals; and (7) create a bridge to promote positive communications with providers.
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To date, the bill review with concurrent utilization review program has achieved unqualified success. Payer Return On Investment (ROI) is over 30 to 1, gross savings exceed 50%, utilization savings exceed 16%, turn-around times average 3 days and, of critical importance, medical providers indicate that they are very pleased with the results of the reviews and the clarity of the EOB reports, as evidenced by an appeal rate of less than 0.1% and significant positive anecdotal feedback from all concerned.
| PMG clients not only save money through consistent and accurate review of each bill, they also benefit from lower administrative costs associated with the handling, indexing and processing of bills. Depending upon a client's needs, PMG can accept bills in paper or electronic form, index the bills, review and re-price the bills, and then forward or electronically upload all necessary data to authorize and pay the bills, and issue appropriate explanations of medical benefit (remittance advice to the doctor or hospital as required by law).
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