Bill Review FAQ’s:
State Fee Schedule Adjudication (Including applicable rules and regulations)
Bill review is not a commodity. Bill review software alone cannot properly adjudicate your billed charges, even with a “robust” application. Bill review requires sophisticated software and seasoned analysts that understand the “Rules and Regulations” that govern how a CPT code is applied. Our software incorporates an extensive set of automated rules for each state; when complex, unusual, hospital and by report charges are entered, these bills are pended for Specialty Bill Review (SBR). Our analysts average over 12 years of bill review experience and trained to identify areas prone to incorrect and abusive billing.
Level Service Review
The 80/20 rule applies to your medical charges. Our “Pended” bill status allows our seasoned analysts to triage certain bills to criteria developed over 12 years of actual experience. There are thousands of CPT codes and a small percentage of these codes affect the majority of your medical costs. The codes/bills are categorized according to specialty and reviewed by in-house analysts or to a contracted expert for their expertise. The combination of human skill and automated rules red flag unbundled and duplicate (full, partial), and more importantly non-network and other charge types to provide our clients with a review process that ensures a proper, defensible and best net value to our clients. This best net value approach is the benchmark whereby our customers see value. Our results have been “certified” by outside consultants that measure and quantify workers’ cost containment companies. Definiti has entered into “performance guarantees” with certain clients and have met and exceeded our benchmarks.
This approach provides consistent accurate and comprehensive edits to your charges for savings usually missed by a “robust” computer application or data entry personnel.
Care Management FAQ’s:
Q. Why would I use telephonic case management?
A. Telephonic case management manages and controls the costs on each claim until return to work or claim resolution. The goals of telephonic case management are to ensure an appropriate treatment plan and a safe, early return to work, through effective negotiations with the provider, the employer and the injured worker.
Q. When would I use telephonic case management?
A. Telephonic case management is ideally used in the following scenarios:
- Catastrophic or severe injuries (burns, spinal cord injuries, brain injuries, amputations)
- All lost time claims—whether lost time occurs initially or a medical only claim converts to lost time
- Medical only claims with pending surgery
- Claims with multiple diagnoses
- The injured worker has multiple claims with the same employer or a concurrent employer
- Claims with multiple providers
- Claims with pre-existing conditions, such as diabetes that may complicate recovery
- Re-injury of the same body part
- Injuries that occur within the first 90 days of employment
- Injured workers that appear to be non-compliant
- Diagnostic referrals, PT/OT/chiro referrals, referrals to a specialist
A. All of Definiti’s nurse case managers hold a minimum of an RN or LPN degree. Many have advanced degrees and additional certifications with varied clinical experience in both hospitals and outpatient settings. Our director of medical management also has experience as a claims manager which brings another level of expertise to case management.
Q. Why Definiti?
A. Definiti has a dedicated team to ensure timely implementation of your account. We work closely with you to determine your needs and formulate a program that works for you. We offer embedded utilization review in our case management program which ensures oversight of the treatment plan and is included in the TCM charge.
Definiti uses nationally recognized, evidence based guideline criteria, such as ACOEM (American College of Occupational and Environmental Medicine), ODG (Official Disability Guidelines), MDA (Medical Disability Advisor), as well as various state mandated guidelines. Our Utilization Review process adheres to all state requirements as well as URAC standards.
Q. How will the Utilization Review decisions be communicated to bill review?
A. After documenting all medical treatment requests according to state mandated guidelines or URAC processes, our UR/CM application transmits all determinations (authorization, non-authorization or modification of the treatment request) to our bill review system to support accurate adjudication and repricing of the bill.
Catastrophic Care/DME FAQs:
Q. If I place and order for supplies today, how long will it take for me to receive them?
A. With Definiti, if you place an order before 2:00pm you will receive your products the next day.
Q. How long will my wheelchair last? How often should I replace my wheelchair?
A. Depending on the usage of your wheelchair, wheelchairs last approx 5 years.
