Client Solutions

Bill Review Overview

Combining industry-leading bill review technology with highly trained and experienced analysts gives Definiti’s clients a competitive edge. Bill review is not simply automation or a data entry transaction to us. While technology can provide speed and efficiency by automating state fee schedule rules and regulations, it’s our bill review analysts who rigorously evaluate each medical bill along with corresponding documentation to ensure we achieve the best possible results. Our primary focus is to deliver the “Best Net Value” while maintaining a superior level of compliance, accuracy, and efficiency.

Specialty Bill Review

Specialty Bill Review (SBR) – For services not covered by state fee schedule or PPO, our SBR program ensures our clients are only liable for the “fair and reasonable” payment of medical bills.

  • Fair value pricing
  • Complex file review
  • Out of Network negotiations
  • Inpatient/Outpatient line item audit

Once a bill has been audited by our team for accuracy (i.e. the service billed is consistent with service rendered), the service is benchmarked against several accepted payment methodologies. This allows us to establish a base allowance that is then used for negotiation or payment recommendation. Our Specialty Bill Review program generates savings ranging from 55% to 85% off billed charges.

National Access – Preferred Provider Organizations (PPO)

Definiti offers a comprehensive and highly configurable network solution that provides clients with access to over 20 leading national and regional PPO networks.

Using a best-of-class approach, Definiti provides clients with analytical support using our bill review platform’s network optimization tools and reports. Actual client data can be used to obtain an objective comparison of multiple network configurations and tiers, with the primary goal of achieving optimal network savings and penetration. As networks are assessed objectively, using the same criteria, biases and inconsistencies potentially introduced with network self-analysis are eliminated.

PPO network offerings can be quickly and easily customized by the client, geographic location, bill type, and hierarchy (primary, secondary, tertiary, etc.). Additionally, the automated application of contractual network discounts is inherent within the bill review system to ensure maximum savings below fee schedule.

Ancillary Networks

In addition to providing conventional PPO network offerings, Definiti also offers access and connectivity to multiple ancillary networks, including:

  • Imaging and Diagnostics
  • PT, Chiro, OT, FCE
  • Implants
  • DME
  • Transport and Translation
  • Home Health
  • Pain Management and Skilled Nursing
  • Dental
  • Catastrophic

A key feature of this offering is not only the Prospective automation of ancillary network rates but the Retrospective automation of rates, including access to provider “leakage” reports that can be used to identify and track network providers billing out-of-network.

Technology Solutions

Definiti’s Medical Bill Review program is powered by a proven, industry-leading bill review system that utilizes rules-based technology to ensure a systematic and cost-effective solution to your medical cost containment needs. Our comprehensive bill review process combines this sophisticated application with the expertise of our highly skilled and tenured staff of professional employees to assure compliance, accuracy, and efficiency while maximizing client savings.

Bill Review Software Features:

  • Timely and accurate State Fee Schedule and UCR updates
  • Robust bill review rules engine that automates bill review decisions consistent with state-mandated fee schedule rules and regulations
  • Automated application of PPO, Ancillary, and PBM network rates
  • Comprehensive detection of duplicate provider billings, including enhanced configuration options
  • Bill Review integration of NCCI, including Medically Unlikely Edits to enforce national correct coding methodologies
  • Integration of Utilization Review decisions and nurse treatment plans to facilitate a collaborative system for utilization control and cost containment
  • A flexible workflow rules engine that allows customization tailored to meet client business objectives
  • Fully-integrated and customizable interfaces with multiple claims management systems, including:
    • Claims
    • Vendor
    • Payment
    • Post-Payment (Paid date file)
  • Web-portal access to numerous standard reports, in addition to Ad Hoc reporting capabilities to address custom reporting requirements
  • Medical EDI State reporting and NCCI Medical Data Call reporting
  • Web-portal access to streamline decision making and allow adjusters to effectively review, edit, approve and deny medical bills pre-bill review and/or post-bill review
  • Single Sign-On (SSO) capabilities
  • Bill Review integration with Medical Treatment Guidelines (ACOEM, ODG), including CPT/Diagnosis color coded validation
  • Fully-integrated electronic medical bill intake services, including:
    • Image scanning
    • Bill indexing
    • OCR and/or keyed data
    • Data validation
    • Document storage
  • E-Billing connectivity with multiple Clearinghouses to ensure compliance with jurisdictions legislating electronic billing standards
  • Automated application of nationwide MPN/HCN/MCO provider networks with configurable payment options

UR Integration

Definiti offers seamless integration of medical bill review and utilization review to facilitate a collaborative system for utilization control and cost containment. Our bill review platform automatically links third-party utilization review decisions, nurse treatment plans, pre-authorizations, and bill negotiations ensuring our clients only pay for approved medical services, resulting in more precise workers’ compensation medical bill re-pricing.

Features include:

  • Real-time utilization control and cost containment of your claims by allowing nurses to establish appropriate treatment parameters and discounts via treatment plans.
  • Increased efficiency through the elimination of manual intervention and review of UR decisions during the medical bill review process, unless required.
  • Minimized financial leakage as a result of missed UR savings.
  • Electronic integration with other UR systems in which data can be electronically uploaded via EDI import.

Pharmacy Benefit Management- DefinitiRx

DefinitiRx is an innovative, forward-thinking, National Pharmacy Manager, serving the Workers Compensation, Longshore/Maritime, Occupational Accident industry and Auto. Since 2002, Definiti has been focused on providing the highest level of customer service with an internal mantra of “Customer for Life”. It is with that same level of commitment that we are delivering our new PBM services. With over 70,000 pharmacies in our national network we are here to help you reduce your prescription cost through an effective and well designed, PBM.

Benefit of DefinitiRx PBM Services Include:

  • State-of-the-art analytics and reporting capabilities
  • Robust processing and/or data capture platform
  • Comprehensive Clinical Management programs
  • Customer-focused Mail order pharmacy
  • Smart Specialty pharmacy programs
  • Interactive portal
  • Maximize clinical outcomes with drug utilization review programs
  • Earlier intervention on high-risk claim
  • Ensure clinically appropriate medications
  • Significant cost savings with robust in-network strategies
  • Fewer out-of-network and third-party bills
  • Individualized formularies
  • Retro program with Definiti’s bill review interface
  • First fill program
  • EDI/Eligibility portal capabilities
  • Access to Clinical Pharmacist

DefinitiRx offers Claim Adjusters, through our interactive portal, the ability to view the activity from start to finish. Our secure web interface is available 24/7 and allows claims handlers to submit referrals; assess utilization with powerful analytic tools; view, download or print reports; review claim history; and complete custom workflows.

Simply contact the Definiti RX Customer Care Center at 1-8-DefinitiRX (1-833-346-4847) to speak with a representative.

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Clients For Life

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