Third-Party Review: Auto and Liability

We are the best resource to help formulate your demand package. An accurate and reasonable measure of what is owed on past and future medicals is needed for a demand package. Upon request for review PRIZM will:

  • Ensure bills are coded properly
  • Determine accurate UCR, Fee Schedule or Medicare values
  • Identify inappropriate billing e.g., upcoding, unbundling and balance billing
  • Provide values to assist settlements

PRIZM provides clients with detailed data analytics and profile in a comprehensive report.

The PRIZM Difference

Certified Professional Coders (CPC) or Nurse Certified Professional Coders conduct the audit. We provide detailed, fact-based narrative for each deduction analyzed. Coders can present as expert witnesses to defend all report findings. 

Bill Review Triggers

  • Improper coding or format
  • Unmanaged or unverified medical bills
  • High ambulatory surgery center bills
  • No medical bills in the file only procedures and reports

Tier 1: Preliminary Review

  • Key medical bills.
  • Produce Explanation of Benefits (EOBs).
  • Detail provider charges and reductions.
  • Identify and remove duplicates.
  • Zero out all charges prior to date of loss.
  • Provide top and bottom line demand values

Tier 2: CPC Review

  • Complete Tier 1.
  • Review of medical records and bills by CPC.
  • Complete summary report by CPC.
  • Provide testimony as needed.

Tier 3: Nurse CPC Review

  • Complete Tier1.
  • Review of medical records and bills by a Nurse CPC.
  • Complete summary report and medical necessity comments.
  • Provide testimony as needed.

Physician Review or Exam

  • Identify pre-existing conditions.
  • Determine medical necessity and complexity.
  • Use findings to revise bill review totals.

 

 


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