Medical cost Containment
Medical Bill Negotiation
Medical Bill Negotiation SFUR has successfully negotiated medical bills on behalf of payers for over 20 years. The utilization of practicing physicians typically with medical coding experience has been the single largest factor in our success with medical bill negotiation. Over 70% of the time, SFUR achieves success through this process. Our fee structure can either be based on a fixed fee or percent of the savings we achieve. Because of the 20 plus year history, SFUR has develop strong working relationships with various hospitals and health systems throughout the United States.
Summary
Medical Bill Negotiation is deployed on behalf of payers both in the workers compensation and heath plan market place. The single biggest factor driving SFURs is the review of the medical records by board certified physicians that are also credentialed in medical coding. Without the medical charts, SFUR is not able to provide this service.
SFUR charges a percent of savings for this service. The return on investment is over 1,500% to our payer customers.
Example
With the real world example below SFUR achieved a savings of $37,863 off an allowed amount of $58,863 because of the DRG changing to 482 from 48.
The patient was admitted for treatment of a hip fracture.
The submitted DRG 481 – HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC reflects the diagnosis of acute/chronic renal failure as a complicating condition. Although the patient may have had a prior history of renal insufficiency, there is no clinical documentation in the records submitted which would indicate that this prior condition was relevant to this care episode.
Review of the records does not indicate that the patient had any specific diagnostic evaluation monitoring or treatment for this chronic condition or that it impacted the length of stay. Accordingly, these secondary diagnoses should not constitute a complicating condition and the DRG should be adjusted to:
- 482 – HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC
Recommendation:
The allowance should be adjusted to reflect DRG 482 rather than DRG 48