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Services
DRG Validation
1. What size bills can we submit for DRG validation?
We prescreen all hospital in-patient claims that are paid on a
DRG methodology regardless of the itemized charge amount.
2. Is there a fee for DRG prescreening?
No, DRG prescreening is performed free of charge.
3. Can DRG claims be prescreened prior to payment adjudication?
Yes, DRG claims can be prescreened prior to payment adjudication.
Within 48 hours clients are notified of which claims are selected for DRG validation.
DRG claims post payment may also be reviewed for validation.
4. Is the DRG staff AHIMA credentialed?
Yes, all members of the DRG staff are AHIMA credentialed. The staff are Certified Coding Specialists and several members are also Registered Health Information Administrators. The DRG staff has over 45 years of validating DRG's & coding experience.
5. Are medical records requested for DRG validation?
Yes, medical records are requested for selected cases for DRG validation. If there is a high volume of DRG claims for validation, the review audit is performed on site at the hospital.
6. Briefly explain the DRG validation process?
The medical record is reviewed to verify the ICD9 diagnosis and procedure
codes for correct DRG assignment. The Certified Coding Specialist
utilizes client customized DRG coding software to ensure that the
selection of the correct principal diagnosis/procedure reflects the
clinical findings in the medical record. The hospital is contacted
with detailed correspondence regarding the adjusted DRG assignment.
The hospital representative signs the DRG finalization form agreeing
to the DRG adjustment.
7. Is medical record confidentiality maintained?
All of our staff are required to sign Privacy agreements to maintain the confidentiality of the medical record/client information.
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Claim Negotiation Services
1. What type bills do you accept?
We accept all out of network claims $500 and greater for all provider bill types including hospital inpatient and outpatient, physician, pharmacy, home health, ancillary facilities, and outpatient surgery centers. All claims $5,000 are also reviewed for audit potential.
2. Do you accept paid claims?
No. Most negotiations are based on prompt receipt of payment. If the claim has been paid, other options are available through the audit services department.
3. What is your turnaround time for claims?
Most claims are completed in less than 72 hours.
4. How do we submit claims to HDI?
HCFA 1500s, UB92s, or client screen prints for claims can be faxed or electronically submitted for negotiations. If claims are submitted electronically the minimum threshold of $500 may be lowered.
5. Who negotiates the discounts?
All negotiation staff members have prior management/supervisory experience in the healthcare setting or are experienced registered nurses. Each negotiator has at least 10 years experience in healthcare cost containment strategies.
6. Does HDI look for potential errors on bills prior to negotiating?
Yes. All claims are reviewed for potential errors and/or aberrant billing.
7. Is the confidentiality of the information submitted to you maintained?
Yes, it is. All staff members sign confidentiality agreements and HDI will be fully HIPAA compliant.
8. Will we have balance billing issues?
No. Signed off agreements are obtained from the providers for all prompt pay reductions.
9. Do you perform usual and customary reviews for physician claims?
Yes. The Analyzer performs an audit that is based upon accepted industry standards. Our software uses a comprehensive database that contains claims coding edits consistent with the CPT Physician Current Terminology Manual.
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Pre-negotiated Discounts
1. What is a pre-negotiated discount?
HealthDataInsights has PND (pre-negotiated discount) agreements in place with providers. These agreements permit discounts to be applied to claims submitted from our clients. We also have arrangements in place with Supplemental Networks whose contracts with providers permit access to their pre-negotiated discounts. This layered approach provides you with the greatest cost savings potential.
2. What part of the country do you cover?
We have providers from every state participating in this program.
3. What provider types participate this program?
Hospitals, physicians, pharmacies, laboratories, radiology centers, outpatient surgery centers, dialysis centers, home health agencies and most other provider types participate.
4. Will I need to identify HDI or the network on the Explanation
of Benefits?
Yes. All providers require the identification of the network. The language you need to use will be provided to you on a case by case basis.
5. What is the minimum bill size?
We accept all out of network claims $500 and greater. If you select
to submit claims to us electronically, this minimum threshold may
be lowered.
6. Will we have balance billing issues?
In most cases there are no balance billing issues. If a provider does question the discount, HealthDataInsights will handle all phone calls from providers concerning the discounts reported to you.
7. Can we submit our in-network claims for additional discounts?
No. Only out of network claims qualify for this program.
8. What is your turnaround time for claims?
Most claims are completed in less than 72 hours.
9. How do we submit claims to HDI?
HCFA 1500s, UB92s, or client screen prints for claims can be faxed or electronically submitted for negotiations.
10. What savings will I see from pre-negotiated discounts and/or
supplemental network discounts?
You will see significant savings. For 2002 inpatient savings averaged 17% and physician savings averaged 26%
11. Is the confidentiality of the information submitted to you
maintained?
Yes, it is. All staff members sign confidentiality agreements and HDI will be fully HIPAA compliant. We obtain Business Associate agreements from all networks.
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Hospital Bill Auditing
1. Is there a fee for prescreening?
No, prescreening is performed free of charge
2. What information is necessary for prescreening?
Generally, prescreening can be completed with the information included on a UB92. This can be sent by mail, email, fax, or electronic submission in our format or as a data dump that HDI will then format.
3. What size bills can we submit for hospital bill audit prescreening?
We prescreen all hospital bills of $5,000 and higher.
4. Most of our claims have PPO or HMO discounts. Can these claims
be audited?
Absolutely. Any claim paid by a % off of charges methodology can be audited. The majority of claims we audit have already received some type of discount. However, that discount is not as great as you may think since there could be significant overcharges on the bill.
5. Some states, such as Texas, have government regulations dictating
a strict time frame for claim payment or penalties are applied. Can
these claims be audited once paid?
It is not necessary to withhold any payment pending an audit. The majority of claims we audit have 100% of the payer's liability paid. Most hospital's audit policies require 90% to 100% of the charges be paid prior to audit.
6. Are medical records requested for audit?
With very few exceptions, audits are done onsite at the hospital. This ensures all documentation available at the time of audit can be presented by the facility and discrepancies can be resolved in a timely manner. This usually results in a signed agreement received on the day of audit. This method also adheres to the hospital's policies and procedures thus maintaining a respected professional relationship between HDI, the hospital, and the payer.
7. Who performs the audits?
Our auditors are nurses with extensive clinical experience and an average of 9 years of audit experience, most of it with HealthDataInsights.
8. Is confidentiality maintained?
All of our auditors are required to sign confidentiality agreements and HIPAA addendums. In addition, our HIPAA compliance officer is on schedule to ensure HDI is HIPAA compliant before the April 14, 2003 deadline.
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National PPO Network
1. How many providers are in your network?
Our network contains over 3,600 hospitals and more than 483,000 physicians. Our dental network consists of over 26,000 general dentists and more than 6,500 specialists.
2. What is the average discount?
Discounts vary by state, however, nationally our experience reflects average savings of 24% on inpatient hospital claims, 17% on outpatient hospital claims and 26% on professional services. Nationally dental discounts average 31%.
3. How can I locate a provider?
You can locate a provider by utilizing the "Search for a Provider" option on our website or call our office at 800-952-5277 and speak to one of our provider locators.
4. Can I nominate a provider and are there any restrictions?
If your provider is not in the network you can nominate the provider by completing a "Provider Nomination" form posted on our website. The networks do require that the physician have admitting privileges to a hospital that participates in the network.
5. How do I obtain a directory?
Directories can be downloaded from our website or requested from your employer group.
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