Treatment Audits, Medical Peer Reviews, and Billing and Coding Reviews: Which Service do I need?

In the independent medical review industry the IME (Independent Medical Exam) tends to be the most popular service, and for good reason. It combines a physical examination of the patient with a review of all available medical records for the most comprehensive assessment of the case at hand. However, in some cases the physical presence of the claimant for examination is either not possible or not required. In such situations we offer three different types of medical file review services to meet your needs. The following is a guide to help you understand which service best fits your particular situation.

Medical Peer Reviews in short can be described an IME without the examination, however, such a description is actually an unfair generalization of this service. When performing a Medical Peer Review our most experienced examiners review the records with a fine-toothed comb with a strong emphasis on the relatedness of treatment and billing to the incident in question. The reviewer then forms his/her opinion of what treatment and billing would be considered reasonable, necessary and related to the incident in question based on American Medical Association (AMA) guidelines. The relationship between types of treatment rendered and their corresponding billing codes used for each service are reviewed in detail. This helps to identify whether or not each medical provider is using the appropriate coding methods for the services provided. The end result is a clear picture of what specific treatment is reasonable, necessary and related to the MVA as well as which billing was done appropriately giving you accurate details on your responsibility to the claim in question. For more information on the Medical Peer Review click here.

Billing and Coding Reviews are a service that MMO offers to help you evaluate the appropriate dollar amount billed for each service on a claim. If you are wondering if you are overpaying for a service on a claim then a BCR is what you need. When this service is provided we have an in-house Certified Billing and Coding Specialist review all of the CPT codes used in accordance with all relevant and current billing protocols. In your final report you will see a total dollar amount billed for each service as well as the actual amount allowed for each service based on all relevant billing protocols. You will then be given your actual monetary responsibility to the claim broken down by each service.  For more information on this service click here.

Finally, Treatment Audits are one of our most powerful claims evaluation tools. They combine the Medical Peer Review and Billing and Coding Review to give you a comprehensive understanding of your responsibility to a given claim. The medical file is first reviewed by an appropriate medical examiner in the form of a peer review. After that portion is complete our billing and coding specialists use the peer review examiners recommendations as a guideline for their evaluation of the billing. The end result gives you a clear understanding of your responsibility to a claim in terms of treatment rendered, future treatment recommended, and billing. For more information on Treatment Audits click here. 

We hope this give you a better understanding of each of these great services we offer. Always feel free to give us a call if you are still unsure which type of service best fits your needs. We are here for you!

About the author

Mike Acker
Records Coordinator/ Information Technology/Quality Assurance |