Prairie States Can Help Your Clients Avoid Paying Bogus Medical Bills

To err is human. To forgive, divine. To pay thousands of dollars for false medical bill charges is ludicrous! According to the Access Project, a Boston-based health-care advocacy group, bogus charges happen with startling frequency. It’s estimated that 80% of medical bills contain errors1, which employers and employees all too often unquestioningly pay. But not if they’re Prairie States’ customers.

Claims Investigators

An invaluable difference from one health benefits administrator to another is the way it looks after your money. Most administrators use computer systems which they hope will catch errors when paying claims. At Prairie States, that’s not good enough.  In addition to these systems, Prairie States has  knowledgeable, diligent and perceptive claims investigators. The company, founded by a clinician, has experts in house who understand care delivery from the inside out. Those experts work to weed out charges that are missed by computer systems. The result is huge savings in the aggregate and on individual items.

Decoding the Problem

Prairies States understands the myriad of reasons for billing errors, beginning with typos. As hospitals and physicians rely more on electronic health records that require typing patient information, Medical Billing Experts of America (MBEA) expects typing errors to further negatively impact medical bills’ accuracy. For example, MBEA points out, if you hold a key down too long 1 injection can become 111. Mistyping a billing code, such as CPT, HCPCS or ICD-9, can cause thousands of dollars in overcharges.
There’s also the issue of legitimate, yet grossly inflated charges. They can be challenged, although few employees or employers do simply because the charges sound valid. For instance, a hospital bill may include charges for thermal therapy, which is hospital jargon for a bag of ice. Disposable mucous recovery systems are tissues and a cough support device is a small pillow that patients  hold to their chest to ease coughing.
The category Miscellaneous can appear on a bill and it may contain fraudulent charges that only a scrupulous audit would pick up on. In fact, the National Health Care Anti-Fraud Association, a Washington, D.C.-based group of health insurers and state and federal law-enforcement officials, estimates that at least 3 percent of annual healthcare spending, or $60 billion, is lost to fraud.2

It’s enough to make you sick!

Good News

It’s possible to spot and correct billing errors. Prairie States has experienced clinicians on staff who scrutinize all inpatient hospital claims over $5,000. They rectify mistakes and save customers thousands of dollars. Unlike automated computer software programs, Prairie States’ hands-on bill audits are conducted by highly skilled medical professionals who know what legitimate services include and cost.
Here’s how Prairie States’ billing audits work in your clients’ favor:

  • Our claims processor hands over the claim before it’s paid. 

  • A Prairie States clinician, who who has access to the claims’ history and understands the claimed procedure and follow-up treatment, determines a fair cost estimate for the billed procedure. For example, our clinicians know which and how many specialists a surgeon needs for the billed procedure; anesthesia requirements; typically required drugs; and appropriate recovery room time. Our clinician then compares the fair cost estimate against the actual bill. 

  • Inaccuracies, and anything that simply doesn’t fit the clinician’s fair cost estimate, are presented to appropriate hospital administrators and/or physicians in order to have erroneous charges removed or adjusted down. For example, let’s say our clinician spots a recovery room charge for 990 minutes, but knows that 90 minutes are typical. Having this cost reviewed and adjusted may produce a $100,000 savings.

Nothing to Sneeze At

Unlike any other medical bill audit process, Prairie States’ deep investigative work, conducted by medical clinicians rather than just an automated system, helps your client’s keep medical bills legit and safeguards their cash reserves.  
Let Prairie States’ experts use their experienced expertise to spot errors, lower claims and save your clients’ money. Talk to your client’s about Prairie States today!

1. As reported in the WSJ; updated Feb. 19, 2011 12:01 a.m. ET
2. LexisNexis white paper; Bending the Cost Curve: Analytics-Driven Enterprise Fraud Control; April 2011, page 2 (last accessed March 1, 16:

Prairie States Enterprises, Inc. is a third-party health benefits plan administrator that brings industry expertise and a clinical focus to self-insured companies. Our in-house claims administration, health management services, wellness programs, plan analysis and predictive modeling tools result in remarkable and unprecedented cost control for employers. We also provide the most compassionate and personalized level of service for plan members.
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