When I’m contacted for a medical bill review, the request typically falls into one of two categories: a simple review or a comprehensive review. A simple medical bill review focuses on determining whether the charges are reasonable based on UCR (Usual, Customary, and Reasonable) rates. The comprehensive billing analysis, which I’m asked to perform more often, takes that evaluation a step further. In addition to identifying reasonable values, I also assess coding accuracy and documentation support to validate each billed item or service.
So, what is widely used to make sure a comprehensive medical bill review is complete?
Several major commercial insurers closely follow the Centers for Medicare and Medicaid Services (CMS) coding and billing guidelines. This alignment simplifies claims processing and sets a national standard for accurate billing. Various medical bill review experts rely on this CMS foundation. When conducting medical bill reviews for litigation or cost analysis, I evaluate charges against CMS-based rules that commercial payers also adopt. This ensures that all charges are accurately coded, reviewed for unbundling errors and verified for compliance with applicable regulations and industry standards.
Why do CMS guidelines matter for Medical Bill Review?
- CMS defines and updates code sets (HCPCS, CPT, DRG) used industry-wide
- Major payers follow CMS’ National Correct Coding Initiative (NCCI) edits to flag unbundling and incorrect coding
- In medical bill review, grounding analysis in CMS standards strengthens expert testimony
Does this mean I use CMS reimbursement rates for medical bill review?
Not at all. I rely on the coding guidelines but not their fee schedule. I use UCR rates instead. Healthcare.gov defines UCR as “the amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.”
Why use UCR for Medical Bill Review?
UCR rates capture what providers in a specific geographic area actually charge for services, typically based on the 75 th /80 th percentile, making them an appropriate point of reference to actual provider charges. CMS, by contrast, has fee schedules and their rates are administratively fixed. Likewise, commercial insurance reimbursement rates are based on negotiations and contracts with large facilities and medical groups. In medical bill review, UCR provides an objective, data-driven benchmark for determining if billed amounts are reasonable.
Ultimately, a billing analysis is comprehensive when established coding and billing guidelines are used, combined with UCR utilization to ensure objective valuation. This industry-standard approach provides defensible data, not just for medical bill reviews, but also for life care planning.