Medical Bill Audits

Bill audits ensure charges are related to allowed conditions and within medical necessity guidelines.

• A nurse reviews bills to reflect maximum savings while still observing any jurisdictional requirements that may exist.
• Bills are reviewed line-by-line to determine the relationship of billed amounts to documented procedures and relevance to the allowed claim.
• We ensure that the parent institution only pays for services medically related to the claim and allowed conditions.
• The cost for hospital bill audits is only a percentage of the realized savings. The parent institution reaps the majority of the cost savings.
• Our nurses can defend audit recommendations if questioned by a provider.

Utilization Management

Nurse-driven reviews to ensure appropriateness and cost-effectiveness of treatment.

By managing treatment—and negotiating the treatment, if necessary-we ensure that the offender receives only appropriate and necessary care. Parent institutions benefit when costly, unessential medical procedures are reviewed. National treatment guidelines and appropriateness criteria support the review process.

Online access enables you to search for medical providers by geography, specialty and name. Postings of network providers can also be provided, and parent institutions can nominate providers for inclusion in a network arrangement.

Our Utilization Management is integrated with our early intervention and telephonic case management services. Where appropriate, our nurses channel offenders to network providers.

In addition, CareWorks can provide consulting services to develop customized, location-specific networks of providers trained in disability management and correctional health care services.