What Is Demand Bill Review?

What you will find below:

• Overview of Demand Bill Review
• How Demand Review Differs from Standard Bill Review
• Use Cases for Demand Bill Review

Most medical bills follow a fairly standard review process. A bill comes in, it’s checked against the applicable state fee schedule and coding rules, and a reimbursement amount is determined.

But not every bill fits neatly into that process. Some charges are unusually high. Others involve services that don’t fall cleanly within standard fee schedule categories. And sometimes, the main question is simply whether the amount being billed is reasonable. That’s where demand bill review can come in.

What Is Demand Bill Review?

Demand bill review is an extension of traditional medical bill review. It is designed for bills that wouldn’t typically go through the standard review process because they are more complex, unusual, or high-value.

Standard bill review generally compares charges against a state’s fee schedule, regulatory requirements, negotiated rates, or other established benchmarks. Demand bill review takes a different approach, using additional data and comparisons to evaluate whether a charge is reasonable for the specific circumstances.

The distinction is important because standard bill review isn’t designed to answer every billing question.

Example

Consider a workers’ compensation claim involving an extended hospital stay with a total charge that is significantly higher than what is typically seen for similar treatment. The bill may also include several line items that don’t map cleanly to standard fee schedule codes.

Standard bill review can address the portions of the bill that fit within its established guidelines. But it may not be equipped to evaluate the bill as a whole.

Demand bill review can fill that gap by taking a closer look at the charges and determining whether they are supported by comparable billing data and other relevant benchmarks.

Demand Bill Review vs. Standard Bill Review

Standard bill review is built around consistency and efficiency. Most medical bills tied to a claim are relatively straightforward. Applying a state fee schedule, negotiated rate, or other established guideline allows claims organizations to process those bills efficiently and at scale.

Demand bill review is intended for the bills that don’t follow that pattern. Instead of relying primarily on a fixed fee schedule, demand bill review can look at usual and customary charge data, comparable billing for similar services, and other relevant benchmarks.

In other words, standard bill review answers a more straightforward question: Does this charge align with the applicable rules or fee schedule?

Demand bill review also takes a closer look when that question isn’t enough: Is this charge reasonable based on what similar services typically cost?

That additional analysis makes demand bill review better suited to the smaller percentage of bills that require a more case-specific review.

When Is Demand Bill Review Used?

Demand bill review can be useful in several situations, particularly when a bill raises questions that standard review can’t easily answer.

• Questionable Charges: When a bill appears disproportionate to the services provided, demand bill review can help determine whether the amount billed is supported by comparable charges and other relevant data.
• Complex or High-Value Claims: Extended hospital stays, unusual procedures, and high-cost treatments can create bills with enough complexity to warrant a closer review than a standard fee schedule comparison provides.
• Unusual Billing Situations: Some bills involve non-standard billing formats, services outside a typical network arrangement, or circumstances that aren’t well addressed by the applicable fee schedule. These situations may require a different set of benchmarks.

The objective in each case is the same: give unusual or high-value bills the level of review they require.

Not every bill needs this level of analysis. In fact, most don’t. But when a bill falls outside the standard process, applying the same approach used for routine bills may not provide enough information to determine whether the charges are reasonable.

Looking for demand bill review? Connect with our team to learn how a more targeted approach can help evaluate complex or high-value medical bills.

Sources:

• Centers for Medicare & Medicaid Services. “Medicare Program Integrity Manual, Chapter 6.” CMS.gov.
• Centers for Medicare & Medicaid Services. “Liability Notices & Beneficiary Appeal Rights Review.” CMS.gov.
• National Council on Compensation Insurance. “Making Workers Compensation Medical Fee Schedules More Effective.” NCCI.com.