Every  month  there is an article about a hospital or chain of hospitals settling civil whistleblower lawsuits, repaying overcharges, duplicate charges  and phantom charges. Implants costing the hospital thousands of dollars are marked up 400% or more. At the same time hospitals, through mergers and acquisitions,  are using their increased market power to compel insurers to contract for higher reimburse-ment.  Yet hospital, ambulatory surgery center and surgeon’s bills vary widely -- even within a particular geographical area -- with price discrepancies ranging as much as 40%.  For the insurer,  the task of debt analysis and debt reduction becomes an important strategy in remaining competitive and in retaining customers.  The insurer that pays the bill in full as it presented, with no more than a pro forma scrutiny, and that hopes that a network savings will suffice, will in the end lose customers and cease to be competitive. 

South Florida Utilization Review offers a solid Agreement that is legally binding,  and that resolves the claim without further dispute or litigation. The South Florida Utilization Review Agreement means that there will thus be no dispute about the "re-pricing" done by some bill review company that arbitrarily inputs figures that are not supported.  A "payment"  based on a “re-pricing” can be disputed by the hospital or ambulatory surgery center, and is fraught with the potential for fines, liens, reversals, and litigation, the cost of which ultimately becomes the responsibility of the payor.

                                South Florida Utilization Review  

South Florida Utilization Review has the knowledge,  experience and contacts to do Bill Negotiation. We can put our skills to work for you.  

We do the work. You enjoy the savings. Here is how.                                 

                 HOSPITAL AND AMBULATORY SURGERY CENTER BILLS

A first or second pass audit of high ambulatory surgery center bills (excess of  $10,000), hospital bills (excess of $50,000) and surgeons’ bills (excess of $10,000) is initiated. 

In the ambulatory surgery center and hospital bill audit the significant recoupments (savings)  are achieved in the negotiation by someone who has negotiating skills, established hospital contacts, and the data on usual, customary and reasonable fees for goods and services -- not by the network discount and not at the level of the automated bill review.  

                                          Who Are We?

South Florida Utilization Review is an independent peer review organization in business for 23 years. In 2004 we acheived the coveted URAC accreditation,  a distinction enjoyed by just 30 other independent review organizations (IRO’s) in the United States.  Our main activity is physician advisor doctor-to-doctor review.

Joel Grossman, M.D. is a Certified Medical Audit Specialist, a Certified Professional Coder and is on the CPT Advisory Committee of the American Medical Association.  Over the past nine years Dr. Grossman has achieved solid relationships with the key business or finance office negotiators at approximately 300 facilities and chains that habitually overprice. Tracking in our data base the tendencies in each negotiation; negotiating  recoupments as large as $49,000 on a bill already discounted to $98,000; and allowing one of our clients to enjoy a monthly savings of $100,000 are all features of the South Florida Utilization Review Bill Negotiation. 

With different states and types of claims there are legal and tactical considerations that may preclude the payor from doing its own bill negotiations.

Bills are negotiated by Dr. Grossman to the end and you, the payor, are not charged for our services until you receive our legally binding agreement signed by the facility or physician designee and by the insurance carrier’s designee.  If the negotiation does not succeed the bill analysis is forwarded to you the payor at no charge.
 
                                             What Does This Cost? 

For hospital and ambulatory surgery center bills the savings service charge is 25% of the savings after subtraction of the state mandated discount and any network discount.

By way of example, if the bill is $9,000, the total of the discounts is 20%, and the final negotiated payment by South Florida Utilization Review is $4,000, then the savings service charge would be calculated thusly:

$9,000 – 20% of $9,000 = $7,200

Gross Savings to carrier: $7,200 - $4,000    = $3,200

Savings Service Charge: 25% x  $3,200       = $  800

Net Savings to carrier:   $3,200 - $800        = $2,400

For non-contracted facilities a direct negotiation without consideration of any network discount is undertaken.

For surgeon’s professional fees the savings service charge is 25% of the savings after repricing of the codes at the fee schedule or usual, reasonable and customary surgical fee. Any need for specialist review will be sent at no additional charge for further review to the  matching board-certified specialist. Any further report will be done at no additional charge.  If there is no Agreement, there is no charge, and the Fee Analysis is made available free to the carrier.

If there is no success in achieving an Agreement, there is no charge.

                                       How Do I Make a Referral?

Fill in the appropriate Bill Negotiation Referral Form. 

1)  For a Hospital or Ambulatory Surgery Center bill include the UB-92 and, if available,  the itemized line-by-line bill and what ever hospital notes have been provided to you. 

2)  For a Surgeon’s Bill submit the Health Insurance Claim Form (Form CMS-1500) plus the operative report.

At no charge we will scan a hospital, ambulatory surgery center, or surgery bill and inform you if it is worth negotiating or should be paid straightaway. The negotiation is done in a courteous and tactful manner. In the end all parties must agree to the negotiated sum; there are no “winners” or “losers.” We realize that your providers must be available for services the next time the need arises so we avoid doing or saying anything that would alienate the provider or reflect ill on any of the parties involved.  A time limit according to when by law the bill must be paid by your company is imposed on the process; all parties must agree to any extensions.  

The final Agreement to which all parties sign off is legally binding and precludes balance billing to the claimant.  In some exceptional cases a letter of intent from the provider may be substituted for an Agreement. 

If you have already done a utilization review on a particular claim  with South Florida Utilization Review, and wish to go further on that same bill with a negotiation, then the SFUR fee already charged would be applied against the final savings fee. 

Thank you for giving us the opportunity to work with you on these bills.   We are confident we can achieve surpluses for you and your clients within a short period of time.   


Joel Grossman, M.D.
Certified Medical Audit Specialist
Certified Professional Coder