Medical Bill Review

Xybion is proud to offer the Workers’ Comp industry a new choice in medical bill review software and service. Designed to create efficiencies and reduce the total cost of ownership or service, Xybion’s national medical bill review platform is the first of its kind.

Our platform is more than an adjudication system. The configuration of our bill review system is a consultative process. We understand our clients have a broad range of claim philosophies and while state legislatures and regulators make rules, interpretation of those rules may differ. We incorporated an option driven system allowing for almost infinite custom configuration possibilities. Completely configurable, national and state medical treatment guidelines and fee schedule rules built in, and an embedded document management system, Xybion enables you to create “Your Process – Your Way”.

  • Supports workers’ comp, auto and group health
  • Seamlessly integrates with claims system – proprietary or third party
  • 100% cloud-based and accessible via any device
  • No software to download
  • Network management and contract pricing available within the system
  • Immediately access and connect internal systems that drive medical bill review
  • Available as a lease option or as service option
  • Mailroom service available
  • Multiple bill intake options
  • Real-time integration with ODG
  • Embedded document management system – no third party needed
  • Fully compliant with latest data standards and regulatory guidelines
  • Configurable – updates take days, not months
  • Established interfaces with clearinghouses and preferred provider organizations

Core Bill Review features:

  • Medical Bill Review Basics: Fee schedule values, out of network negotiation.  PPOs, MPNs and other specialty network connections, standard and custom reporting, data analytics and business intelligence.
  • Appropriateness of Care: The system checks whether a provider can invoice for the service billed. E.g, A Registered Physical Therapist may not bill for a physician office visit.
  • Unbundling: If the supply or service was already allowed under a previous billing, the platform checks and determines that the “unbundled” code should be denied.
  • Duplicate Billing: The platform will identify and deny payment for services or supplies that duplicate previous charges.
  • Clien-specific Business Rules: For Example: (1) When bill type is a hospital bill (inpatient or outpatient, billed on a UB) AND an observation revenue code (760-769) is used AND billed charges are greater than $10,000 PEND the bill to a nurse task list. (2) When the bill type is a physician bill (HCFA) AND the rendering TIN is xxxxxxxxxx AND the procedure code is 99213 reduce the bill to $25.00 AND DO NOT send to PPO.
  • Utilization Review: Alerts both the provider and the adjuster to potential over treatment and will request objective documentation from the provider.
  • Recon/Appeals: Supports reconsiderations while keeping the integrity of the original bill/pricing intact while linking the reconsidered bill to the original.
  • Multiple Bill Intake Methods: Our interface provides multiple options and formats for billing that can save time and effort for the patients and the providers:  EDI / FTP,  Scanned Bills, Fax,  Email / Mail, manual .
  • Diagnosis and CPT Entry: It has all possible diagnosis options included that can be readily chosen and auto-populated minimizing data entry. Along with this, it also has embedded rules that allow customizable triggers.
  • EDI Support: Integration with PPO networks is another added feature that evaluates pre-existing relationships with multiple PPO providers to assist with additional savings. Bills that are uploaded to the CORE system, bridge directly to the network for application of contracted rates, thereby saving Broadspire and its client’s money.
  • Bill Review Dashboard: The bill review software platform includes a robust, real-time dashboard that displays KPI’s and other key data sets.  Dashboards and key data sets are role-based and integrate number of bills by client, daily savings, status of multiple bills, workload and assignee’s information. auto-populated minimizing data entry. The system also has embedded rules that allow customizable triggers.

Bill Intake

Within the Bill review platform is a comprehensive bill intake module designed to streamline the overall intake process. Our interface provides a bundle of options for billing that can save time and effort for the patients and the providers.

  • EDI: Data is first transferred via EDI which then gets loaded onto the CORE system for processing with the desired state and review settings. Some of them  directly return while others enter the adjuster queue for review.
  • Scanned Bills: Our platform also allows clients to load bills at their location and images get loaded to the FTP site. The bills are then conveyed to the CORE system for processing with the desired state and review settings.
  • Email/Mail: Clients can also mail their bills, which are scanned on site and keyed into the CORE system for processing. Original bills are either returned or shredded. Reviewed bills are printed and returned to the patient.
  • Manual: On site manual uploading to the CORE system can also be done.
  • Fax: These also have to be manually uploaded to the CORE system for processing.
  • FTP: Bills can also be transferred via File Transfer Protocol(FTP) which is a standard network protocol for relaying data between a client and server on a computer network.

Fee Schedule

Built-in automated calculation based on bill type and jurisdiction, etc.

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KFI: Key from Image

Auto populate all the details of the patients and providers from the uploaded health insurance forms. Powerful OCR Engine can digitize and create claims forms

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Diagnosis and CPT entry

It has all possible diagnosis options included that can be readily chosen and be auto-populated minimizing data entry. Along with this,it also has embedded rules that allow customizable triggers. For instance, when diagnosis codes do not support the CPT codes or services rendered, manual entry can be done.

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EDI Support

Integration with PPO networks is an other added feature that evaluates pre existing relationships with multiple PPO providers to assist with additional savings. Bills that are uploaded to the CORE system bridge directly to the network to include the contract rates applied and thereby save money for the patients.

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State Reporting for Workers’ Comp Medical Bills

  • State Reporting for Workers’ Comp Medical Bills
  • Electronic Integration with reporting states
  • Built in edits to reduce rejections
  • Integrated with Medical Bill Review Engine
  • Timely Filing rules with built in alerts
  • Risk Reports to manage potential fines and penalties