Medical Bill Repricing Solutions

By fully integrating key financial tools for reviewing medical costs into a single, knowledge management program, RISING is able to deliver one of the most powerful and effective medical cost containment solutions in the industry.

>> Medical Bill Analysis

RISING's flagship medical bill review program is a financially empowering solution that allows clients to make well informed and equitable payment decisions regarding their medical expenses. This solution is the culmination of sophisticated software systems, artificial intelligence technologies, advanced data management techniques, expert bill analysis professionals, seasoned nurse reviewers, experienced professional negotiators, customizable utilization flags, comprehensive Preferred Provider Organizations (PPO) networks and exceptional service into one, state-of-the-art medical bill analysis program.

Program features include:

• Elaborate coding review and repricing
• Automatic state law adjustments
• Usual, Customary, and Reasonable review
• Hospital bill review
• Pharmacy, Durable Medical Equipment and Dental review and repricing
• Customizable utilization review parameters / flags
• Robust duplicate bill detection - 99.9% accuracy vs. 85% industry average
• Aggressive fraud detection and tracking with SIU flags
• Seamless referrals to case management and negotiator professionals
• EDI capabilities
• Web-based reporting - savings and underwriting specific
• Web-based bill review and approval capabilities
• Provider payment solutions / check-writing options

Return On Investment (ROI):

• Unparalleled success rate in increasing clients' net savings
• $8 - $78 return per $1 in fees
• An additional return of $3 - $4 return per $1 in fees when program is enhanced with our Specialty Bill Analysis services

>> Specialty Bill Analysis

Rising's tiered bill review levels ensure that our most highly trained and experienced staff handle our clients' most complex medical claims - which are also those that drive the best savings outcomes. This type of tiered bill processing greatly reduces clients' financial exposure, with our staff producing an average of 22% in additional savings over traditional bill repricing processes.

Rising's Specialty Bill Analysis Unit includes our most senior bill auditors, nurse auditors and professional negotiators. Bill types typically routed to the Specialty Bill Analysis Unit include:

• In-patient / Out-patient hospital bills
• Complicated diagnostic testing
• Home health
• Complicated surgery bills
• Excessive pharmacy / DME bills
• Out-of-Network bills
• Casual relationship/compensability issues
• Reasonableness and necessity of treatment issues
• Implant and supply overcharges
• Bills over $2,500 (or other amount specified by client)

>> Out-of-Network Negotiations

RISING is exceptional at reducing the costs and hassles associated with large, non-network bills. This program utilizes our medical knowledge, contractual relationships, various repricing databases, veteran negotiators, and expert coding review to target 17% of bills that drive 50% of our clients' medical costs.

With a 68% success rate, benefits of our negotiations services include:

• Reduced expenses: medical; IME; audit; legal; administrative
• Improved: loss ratio; provider relationship
• Increased: adjuster capacity; PPO retention
• Early: fraud/SIU case discovery; IME / case management flags
• Complete integration with: medical bill review; PPO program

Additionally, for those clients who have already committed to a PPO or bill review program, our out-of-network solution is the perfect enhancement for existing cost containment programs. Producing tangible savings with contingency based pricing (clients pay nothing if we save them nothing), this solutions poses absolutely no financial downside.