Medical Bill Review and Audit

  1. Seems to me a lot of us nurses are searching for ways to make a living outside of traditional nursing. I am making an attempt to begin a review and audit business and am wondering if anyone out there is trying to do the same or has even heard of it. So far marketing it has been a bust and I would love to brainstorm with other nurses - although I have over 14 yrs nursing, I feel very unsure of where this is heading. I appreciate everyone's input.
    Last edit by VSRN on Feb 17, '02
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  2. 11 Comments

  3. by   SharonH, RN
    Hi VSRN, brainstorming and trying to help each other is exactly what this board is for. I've never heard of what you're doing. What exactly is involved and what are you doing as far as marketing(since it isn't working)?
    Last edit by SharonMH31 on Feb 18, '02
  4. by   VSRN
    Hi Sharon. The business reviews hospital bills and audits them for overcharges. The company that got me involved recruited nurses because of our background. It is a niche service that the companies I have talked to so far are unwilling to go the extra step to release the bills to a contract entity (too much hassle I have been told). Now I am looking at talking with lawyers, or insurance companies to see if I can get in there. I am finding the company that provided the training to be lukewarm if not negative in it's support of this business (something I am hearing in relation to similiar things). I am not in a position to be able to go out everyday and knock on companies' doors to drum up business. And I am feeling enough insecure about my knowledge base to do this anyway. So that is why I posted my inquiry. Honestly I am wondering if I am another statistic in the well funded scam business. Somehow I will make this work, but I am looking at a hsb in school full time (a casualty of the airline business), 3 kids at home, a committment to stay at home, and the list goes on (not to mention I have 2 other part-time jobs). Whew. I am wondering if anyone has been able to do this business......I certainly am not wondernurse or wonder marketer. Ideas?
  5. by   NurseDennie
    VSRV -

    I don't know anybody who has had their own business doing this, but one of my friends used to have that job working for an insurance co. She loved it, and did it until she got laid off.

    She would look at the charts and tick off all the tests, meds, etc., etc., that were supported by the chart. Then she'd go to the hospital and they'd write off a certain percentage. When it became obvious to the insurance company that the percentage was fairly consistent, they laid off my friend and the three other nurses she worked with. Now the former supervisor of that department goes to the hospitals and says "We'll allow "X" percentage of what these charges are. If you just agree and pay it, then we won't audit."

    Shame, isn't it?

    Love

    Dennie
  6. by   VSRN
    Yup, that's exactly the job I am supposed to be offering. Thx for the info. I am planning to talk with a few insurance agent friends of mine.....sure wish I could connect with some nurses who supposedly have gone through the same "training" that I have and are making a go of this......
  7. by   ur nurse
    VSRN- I too have been wanting to try to set up a home based business doing chart audits,etc since I have loads of experience in this area and loved doing it. There was an ad in our state nursing newspaper soliciting for people to start these businesses.
    However when I checked into it, the solicitation was for the business and not the auditors! They wanted $7000 to get computer set up,etc etc. When I stated I would like to be one of the auditors instead they were no help. I stopped seeing the ad
    and have not done too much digging since. I tried to speak with several insurance companies and sent out resumes but got nothing. Please let me know if you hear any more, I sure would love to network this out!!!
  8. by   TiddlDwink
    I teach medical billing & coding at a local tech school. I had a student last year whose grandmother thought her hospital bill was too much for the time she had been in it, and what she had been in for. The student told her to get an itemized bill and to obtain a copy of her medical record. When the student compared the bill with the record, she found an amazing $40,000 worth of undocumented charges. Instead of calling the hospital, she called the Medicare fraud hotline. Guess what?! (making a long story short here) Medicare paid her a percentage of the $40,000 finder's fee! The student is now in business auditing charts for Medicare fraudulent billing. Her clients gladly let her do this, and she reimburses them the cost of the itemized bill and the medical record. She originally got her clients from her grandmother's church, where she went and talked to the congregation about what she wanted to do. In 3 years she has become downright wealthy!
  9. by   VSRN
    Wow. This is the first time I have heard of a bona fide person actually doing this on her own. UR Nurse, Medicare is one possible client base (although finding individual clients would be very time consuming). I tried self insured companies, TPAs, lawyers and even insurance companies as a consultant. No interest. Seems no one wants the extra hassle of allowing an outside entity get records, charts ect. I was told it was too much extra work. This is viable work, but I have not been successful finding the right connection. I absolutely would not recommend any one to purchase training information on this. It really is common sense. Unfortunately I did pay about half of what URnurse saw, and I know the money was not well spent. Basically I got an expensive business course. And the company I purchased from has disappeared off the face of the business world.....hmmmm. An expensive course in the school of hard knocks. Thanks for the input everyone. Vicki
  10. by   Agnus
    Originally posted by TiddlDwink
    I teach medical billing & coding at a local tech school. I had a student last year whose grandmother thought her hospital bill was too much for the time she had been in it, and what she had been in for. The student told her to get an itemized bill and to obtain a copy of her medical record. When the student compared the bill with the record, she found an amazing $40,000 worth of undocumented charges. Instead of calling the hospital, she called the Medicare fraud hotline. Guess what?! (making a long story short here) Medicare paid her a percentage of the $40,000 finder's fee! The student is now in business auditing charts for Medicare fraudulent billing. Her clients gladly let her do this, and she reimburses them the cost of the itemized bill and the medical record. She originally got her clients from her grandmother's church, where she went and talked to the congregation about what she wanted to do. In 3 years she has become downright wealthy!
    I did know medicare pays a persentage of the fraudulent bill to anyone who discovered it and pointed it out.

    My question is this. You said she reimburses the client the cost of the itemized bill and the medical record.

    I am not clear what she is doing.

    Do you mean the client must pay to get an itemized bill? And must pay to get thier own medical record?
    Is this All she is giving them?
  11. by   mattsmom81
    I did some third party bill auditing and it was Ok til the facilities hired their own nurses to go through the nurses' notes line by line and tack on extra charges.

    So it became a big, long argument everytime I went to the facility to try to resolve a bill, and it became not worthwhile to pay me to try and negotiate a settlement. I don't think my company is in business anymore for Nurse Dennie's reasons.

    I wouldn't mind getting back into it at this point in my life...so if anyone has any leads please share. .
  12. by   mattsmom81
    As an update...I have answered a few ads for nurse auditors....but what they wanted was workers comp auditors...more like case managers. To monitor and manage WC claims. Oh well.
  13. by   Mary-Liza
    Interesting responses. There is a national organization for medical auditors that you can join and network with. This is the only official national organization for medical or clinical auditors engaged in this type of business. The AAMAS - American Association of Medical Audit Specialists is on its 10th year. There is also a certification examination for those interested on being certified as CMAS - Certified Medical Audit Specialist. Visit aamas.org.

    Marilyn Balcita RN CMAS
    Special Advisor AAMAS

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