Hospital bill audits
As part of Premera’s overall payment integrity program, Premera contracts with Carewise Health (CWH), an independent company, to conduct post-payment reviews of hospital bills. Hospital bills are currently being audited to ensure Premera has been billed
correctly for services and/or supplies. These reviews are independent from prior authorization or medical necessity. CWH will review the claim and documentation for coding accuracy, contract compliance, and level of care.
The purpose of the audit is to:
- Compare the provider’s billed charges to documentation in the medical records and ensure that services to our members are ordered, documented, administered, coded, and billed correctly.
- Compare the provider’s coding on a claim against the provider’s contract terms.
- Compare level of care billed against level of care provided.
- Validate the provider’s billed charges are aligned with Premera’s payment policies.
When the audit is completed, the auditor will provide written results to the facility for their review. The facility may dispute the audit results via the rebuttal process directly with Carewise Health.
NOTE: Failure to provide documentation/medical records requested by Carewise Health within the specified timeline will result in a technical denial of the claim and a refund request for the entire payment amount and forfeiture of appeal rights.
Facilities can request additional time to provide documentation by contacting Carewise Health directly.
Audits findings will result in refunds and/or the reprocessing of claims. For questions about Premera processes, please call 800-364-2991.
Itemized hospital bill review
Premera also contracts with CERIS, an independent company, to conduct pre-payment reviews of itemized hospital bills. These itemized hospital bill reviews are conducted by reviewing an itemization of all of the charges billed by date of service for the
patient’s entire stay.
The CERIS prepayment review process ensures payment accuracy by identifying errors, duplicate charges, capital equipment, routine services and supplies, unrelated charges, and nonseparately billable charges on acute facility claims for inpatient and outpatient
services.
Facility claims should be billed and appropriately coded according to policies regarding contract exclusions or disallowed inpatient and outpatient facility charges, along with industry standards for the bill type including, but not limited to:
- UB Editor
- AMA
- CPT, CPT Assistant
- HCPCS
- DRG guidelines
- CMS National Correct Coding Initiative (CCI) Policy Manual
- CCI table edits
- Other CMS guidelines
When the review of the itemized hospital bill is completed, results of the review will be applied to the processing of the hospital claim with specific services that are identified as not separately reimbursable or billed incorrectly deducted from the
facility claim allowed amount. If the facility is not in agreement with the results of the hospital bill review, the facility may dispute the results via the standard claims appeal process.