COMPLEX HOSPITALIZATION BILLS · LATIN AMERICA
Background
The client runs clinical review on complex hospitalization bills. Its reviewers work through a bill item by item against the medical record, the clinical guideline and the contract that priced each service.
Every item the review clears or challenges carries the reason behind it. What the team can cover is set by how many accounts it opens and how long each one takes.
Challenge
A complex hospitalization bill runs to thousands of pages. To decide one line on it, a reviewer reads the clinical record behind it, which can run to a thousand pages of its own, then the clinical guideline, the regulation, and the contract terms that priced the service. One bill takes about five days of one person working on nothing else.
The bills that carry that cost are the ones at a hundred thousand dollars and up. Below a certain amount, the team reviewed nothing at all. The reading cost more than the account could return, so those accounts were closed without a reviewer opening them.
Solution
Falcon’s agent connects to the sources the team already holds: the bill, the clinical record, the guidelines, the regulation, and the team’s own clinical rules. It reads the whole bill against all of them and returns each finding with the rule it applied and the evidence in the record behind it.
The reviewer accepts or rejects each finding, and every decision is written back into the model, so the next bill runs on it. Bills run in parallel, so how much the team can review depends on how many findings its reviewers confirm.
Mechanism
Fig. 01 · One bill, read against the record, the guideline and the contract
“It evaluates items a normal audit does not reach, given the time available to find them: routine lab work, low-cost medications, low-cost supplies.”
HEAD OF CLINICAL REVIEW · LATIN AMERICA
Results
For providers
A hospital runs the same agent on its own accounts inside the bill hold window. It reads each item against the clinical record, the guideline and the contract, and returns the same finding with the same evidence behind it, while the account can still be corrected.
Most of what it returns is care the hospital delivered and documented thinly: charges the record does not yet support, and services that never reached the account at all. Correcting those inside the bill hold window takes a note in the record. Correcting them after the account goes out takes an appeal.
Next steps