Property and Casualty Services

Liability Claims Management


  • Review Medical Bills for Relatedness and Appropriate Care
  • Review Medical Charges for Accuracy
  • Determination of Extent of Injury
  • Determination of Reasonable and Necessary Fees
  • Review Accuracy of all Coding and Calculations
  • Maintain Electronic Record of all Pertinent Clinical Information


Review of Provider Bill Charges


All liability bills for medical care incurred are evaluated in accordance with the rules and guidelines as established by the Usual and Customary Regional (UCR) geographical database for provider & facility charges.


Screening of all medical bills is a pivotal portion of the audit process. The initial stage of the screening process involves a review of each medical bill for adherence to the "proper submission" criteria, which include:


  • Use of - mandated or applicable billing forms
  • Appropriate completion of these forms (including appropriate itemization of medical services)
  • Inclusion of required reports or other documentation/information


Bills, which fail to meet the basic "proper submission" criteria and are not duplicate bills per our claims records, are returned unpaid to the provider with a specific notification to the provider regarding proper submission of the bill(s) to the client.


All properly submitted medical bills are prepared for audit by comparing each bill with our claim records. Each bill is entered into our automated system. Careful screening for duplication of bills and services is performed before, during, and after each bill review, both manually and by the system. The Argus consultant then evaluates each bill in accordance with pertinent criteria with regard to:


  • The date and nature of the injury,
  • Relatedness and appropriateness of the diagnosis to the reported injury,
  • Relatedness and appropriateness of the medical services to the compensable diagnosis,
  • Utilization of medical services,
  • Accuracy of coding as related to the medical record,
  • Services billed for services documented in the medical record as rendered,
  • Accuracy of all calculations,
  • Reasonable and necessary fees for same.


Concurrently, the entire treatment and payment history is reviewed and considered before any recommendation for payment is made.


The Argus consultant maintains for each claim an electronic record of all pertinent clinical information as gleaned from each bill/report received from medical providers, including:


  • Treating physician(s),
  • Diagnostic testing results,
  • Past medical history and pre-existing conditions,
  • Therapy prescriptions and plans of care,
  • Medical equipment rentals and purchases,
  • Anticipated/realized surgical procedures and hospitalizations,
  • Patient progress,
  • Changes in work status.


This electronic record also includes bill audit information such as notes of reductions, provider-billing strategies, applications of rental fees to purchase price, utilization review referrals, and requests for information. A computer record of each bill and each bill review is also maintained from which client reports, follow-up provider correspondence and/or re-review, and determination of duplications is made. Claims activities such as compensability of certain treatments, changes in work and/or clinical status, identification of over-utilization, multiple claims by the same claimant, controversions, compromised settlement agreements, agreed judgments, and benefit review conferences are common, and exchange of such information is indeed crucial to the bill review process. Thus, throughout the bill review process, direct discussion with the claims adjusting staff is accomplished as needed with regard to specific concerns or recommendations. All claims information gained during such discussions is also recorded in our claims records for consideration during all future bill reviews.


All medical bills, which meet the criteria for each aspect reviewed, are processed as recommended for payment in full. Such bills are accompanied by a computer-generated report in triplicate that acknowledges that all items were appropriately billed in accordance with all germane criteria. All bills, which do not meet each criterion (regardless of amount), are reduced by audit to the recommended payment, and an audit summary in triplicate is generated for each reduced bill in accordance with Usual& Customary guidelines and rules. The audit summary report indicates the allowance for each service billed by the provider along with explicit explanation(s) of each reduction. When appropriate, partial payment is recommended in accordance with each state’s guidelines and rules when further documentation, peer review, or on-site hospital audit is needed.


Argus provides superior medical fee guideline review services because our system reflects an audit philosophy, which recognizes the need for a distinct balance of, detailed personalized review by a qualified medical professional in tandem with an accurate efficient computer system for the generation of a clear and concise product for our clients.


Argus is able to offer Physician Bill Review for those bills that violate agreed criteria of medical necessity and appropriateness. We have developed criteria in particular for physical therapy, chiropractic and other rehabilitative services where extreme over-utilization has been documented in the General Liability system. Argus has contracted with a general surgeon, an orthopedic surgeon and a chiropractor that are available for immediate review of questionable patterns of treatment. A peer review report is written that serves as a basis for denial of payment on the bill triggering the review and on subsequent bills unless additional medical substantiation is provided.


Hospital and Health Facility Bill Audit


All bills for hospital care incurred on a General Liability claim is evaluated in accordance with rules and guidelines as established by each the state.


Argus reviews each and every hospital bill for:


  • Services unrelated to the injury of the claimant,
  • Undocumented (and thus, undelivered) services,
  • Personal items,
  • Duplicate or erroneous charges,
  • Unreasonable fees for services rendered,
  • Medically unnecessary services, inpatient admission, and lengths of stay.


Each hospital bill is carefully screened for these criteria as well as for facility and bill-specific flags that may prompt the Argus consultant to recommend an on-site audit of the medical record at the hospital. Under the current Texas Acute Care Inpatient Hospital Fee Guideline, carriers retain the right to audit any facility’s billing, even if the total amount falls below the stop-loss threshold.


Current familiarity with individual hospital billing and documentation practices allows the Argus consultant to identify overcharges, which can only be validated during on-site review of the medical record. Such bills are recommended for partial payment at the time of referral, and the bills are then processed for on-site hospital audit through the Argus Referral Supervisor. The on-site audit is arranged with the facility in accordance with state rules and, upon completion, a final report and recommendation for payment is forwarded to the hospital and to the claims adjuster for payment.


When appropriate and/or when an exit interview opportunity with the facility is not made available, medical records are requested and a desk audit is performed and completed by the audit nurse in the same manner as the on-site hospital audit.


After careful screening and when appropriate, the audit consultant makes a payment recommendation for straight-forward, reasonable, and necessary hospital services (e.g. outpatient or reasonable LOS inpatient diagnostics/procedures) without requesting partial or complete medical records from the facility. Argus’ hospital bill auditing services are not subcontracted. Our audit consultants and on-site hospital audit nurses are trained experienced professionals who possess state-of-the-market knowledge of medical facilities. Such expertise gives ARGUS a formidable advantage when reviewing a client's medical bills at large, for the Argus consultant is capable of identifying the audit strategy, which will most benefit the client.


This expertise allows Argus to recommend that a hospital bill not be audited on-site at the hospital when it is clear in our experience that such an audit would merely identify additional charges on behalf of the facility. Thus, Argus is able to identify savings to the client, which might otherwise be overlooked and consequently lost. Industry studies indicate that virtually all hospital bills contain erroneous charges, and these billing inaccuracies can amount to as much as 15% of the total charges.


Argus will develop a consistent and reasonable payment policy for each client that complies with the statute and tightly controls medical costs. For ambulatory surgery centers we will use the Medicare ASC grouper with geographic cost index adjustments. For hospital outpatient services we will use the Medicare Hospital Outpatient Prospective Payment System (APCs) with the proper geographic practice adjustments.


Retrospective Utilization Review (Peer Review)


Retrospective Review is the process by which medical services are reviewed during or after being performed, but prior to payment. This review evaluates the medical necessity and causal relatedness of the hospital admission, surgical or diagnostic procedure or outpatient courses of therapy for general liability claims. Peer Reviews are useful for treatment for which preauthorization is not required. It is also useful when a review of the overall course of treatment is needed to determine what future medical treatment is necessary. We offer several types of peer reviews.


Peer Review. A Peer Review addresses a larger question of medical necessity or causal relatedness than does the physician bill review. A peer review looks at a larger portion of care being provided and issues a medical decision as to the relatedness or necessity of an entire course of treatment. The review can address specific questions as outlined by the adjuster. Reviews are matched by specialty of the treatment being reviewed and all Argus review physicians provide a signed, written review decision.


Pharmacy Medical Necessity Review. If needed, Argus can provide a physician opinion in response to a statement of medical necessity submitted by a prescribing physician. The Argus bill review staff requests these statements when deemed appropriate. Though the nurse auditor provides the first level of review, Argus physicians are available to provide a written opinion should the prescribing physician appeal an audit denial based on the statement of medical necessity.