Itemized bill review on every line of every high-dollar bill, matched to the chart by time and signed by an auditor
Every charge line reviewed, not a sample, and each finding signed by an auditor.
See one case, screen by screen ↓Itemized bill review (IBR) is the payment integrity check of a high-dollar hospital bill line by line against the medical record and the provider contract. It finds charges that are duplicated, already included in the room or OR rate, not documented in the chart, or posted after the patient went home. Itemized Bill Review does it on every line of every bill over the threshold, and an auditor signs each finding.
How to choose AI solutions for insurance →
Updated
When an inpatient stay passes the review threshold, the plan asks the hospital for the itemized bill: every drug, supply, test, room day and implant, each with a revenue code, a charge code, units and a time. A lumbar fusion can run past 2,000 lines. The clinical bill auditor has the bill PDF in one window and the chart in another, and the provider contract in a third.
There are more bills than auditors, so teams sample — pharmacy and implants first, the rest if time allows. Duplicates, routine supplies already in the room rate, drugs the MAR never records and charges posted after the patient went home are paid as billed. On a stop-loss stay paid at a percentage of billed charges, each of those dollars costs the plan the contract percentage of it.
Estimated split of auditor time on one high-dollar inpatient bill, by hand and with the solution.
Six agents match every charge to the chart by time and to the contract; the auditor signs each finding.
St. Aldric Regional Medical Center bills $418,624.90 on 2,184 lines for Lorraine K. Abernathy’s five-day lumbar fusion stay. Here is what happens next, screen by screen, in the working solution.
Nadia’s queue holds 412 inpatient bills over $100,000 since 1 Oct: $96.4M billed, 1.31M charge lines read, 9,318 flagged. Bills sampled: 0. The list is ranked by what is at stake and the prompt-pay date, and Lorraine Abernathy’s stay is at the top — $25,274.03 recommended, ready to sign, pay by Mon 2 Nov.
Claim HP-26-0921-44731 opens on the stay, hour by hour: OR, ICU bed 6, 4 West bed 412, and the time after she left shaded red. Every charge is a tick on that ribbon. The review run reads the bill (2,184 lines, totals the same as the claim), reads the record (412 pages, 1,906 timed entries), finds the contract in force on 21 Sep, and matches every charge by time while the recommended reduction counts up.
“Every charge matched by time · window 30 min · 2,111 lines supported.”
Cefazolin is billed at 07:31 and the anesthesia record has 2 g IV before incision at 07:52, 21 minutes apart and inside the 30-minute window, so it is marked supported and not flagged. The operating room and anesthesia charges sit beside the anesthesia record’s in-room and out-of-room times, 07:45 to 13:20. Of 2,184 lines, 2,111 are supported this way.
Never flags a charge inside the window that has a matching entry.
Lorraine left 4 West at 11:42. Hydromorphone 1 mg is charged at 17:42 with no MAR entry, and the PRN order was stopped at 10:05. Ondansetron, pantoprazole and enoxaparin follow that evening, then a room day for the day of discharge and a CBC and metabolic panel with no specimen the next morning — seven lines after discharge.
“No MAR entry · she left 4 West at 11:42 · PRN order stopped 10:05 · billed 6 h after discharge.”
Nadia opens the line. A time strip shows the last MAR entries, the discharge, the 30-minute window around the charge and nothing in it. The reason cites three sources — the nursing discharge note, the 25 Sep MAR and §6.6 Eligible charges — and the effect: $286.00 removed from eligible charges, $194.48 at 68%.
“Waiting for the auditor — no finding counts until a person signs it.”
The nursing discharge note, medical record p. 371, opens with the passage highlighted: “Patient left unit by wheelchair at 11:42.” Beside it, the five bill lines that rely on that page. The MAR, operative report and implant log, anesthesia record, transfers and midnight census, lab and orders are a click away.
The implant log scanned at the table shows 6 pedicle screws (L4, L5, S1 both sides); the bill has 8, so $7,360.00 comes off. Bone graft: 2 billed, 1 logged. The spine instrument set is billed again one minute later — §5.1 allows one per case — and the gown and drape pack is already in the OR rate.
Billed charges $418,624.90, less 73 flagged lines of $37,167.70, leave $381,457.20 eligible under §6.6. Paid at 68% that is $259,390.90, against $284,664.93 as billed. Eligible charges stay above $250,000, so §6.4 still applies. The letter to St. Aldric is drafted on template HP-L3, with the evidence for each kind.
Recommended reduction: $25,274.03 — 8.9% less than paying as billed.
Nadia signs every kind but level of care. The ICU day on 22 Sep — $11,960.00 billed when the transfer note and midnight census put her on 4 West, where the surgical floor rate is $6,840.00 — goes to Dr. Okonkwo-Reyes with the transfer note and census. He signs it, and the letter goes to Colleen Marsh at St. Aldric with all 73 lines cited.
“Letter sent to Colleen Marsh, St. Aldric · payment $259,390.90 released for Mon 2 Nov.”
Wexley General disputes three findings on a pancreaticoduodenectomy. A new intensivist note shows a vasopressor drip and an ICU bed at census, so the ICU reduction is reversed — the hospital is right. Albumin is upheld: the MAR records two doses given and two held. The response is drafted and sent only when Priya signs.
“Ordered is not given. The MAR records two administrations; the other two were held.”
The same stay, seen by the four people who carry it — what their day looked like, and what it looks like now.
Six agents match every charge to the chart by time and to the contract; the auditor signs each finding.
Turns the itemized bill into lines: revenue code, charge code, NDC when present, units, amount, service date and time. The lines must total the claim.
Reads the medical record for the stay and extracts timed entries: MAR administrations, orders, nursing notes, anesthesia record, implant log, transfers, the midnight census and the time the patient left.
Matches each charge to its chart entry by item and timestamp — 30 minutes for drugs, the day for supplies, the midnight census for rooms — and flags charges with no entry, after the patient left, by a different route, or above the documented units.
Applies the agreement and amendment in force on the date of service — room and board, routine supplies, operating room and stop-loss clauses — and flags duplicates by item and minute or specimen.
Compares each implant charge with the operative report implant log scanned at the table, by item and count, and with invoices when asked.
From signed findings only, recalculates eligible charges and the payment under the contract, and drafts the provider letter on template HP-L3 with the chart page and clause for every line.
Signs each finding; physician signs level of care. The agents propose; a named person decides.
Auditors, physician advisors and dispute analysts ask in plain words. Every answer cites the bill, the record, the contract or the billing rules it comes from.
Why is the hydromorphone charge flagged?
It is charged at 17:42 on 25 Sep. The nursing discharge note has Lorraine Abernathy leaving 4 West at 11:42, six hours earlier. The PRN order was stopped at 10:05, and the MAR has no administration after 09:00 that day. A charge for something not given during the stay is not an eligible charge. Four more pharmacy lines that evening have the same gap.
How much do we pay on this bill after the findings?
$259,390.90. Billed charges of $418,624.90 are over the $250,000 stop-loss, so the stay pays at 68% of eligible billed charges. Removing the 73 flagged lines ($37,167.70) leaves $381,457.20 eligible. That is $25,274.03 less than paying as billed. Eligible charges stay above the threshold, so the case rate does not come back.
Does St. Aldric bill after discharge on other stays?
Yes, more than anyone else. 31 of 214 St. Aldric stays reviewed in 2026 had charges dated after discharge, 14.5%, against 4.1% across our hospitals. 26 of the 31 are pharmacy lines posted 4 to 12 hours after the patient left.
Which findings need Dr. Okonkwo-Reyes?
One: the ICU room for 22 Sep, $11,960.00 billed. The transfer note moves her to 4 West at 08:15 and the midnight census has her there, so §3.2 pays the surgical floor rate of $6,840.00 — a $5,120.00 difference. Level of care is always signed by the physician advisor, never by an auditor or an agent.
13 screens from the working solution, on its sample data. Pick one to see it large.
Which bills are reviewed, how close a chart entry must be and who signs — changed in settings, versioned, with a second approver from payment integrity.
| Setting | Default | Choose from |
|---|---|---|
| Inpatient bills reviewed in full at or over | $100,000 | Any amount — every bill over it, no sampling |
| Outpatient surgery at or over | $40,000 | Any amount, on facility charges |
| Before payment | Pend the claim until the review is signed | On · Off |
| Window for a drug charge | 30 min | 15 · 30 · 60 min |
| Supplies matched to | Day of use | Day · Shift |
| Room and board | Level of care at the midnight census | On · Off |
| Physician advisor signs | Level of care, medical necessity, reductions over $50,000 | Any named physician advisor |
| Second auditor on the letter | Reduction over $25,000 | Any amount |
| Prompt-pay warning | 7 days before the state deadline | Any number of days |
Every figure is labelled: a target the solution is built to, an estimate, a typical published result, or a proven one.
“demo” = seen in the working solution, on its sample bill and record · “target” = the design goal, measured in the live solution · “estimated” = our estimate from auditor workload · “typical” = published figures (Claritev, Itemized Bill Review — charges that should not have been billed on 98% of reviewed high-dollar claims; AMPS, high-dollar hospital claims — about 80% of medical bills contain at least one error). People, health plans, hospitals and patients named on this page are fictional — characters and sample data in the working solution.
Itemized bill review (IBR) is the payment integrity check of a high-dollar hospital bill line by line against the medical record and the provider contract. It finds charges that are duplicated, already included in the room or OR rate, not documented in the chart, or posted after the patient went home. Itemized Bill Review does it on every line of every bill over the threshold, and an auditor signs each finding.
By item and by time. Each charge is matched to its entry in the MAR, nursing notes, anesthesia record or implant log within a window — 30 minutes for drugs by default, the day for supplies, the midnight census for room and board. That catches what item matching misses: drugs billed hours after discharge, a room charge for the day of discharge, an ICU rate after the transfer.
Every line, on every bill over the threshold you set. In the working solution that is every inpatient bill over $100,000 and outpatient surgery over $40,000, with 0 bills sampled.
It applies the contract version in force on the date of service. On a stop-loss stay it removes the flagged lines from eligible billed charges, checks whether they stay above the threshold, and recalculates the payment at the contract percentage — on the sample stay, $259,390.90 at 68% against $284,664.93 as billed.
Yes. No finding counts until a clinical bill auditor signs it, and level of care, medical necessity and reductions over $50,000 are signed by a physician advisor. The agents never change a payment, never contact a hospital and never decide medical necessity.
Yes. The letter gives the dispute window from the contract, 60 days by default. Each disputed line is re-checked against any new pages the hospital sends, with a recommendation to uphold or reverse, and the dispute analyst signs the response before it is sent.
The itemized bill and claim, the medical record for the stay, your provider contracts and amendments, and your billing and bundling rules. The findings letter and line file go to the hospital through your secure provider portal, and the claim can be pended until the review is signed.
The Agentic Solution Engine builds and deploys it from your requirements and documents — your provider contracts, billing rules, letter template and a sample of past high-dollar bills — and it goes live once every quality gate has passed. We will walk you through it on your own bills first.
Every criterion shown met or not met, with the page that proves it.
1-min demoUtilization Management AutomationNo missed 72-hour or 7-day deadline, and the yearly metrics from the same data.
1-min demoAppeals & Grievances ManagementEvery appeal decided on time, with the full file read and what is new marked.
1-min demoWe’ll run Itemized Bill Review on a sample of your own past high-dollar inpatient bills.