How the Two-Tier Review Works
Every demand package goes through two independent passes — a certified bill audit and an expert nurse clinical review — because each one catches what the other structurally cannot.
One Review Answers Half the Question
A demand package makes two separate claims at once. It says this treatment happened and this is what it cost. Testing only one of those leaves the other unexamined.
A bill audit answers the pricing question. It compares every line against jurisdiction-specific fee schedules and standard coding rules, and it is precise about what it measures. What it cannot tell you is whether the treatment should have been billed to this claim at all — a correctly coded, correctly priced charge for care unrelated to the injury passes a bill audit cleanly.
A clinical review answers the causality question, and it takes a nurse to answer it. Separating treatment that stems from the claimed injury from treatment that does not is a medical judgment, not a pricing calculation.
- Bill audit alone — you negotiate the price of treatment you never questioned.
- Clinical review alone — you challenge the treatment but accept whatever it was billed at.
- Both, in sequence — every charge tested for price and for relevance, documented to the same standard.
That second pass is also what makes a reduction defensible. A lower number backed by a certified clinical opinion is a position; a lower number without one is an opening offer.
What Each Pass Covers
Medical Bill Audit
Certified coders review every bill against jurisdiction-specific fee schedules, flagging improper coding, unbundling, and excessive charges across all bill types.
- Inpatient & outpatient billing review
- Diagnostic & prescription audit
- NCCI coding edits applied
- Unbundling & excessive charge identification
Expert Nurse Clinical Review
Certified nurses analyze causality, identify unrelated treatments, assess medical necessity, and deliver clear, actionable negotiation recommendations.
- Causality & relatedness analysis
- Unrelated treatment identification
- Medical necessity assessment
- Defensible clinical documentation
Delivered Through the System You Already Use
The review runs outside your team's workload and lands inside your existing process.
RMIS Integration
Syncs directly with your existing claims management system.
Chronological Package Assembly
Medical records organized chronologically into adjuster-ready packages.
Complete Audit Trail
Full visibility with time-stamped documentation for every review step.
One Package, Both Passes
The two tiers do not produce two reports. They produce one settlement-ready package in which the pricing findings and the clinical findings are already reconciled — so your adjuster is not left comparing a coder's spreadsheet against a nurse's narrative and deciding which one wins.
Every finding carries its source and a time stamp, which is what makes the package hold up if the claim proceeds to litigation rather than settling.
See Everything Included- Line-by-line bill analysis with recommended adjustments
- Proprietary medical treatment calendar
- Comprehensive nurse audit report
- Targeted negotiation strategy & key settlement points
- Complete time-stamped audit trail
How the Review Runs
Which tier runs first?
Tier I. The bill audit establishes what was charged and what the fee schedule allows before anyone looks at whether the treatment belonged to the claim. Running the clinical review first would mean forming a medical opinion about charges that may not survive the audit.
Who performs each tier?
Certified coders perform Tier I. Certified nurses perform Tier II. Every review on every claim is conducted by a certified reviewer — that is what makes the output consistent from one claim to the next rather than dependent on who happened to handle it.
What happens if the demand package is missing records?
Missing or incomplete documentation is itself a finding. The review flags what is absent and what would be needed to substantiate the charges, which gives your adjuster a specific, documented basis to request it rather than a general objection.
How does the completed review reach my adjusters?
Through your existing claims system. DemandPro integrates with your RMIS and delivers the finished package into the workflow your adjusters already use. There is no platform migration and no second system to log into.
Walk Through the Process Live
Bring a demand package you are working on. We'll show you what each tier would find in it.
- Walk through the full two-tier review process
- See a sample deliverable package
- Get your questions answered — no pressure
30 minutes · No commitment · Pick a time that works for you