5 Qualities Workers’ Comp Professionals Should Look for When Choosing a Medical Bill Review Provider

As medical price inflation increases, many in the industry are turning to medical bill review vendors to identify opportunities for cost savings.
By: | February 11, 2023

As the consumer price index continues to chart rising inflation, many in the workers’ compensation industry are wondering how medical services will be impacted by rising prices.

Overall prices for consumer goods increased 7.7% in October 2022 compared to the previous year, a Kaiser Family Foundation report found. In comparison, prices for medical service increased only five percent over the same period.

Medical price increases may lag behind consumer inflation, especially when it comes to workers’ compensation care (which is based on fee schedules), since it takes time for states to update their fee schedules to match the rates providers are charging.

“It’s been a very long time since we’ve had inflation on this scale,” said Melissa Payne, director of medical bill review at Optum Workers’ Compensation and Auto No-Fault. “I can see payers spending quite a bit more for procedures in the coming years.”

Melissa Payne, director of medical bill review, Optum

As prices increase, workers’ compensation professionals may seek out medical bill review vendors to help identify opportunities for cost savings. Medical bill review vendors are trained in billing codes and they can identify errors that claims professionals may miss.

“With the rising costs of medical care and the rising charges coming from providers, you’re going to see more companies looking for a sophisticated bill review vendor,” Payne said.

When choosing a medical bill review vendor, there are a number of factors to consider. Here are five things to think about before selecting a vendor.

 1) Expertise and Industry Knowledge

 The first thing to consider when selecting a medical bill review vendor is their knowledge of the industry.

“It’s important that your vendor validates the accuracy of coding and billing prior to submitting bills for PPO network reductions in order to enhance the financial and clinical outcomes of your program,” Payne said.

Businesses want to partner with medical bill review providers whose coders have extensive training in medical billing and coding, so that they can readily spot errors. Payne recommends seeking out a medical bill review provider whose coders have been through a medical coding training and certification program, such as those offered through the AAPC.

“They know exactly how claims should be coded by the provider’s billing office,” Payne said. “You want a vendor that’s not simply applying reductions based on the fee schedule, they’re also looking for appropriate billing practices from your medical providers.”

 2) Technological Sophistication

Partnering with a qualified team of medical bill reviewers is important, but it’s also crucial to choose a vendor who uses technology to flag potentially problematic bills.

Artificial intelligence systems can be trained to detect any potential billing errors and flag them for a coder who can determine the appropriate course of action.

Matt Newell, vice president of medical and out-of-network bill review with Optum Workers’ Compensation and Auto No-Fault, says that bill review solutions should aim to reduce medical spend by between 8 to 12% on average. As these machine learning systems continue to improve, those percentages should only increase.

“Any technology used to help identify bills with potential billing errors can help a company achieve that 8 to 12% savings,” Newell said. “Companies are becoming more sophisticated in identifying ways to drive down costs for insurance carriers.”

 3) Strong Customer Service

Claims adjusters often have heavy workloads. They manage multiple claims at the same time, working with different providers and injured workers to make sure recovery is progressing. They also handle administrative tasks associated with claims, such as processing claims and ensuring workers receive their workers’ compensation or disability payments.

That’s why they value prompt customer service from medical bill review vendors. If they have questions, adjusters want to know that their vendors will respond quickly so that the claim can stay on task.

“The feedback most often passed to us from clients or potential clients is that they want a vendor partner who actually answers the phone when they call, or answers an email when they send one,” Payne said.

Matt Newell, vice president of medical and out-of-network bill review, Optum

The best medical bill review vendors will work with clients to understand their specific sector and customize their programs to meet the needs of a specific team of adjusters.

“It’s important to choose a vendor that can tailor its program to fit within your workflows and make the process easier for your adjusters,” Payne said.

 4) Easily Integrated Systems

Streamlined, easy-to-use bill review platforms are appealing to providers because they allow adjusters to focus on guiding providers and injured employees through the workers’ compensation process.

 “They’re already dealing with providers and claimants, and they really don’t want to do a ton of work when it comes to approving a bill on a platform. They want something simple and easy,” Payne said.

One way medical bill review vendors can reduce adjuster workload is by fielding bill payment and processing requests from providers.

Many vendors have portals where providers can log in and check the status of bills and payments so that they don’t have to bother claims professionals with these requests. These tools increase transparency and decrease the amount of time claims professionals spend on administrative tasks, allowing them to focus on helping injured workers.

Optum found that having a portal where providers can check the status of their bill reduced inquiries from physicians by 50%.

“Ultimately, we want adjusters to focus on claimants and not bill payors,” Newell said. “It’s our job to remove that administrative burden from adjusters.”

 5) Increased Savings

 Workers’ compensation professionals partner with medical bill review vendors in order to increase cost savings, so it’s critical to select a partner with a proven track record of helping clients identify which costs are appropriate and which are not.

“Your bill review partner’s process should support payment integrity with the lowest, fairest, and most appropriate payment to the provider,” Payne said.

Payne and Newell recommend seeking out a vendor that has a strong clinical auditing program. During the auditing process, medical bill review professionals will examine clinical data to determine whether the treatment was priced correctly and appropriate for the injured worker.

“When we get these medical bills, we’re not just taking them at face value and assuming that the provider’s billing office billed them correctly,” Payne said. “We’re actually looking at medical records to determine whether the service level billed was appropriate or whether the X-ray billed is appropriate based on the documentation submitted.”

 Is There a Benefit to Using the Same TPA and Medical Bill Review Vendor?

While not required, many workers’ compensation professionals prefer to work with one vendor for medical bill review and TPA services.

A single vendor can streamline the workflow for adjusters by allowing them to work with a single platform and to contact one vendor with any questions they may have. Additionally, using one vendor for both PBM and medical bill review services gives claims professionals a broader view of each individual claim. They’re able to see both the medical interventions and the pharmaceutical treatments in one place.

“You’re using one vendor. That means one eligibility file, one connection,” Newell said, However, it’s not really about having a single vendor so much, but that you have the right vendor.

“Having combined pharmacy and bill review data provides a clearer picture of the injured person’s overall treatment,” Newell said.

As the demand for medical bill review vendors increases, more providers will enter the space. When considering what vendor is right for them, insureds should consider their industry expertise, technological systems, customer service, and how much they can save by working with a medical review provider.

“With greater technical sophistication comes deeper cost reductions,” Newell said, “and this allows increased growth opportunity for our clients, as well as our organization.” &

Courtney DuChene is a freelance journalist based in Philadelphia. She can be reached at [email protected].