Drug Trends Series – Part Two: Evaluating In-Network and Out-of-Network Trends
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Bill review is an essential component of workers’ compensation claims management, ensuring that services reimbursed meet the directives of the care plan and providers charge an appropriate amount for those services. Every state has different fee schedules, and the rules are changing all the time. Today’s providers are focused on rendering care versus all the idiosyncrasies of each regulatory rule, modifier, billing code, and other factors. Subsequently, opportunities for errors, omissions, or just incomplete billing become prevalent.
Research from the University of Minnesota has found that between 30% and 40% of all medical bills contain an error. Current bill review solutions are focused on simple, straightforward invoices, so that outliers can easily slip through the cracks — especially if software is out of date.
Over time, these misses can cost payers thousands, if not millions of dollars.
But bill review is more than just catching common billing errors. Unanticipated charges can indicate that clinical treatment is not aligning with the plan of care or is deviating from the course of treatment initially outlined. Identifying these deviations can help course correct and keep the plan of care on track. Getting it right means better outcomes for injured workers, employers, payors and medical providers alike.
The best bill review solution requires leveraging advancements in technology and the expertise of analysts to catch even the smallest of discrepancies. Here are three components of a more agile bill review solution.
Workers’ comp is known for being a state-by-state system.
“Every jurisdiction has its own way of doing things when it comes to how treatment is authorized and reimbursed,” said Lori Landon, Vice President, Network Solutions, CorVel. “Some states like California, Texas, and Tennessee have specific utilization review requirements and timelines for payors to review and approve prescribed treatment, whereas other states do not even recognize utilization review processes at all.”
Conversely, some states have defined fee schedules and reimbursement rules for different types of care rendered in various settings, ie. — inpatient versus outpatient — while others allow reimbursement based upon usual and customary values. Usual and customary values are a much looser criteria in which charges are accepted as long as they seem reasonable. And the rules in place today may not be the same next month.
That’s why bill review needs to be overseen by people with jurisdictional expertise – in tune with the ever-changing landscape of bill review and treatment authorization regulations.
“Bill review is not just the simple application of rules or fee schedule rates. There’s a lot that goes into understanding and interpreting the legislation rules and regulations,” Landon said. “Our teams are locally connected, and they have an in-depth knowledge of the existing laws as well as the proposed upcoming legislation changes. We’re able to actively participate with local and state representatives as proposals for changes in rules and regulations are being put forth, allowing us to bring that information back to our clients and partners to educate them about upcoming changes and proactively anticipate and implement those changes in our systems and workflows.”
A solution that incorporates local expertise and continually adapts to legislative changes minimizes opportunities for inaccurate charges to go unchecked and enhances regulatory compliance.
Many bill review solutions rely on automation to identify and flag inaccurate charges without human intervention, but the algorithms often are not advanced enough to identify smaller discrepancies or suspicious patterns.
“We hear a lot about automation and AI, and we know that there are a lot of repeatable processes within bill review that are ideal for automation. But that technology is most powerful when you apply it to more complex activities and leverage machine learning to recognize patterns and flag outlier activity that common repeatable routines would not identify,” Landon said.
An advanced bill review system looks at more than just a single bill in isolation, but rather leverages the intelligence of the system remembered knowledge of the computer to perform a more comprehensive review of that bill in context of previous bills from that provider and in context of all previous claims including the procedure code in question to better identify potential issues that may be overlooked if only the bill in question is being reviewed. It can also evaluate all available medical records and collect those most relevant so that bill analysts can gain a more holistic view of the treatment and whether it was appropriate and justified.
“Collecting and presenting all that data allows the bill analyst to make a more targeted and informed decision. It’s not about removing the human factor but empowering our analysts to apply their expertise and judgment with the benefit of the machine’s processing power,” Landon said.
Capturing information from medical records is really the next step of applying AI to bill review.
Clinical oversight is a crucial component of effective claims management. And it doesn’t stop with the management and coordination of treatment. Clinical oversight must integrate into the medical bill review processes and solutions, or much of the good work and effective management can be undone.
“Having a bill review platform that takes previous clinical decisions into account as payments are being processed is pivotal in ensuring that clinical expertise and efforts are fully realized in the claims management process.” said Landon.
If clinical decisions, such as treatment authorizations and negotiations, are not integrated into your bill review platform, these decisions can be overlooked or misapplied — resulting in extra administrative costs and incorrect reimbursements.
Bill review is a dynamic process. Thanks to continual legislative changes, evolving standards of care, and nuances from one workers’ comp program to the next, bill review can only do its job when it adapts to a client’s specific and changing needs.
“One of the things that is very unique about CorVel is how effectively all of our managed care solutions and network offerings integrate with each other but can work independently when the need arises to support unique client program requirements,” Landon said.
No two clients have the same needs in their workers’ compensation program. A client should look to customize its program based on those unique needs and choose a partner that meets those needs today while being nimble enough to meet tomorrow’s new challenges.
Some workforces that engage in more manual labor have a higher incidence of musculoskeletal injuries that demand more physical therapy. Others will be based in rural areas that rely heavily on telehealth services. All will have varying pharmacy, DME and home health needs. CorVel’s managed care solutions allow clients to tailor their programs according to their unique needs.
“Bill review is just one part of a continuum of service. It’s not about accepting or rejecting charges — it’s about really looking at our clients’ areas of need and seeing how we can bring in our different solutions to help.”
To learn more, visit https://www.corvel.com/.
This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with CorVel. The editorial staff of Risk & Insurance had no role in its preparation.