This is part 1 in a 2-part series of articles about optimizing medical bill review programs. Click here to read part 2.
At their core, medical bill review programs solve for one single problem: While there are many regulations in the property and casualty industry, the industry generally lacks standards for what medical providers can bill. It is incumbent upon payors to accurately review and correctly reimburse in accordance with state adopted guidelines and fee schedules.
Workers’ compensation and auto casualty claims can be complicated, with a variety of touchpoints and different scenarios that could occur, along with the sheer level of complexity and ever changing nature of regulations and network agreements. To help simplify the process, most claims organizations use a combination of people and technology to help review medical bills to make sure they are paying a fair and accurate price for services rendered.
While most bill review platforms perform their core function—repricing medical bills—to a high standard, a bill review program also needs to be efficient, compliant and customizable in order to achieve the best results. To successfully weather challenges such as the COVID-19 pandemic and economic uncertainty, it is now more important than ever for companies to focus on optimizing the use of technology and increasing automation in their bill review process. As a case in point, a report from Bain & Company found that companies that invest in technology during or immediately following economic downturns can emerge stronger.
7 Steps to Evaluating Your Bill Review Program
To determine if your bill review program is helping you achieve the best results possible, start by analyzing the following seven components:
- Cost Containment
- Systems Integrations
- Data Insights
- Delivery Model
In this article, part 1, we will review steps one through four. Read part 2 to find out more about steps five through seven.
Step 1: Analyze Efficiency Within Your Organization
Improving efficiency is top of mind at most claims organizations across the country—insurance professionals reported in a 2020 Mitchell survey
that workflow efficiency was their top claims challenge. A robust bill review solution will offer claims organizations the flexibility to customize workflows to improve efficiency, allowing them to automate much of the bill review process. As a result of the COVID-19 pandemic, automation is more important than ever for claims organizations to keep up with their competition. A McKinsey study
found that 76% of information and technology executives reported increasing the implementation of automation and artificial intelligence since the start of the pandemic.
Claims organizations need to make sure they are taking advantage of all of the solutions available to them and are assessing different areas of their programs that could be automated or made more efficient and more effective. Ideally, an efficient bill review program would:
- Help segment and triage each claim quickly to the appropriate claims handler at the first notice of loss or first report of injury.
- Automatically process bills that match certain criteria (up to 60–70% of bills could be potential candidates).
- Outsource administrative tasks (for example, mailroom processing or medical bill payment processing)—a McKinsey study found that in about 60% of all occupations, at least 30% of employee activities have the potential to be automated.
- Integrate adjuster best practices and intelligence directly into the bill review process.
- Improve cost containment using fee schedules, networks and business rules.
- Optimize user experience by seamlessly integrating with other bill review and claims tools as part of the claims ecosystem (claims management software, ancillary and pharmacy benefit management systems, utilization review, IME, etc.) so adjusters can have all of the information they need in one interface.
If your program is not hitting these efficiency milestones, you should consider reassessing your internal automation procedures and workflow. You should also make sure that your current bill review software has the capabilities to allow you to make these types of efficiency gains.
Step 2: Optimize Cost Containment
A bill review program can help you easily and consistently pay the fairest price for medical bills, while also addressing any potential fraud issues. Consider these factors to boost cost containment:
Optimize Network Processing
Provider networks play a key role in an insurer’s cost containment solution. To truly improve cost containment, your bill review program needs an optimized network solution. Optimal network penetration can be achieved with a strong and strategic network partner portfolio and a robust modeling capability. The breadth and depth of a network portfolio are just as important as having the flexibility to adjust the network stack. As Lee Haripko, vice president of strategy and planning at Mitchell, put it, “The hierarchy of the networks and cost containment solutions have a tremendous impact on penetration rates, savings and turnaround times.” In order to achieve these benefits, you should be reviewing your network results and optimizing your network processing stack and portfolio on a regular basis.
The breadth and depth of a network portfolio are just as important as having the flexibility to adjust the network stack.
Review Non-Provider Network Savings Opportunities
While a combination of provider networks and fee schedules provide the bulk of cost containment on workers’ compensation and auto casualty claims, some charges can’t be impacted significantly by either. There are a few solutions to make sure you’re paying the fair and accurate price for bills that are not repriced through a provider network.
Medical bill review platforms—no matter how sophisticated—can’t read medical reports and apply the expert opinion of a certified coder or clinician. Use an auditing service that validates medical codes and charges to detect and correct inaccurate billing. On average, bills that run through an auditing solution for extra scrutiny can see an additional 9% savings on top of bill review allowable.
Negotiating directly with providers to accept a payment amount lower than the usual and customary and/or fee schedule allowance in exchange for timely payment can save on average a 20-50% contracted reduction off of original charges, according to Mitchell data. Consider outsourcing this service to expert negotiators to relieve your adjusters’ workloads.
Specialty Bill Review
For workers’ compensation claims, consider using a specialty bill review service to find the most appropriate payment on bills that fall into “gray areas,” such as when state payment rules are ambiguous, incomplete or don’t exist altogether.
Step 3: Compliance Table Stakes
From applying fee schedules to regulatory reporting requirements, your organization should not be penalized with late fees or fines. Your bill review system should be top-notch when it comes to compliance. Here are a few things to look for to make sure your program is doing what it needs to be compliant.
Timely Fee Schedule Updates
Your bill review system should have the most up-to-date fee schedule changes in place. The partner and software you choose for your bill review program should have an expert regulatory compliance team responsible for monitoring the regulatory landscape for new fee schedule mandates and working to support these regulatory changes with frequent system updates so you can feel confident that you are compliant with all of the latest rules and regulations in real-time.
Integrated Regulatory Reporting
If your organization manages workers’ compensation claims, your bill review system should also be connected to a program that helps automate regulatory reporting. With the right mix of integration, editing and automation, you can eliminate countless hours from your workflow, no longer creating and correcting regulatory reporting transactions.
It’s important that your bill review system is flexible enough to allow for immediate updates. For example, at Mitchell, we’ve made hundreds of changes within our bill review system since the start of the COVID-19 pandemic to address emergency bulletins and other changes. The workers’ compensation and auto casualty markets don’t always move that fast, but when they do, you want to make sure your program is prepared.
Step 4: Review Systems Integrations for Efficiency Opportunities
Between claims systems, bill review systems, scheduling systems, pharmacy benefit management portals and liability assessment systems, adjusters may access between three and 15 different software programs every day. Each of these systems helps adjusters do their jobs effectively. However, switching between systems and trying to gather information from multiple programs can be both time-consuming and error-prone. As organizations look to increase automation and optimize technology, claims organizations should assess the number of systems their adjusters need to use and strive to simplify. Here are a few areas to review:
To improve workflows, claims organizations should be looking for opportunities to provide adjusters with consolidated workspaces or portals that give them all of the information they need in one place. Providing a single portal not only facilitates efficiency improvements, but also quickly helps adjusters and claim handlers see the claim and bill information holistically. As a result, they will be better equipped to make informed decisions, ensuring the best outcomes.
Another way to simplify the claims decision-making process
for adjusters is to integrate systems
and the data that passes between those systems. Integrating systems and data can help facilitate adjuster decision-making by providing the right information at the right time. For example, when pharmacy benefit management and bill review platforms are able to talk to each other, adjusters can better see what providers are doing in the office and connect that with what claimants see in the pharmacy. This makes it easier for an adjuster to get a full picture of the claim without manually inputting data and therefore make better decisions.
Not only is it important to ensure all relevant claim data is passed between systems; it’s also important to ensure that the data is exchanged without delay. Many times, this timely data sharing can only be achieved through real-time integrations that include APIs and web services. When data is exchanged in real-time, it expedites processing and ensures that decisions are made with the most accurate and up-to-date information.
“In a Mitchell study, users who completed bill review tasks in a single page saved an average of 88% of total time spent to complete the task when compared to users who had to switch between multiple page locations.”
Exchange of real-time data also helps to facilitate real-time alerts. This is increasingly important as the complexity of claims handling increases, requiring systems to become increasingly “smarter” by assisting claims handlers in identifying areas of concern or early warning signals on claims.
System integrations can also help improve workflow processes and efficiencies. One example of an integration that can improve efficiency is connecting a direct-to-provider negotiation service
and an adjuster portal. By integrating these two solutions, adjusters can simply click a button to send a bill to be negotiated and then automatically receive alerts back with information from the negotiation process.
Without the integration, the process of sending a bill to negotiations can be tedious and time-consuming and an adjuster could easily miss updates that come back from the service.
Click here to read 7 Steps to Elevate Your Bill Review Program Part 2 and find out the final three steps to elevating your bill review program