This is part 2 in a 2-part series of articles about optimizing medical bill review programs. Click here to read part 1.
In order to take your medical bill review program to the next level, you need to look into the details. From reporting and analytics to security, it is crucial that you have the right tools in place across your operation. In part 2 of 7 Steps to Elevate Your Bill Review Program, we will take a closer look into the final three steps to evaluating your bill review program, including evaluating your analytics program, validating security measures and assessing the costs of your bill review delivery models.
Step 5: Evaluate Your Analytics Program
In-depth and real-time actionable reporting and analytics can help provide a full picture of the workers’ compensation and auto casualty claims process and allow organizations to address potential issues before larger problems arise. More and more claims organizations are adopting analytics in the claims process to help guide decision making. A recent report
found that the global insurance analytics market is expected to grow 27% from 2020 through 2026, with the rapid adoption of data-driven decision-making and the growing adoption of advanced analytics techniques driving this growth.
In-depth and real-time actionable reporting and analytics can help provide a full picture of the workers’ compensation and auto casualty claims process and allow organizations to address potential issues before larger problems arise.
Due to the continuing COVID-19 pandemic, analytics programs
are becoming increasingly important—Bain & Company
recommends that organizations overhaul their traditional forecasting models to help better adapt to market uncertainty and the other complexities surrounding the effects of the pandemic. As you consider how to enhance your bill review reporting and analytics program, here are a few key features you should try to incorporate:
Surface Key Findings
Use analytics to surface key findings in the claim to help give adjusters the full picture so they can improve their decision making. For example, the technology exists to help analyze if a claimant has been seeking treatment outside of the set treatment timeline or if a bill submitted for treatment is unrelated to the injury. These types of analytics provide immediate information to adjusters so they can make better informed decisions, ultimately having a direct effect on the claim outcome.
Provide Predictive Analytics
Implementing predictive analytics
into the claims process helps claims organizations more accurately predict the severity of a claim or anticipate the symptoms associated with a type of injury. These types of predictions allow claims organizations to accurately triage claims to the right adjuster or group of adjusters to help make sure the claims are handled appropriately from the start.
Analyze Provider Data
Fraud accounts for 5–10% of claim costs for U.S. and Canadian insurers, costing about $80 billion per year for all lines of insurance, according to the Coalition Against Insurance Fraud
. Using data visualization, a provider data
tool can help claims organizations analyze medical provider treatment and billing behaviors to identify irregular activities that may signal fraud, waste or abuse.
Analyzing provider behavior and surfacing key insights for adjusters can help them understand when a particular provider might be charging above the industry averages for a specific treatment, or to identify treatments that may not be necessary for certain injuries. Adjusters and nurses can further scrutinize questionable billing or treatment practices or ultimately refer them to your Special Investigations Unit (SIU). For example, if a provider’s activities raise a red flag, a provider data tool can help compare billing practices across peers in multiple counties. You can dive deeper into the claim-level details to see which codes were charged and to better understand the provider’s billing habits and refer to the SIU for more scrutiny if needed.
Implementing these types of provider analytics helps claims organizations be more confident that they are paying a fair amount on claims across the board, and that the injured party is getting the right treatments.
Give Insights into Internal Claim Operations
Internal reporting and analytics can help give managers at claims organizations insight into how their claims departments are operating. Specifically, there are a few key metrics that claims organizations can consistently track at the bill review level to help them make real-time adjustments and improvements, including: bill inventory, pend aging, productivity and throughput. Providing managers with insight into this type of reporting can allow them to fully understand how their department is operating and use those data points to make key decisions to improve business outcomes.
Step 6: Validate Security to Help Mitigate Risks
Data security is of the utmost importance in the industry and especially crucial in bill review systems—and the systems that integrate with them—which house a significant amount of medical data. Unfortunately, healthcare data breaches are quite prevalent. In 2019, there were 1.4 healthcare data breaches of 500 records or more reported per day, according to the HIPAA Journal
. In 2020, the average cost of a healthcare data breach was $7.13 million, according to IBM
. Claims organizations should have a robust data security program to help prevent breaches. Here are just a few security best practices to put into place:
Verify Partners’ Security Measures
As most claims organizations partner with one or more vendors for various parts of their bill review programs, it is important that you hold your vendors to the highest security standards. It’s also critical that you independently verify their security measures through onsite visits, security assessments and audits. NIST
, an industry standard for security, recommends a zero trust architecture.
Continuous Training and Education
Make sure your organization and the partners you work with continuously update security training programs to include new phishing scenarios to consistently educate employees about the latest security threats.
Consistent and Continuous Monitoring
You and your technology partners should consistently monitor for security risks and issues. We also recommend that our clients continuously monitor federal security channels for emerging trends. Some recommended channels to follow, especially during the pandemic
, include the Cyber Security and Infrastructure Security Agency Coronavirus page
, the Department of Homeland Security Cybersecurity page
and the Federal Communications Commission COVID-19 Scams page
Step 7: Assess Costs of Bill Review Delivery Model
Claims organizations have the option to operate their bill review program in-house, outsource to a bill review expert or operate using a blend of both approaches. The COVID-19 pandemic has put a lot of pressure on claims organizations’ top and bottom lines, which has in turn, caused many companies to adjust their operating models to accommodate to a new way of working and accelerate automation. McKinsey estimates
that due to the COVID-19 shutdown, the world “vaulted five years forward in consumer and business digital adoption” in about eight weeks.
As organizations face cost pressures in today’s world, many are asking if bill review is a core competency that they should invest in or something that is better outsourced.
If you’re licensing a software platform today and would like to better manage costs, improve efficiency and/or help your adjusters focus on their core tasks, you should consider outsourcing all or parts of your bill review program to a trusted partner. A few of the main benefits of outsourcing include:
Better Management of Operational Costs
Eliminate costs related to manual labor, training, facility management, internal mailroom operations and more. A Deloitte study
found that the majority (59%) of organizations that outsource their operations do so to save costs.
Improved Outcomes and Accuracy
Most claims organizations aren’t experts in bill review. Consider outsourcing to a company that stays ahead of the curve in understanding the latest regulatory changes and cost containment methods to help improve outcomes and bill review accuracy.
Be better prepared to scale your operations based on changes in bill volume or other factors. A bill review partner should be flexible so that as economic conditions shift, changes can be made efficiently and cost effectively.
Reduced Administrative Burden
Take essential administrative tasks off your adjusters’ desks by having a trusted partner manage your bill review, mailroom and data capture program, thereby allowing your team members to focus on higher-value tasks.
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The Hidden Cost of Complacency
After completing the exercise above, you may have found parts of your bill review program that aren’t operating as efficiently, cost effectively or accurately as you might hope. While some of these issues might be easier to overcome, others may be more challenging. If that’s the case, it may be time to consider making more significant changes in your bill review program to address some of these issues at their roots.
While it’s easy to become complacent and get comfortable with a bill review vendor—especially if the relationship has existed for a number of years, and the service has seemed adequate—it can put your company at risk, especially when compared to others implementing more innovative approaches. You should consider what a lack of competitiveness could mean for your organization over time. What will it truly cost? Perhaps it may result in a reduced ability to retain or bring in new business.
Perhaps your company will gradually become overwhelmed with manual processes, inefficiencies, non-compliance penalties and service issues. Though the effort to switch vendors can seem daunting at first; in the long run, making a bill review vendor change can result in major business improvements.
If your organization is striving to achieve a leadership position in the market, your bill review vendor should, likewise, rise to the challenge and help you achieve this objective. To do this, a vendor must be willing to work collaboratively to get to the root of any issues, solve problems as they arise, as well as proactively look for ongoing opportunities to improve results. Ask yourself this: Am I working with a vendor that’s competent or one that I view as a critical advisor and partner? It’s an important distinction. A competent vendor will likely give you more of the same service and results, while a progressive partner with a leadership mindset will strive to deliver increased value in every aspect of its service.
For more information about Mitchell’s bill review program, visit mitchell.com/billreview