The two overarching issues in work comp bill review are state reporting and the non-connect between utilization review/medical management and bill review.
Bill Review
Workers comp payers spend hundreds of millions of dollars each year on medical management – pre-cert, utilization review, peer review, case management, clinical guidelines, and the variations and permutations thereof. Dozens of companies from mom-and-pops to regional players to industry giants like Coventry and Genex employ highly trained professional medical personnel to watch over the care delivered to injured workers, carefully reviewing and approving or not approving thousands of medical procedures.
Then, the medical bills come in to the payer. The frightening/amazing/unconscionable truth is that many non-approved medical treatments actually are performed, and billed for, and likely paid – because those determinations are not automatically fed into the bill review system’s database, and/or the bill review system can’t link the determination to the bill/provider/claimant.
How much of this actually occurs on a national basis is impossible to say, and there’s no doubt some payers have the links in place to ensure most if not all medical management determinations are linked to the right claimant/provider/event.
But many payers do not have this link in place and/or it doesn’t work very well and/or it requires a human to make the link, dramatically increasing the opportunity for error.
I’ve seen anecdotal evidence of this non-connect in audits performed for payer clients, but this is the first evidence I’ve seen of an industry-wide issue.
Implications
There are a number of potential implications, starting with the obvious – how much are payers spending on treatments that have not been authorized or were actually non-authorized? How much are payers spending on medical management programs/services that are not delivering results due to the bill review linkage issue? Which systems/vendors have these links in place, and how well are they working?
State reporting
State reporting is another issue; friend and colleague Peter Rousmaniere has long proved his ability to cut right to the heart of the issue and he did it again in an email to me this morning wherein he asked the question that is likely on many bill review/IT managers’ minds – what exactly are states doing with all the data they are forcing payers to send to them? Are they doing anything? If so, what, and how will that benefit the industry, employers, society? When?
These are both vitally important issues, albeit for different reasons. But at their core, the question we should be asking about both is the same; what are we getting for our expenditure of time, effort, intellectual capital, and money?
Jun
3
If these bill review companies would spend more time on the big things, like making sure pre-auths are done and managing sick patients, rather then playing the “bill review” games of downcoding, automated bill edits and UCR reductions so that we have to appeal everything maybe there wouldn’t be so many issues with non certified procedures being done. I for one would like to see you do a survey from the Providers side about bill review companies. Then when you have to discuss the appeal with somebody, you get sent to India or some other foreign company where the only response they can give you is off of some script. Bill review companies are in it to cut as much of a Dr’s bill as possible and make it more difficult for a Provider to get paid a fair fee for their work.
Peter is absolutely correct…what ARE the states doing with all this data that they are acquiring annually? They certainly aren’t using it to develop fee schedules that accurately reflect the charges of providers in their own state. Instead, they forego taking any responsibility and instead lean on Medicare’s payment model (originally designed only for those 65 and older). And as a result, EVERYONE suffers.
Until States go back to taking responsibility for their OWN fee schedules, freely and openly providing data in a standard electronic format that both payers and providers can understand and utilize, and using data gathered to implement shifts in pricing and and treatment, we’ll continue to see the same problems that have long plagued this industry.