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By MICHELE IACOBACCI, vice president of information management and support, Mitchell Medical

Insurance carriers fall into one of three categories when it comes to medical bill review solutions. They may have an existing solution, which may be suited for current and future evolution of the medical claims arena; they may have a solution in place, which needs updating and refreshing to reflect a constantly changing medical billing world and finally, they may have no medical billing solution at all.

The need for training and retraining of medical bill review personnel and claim professionals is a pressing issue for all insurance carriers in the casualty insurance arena. That's whether they have a good technology solutionor are upgrading and adopting ones able to cope with the complexity of medical billing and claims adjustment in an era of tightened federal standards and electronic billing.

Training claim representatives includes a combination of customized, face-to-face training and online coursework, especially in those areas hitting insurers' profitability hard, such as fraud detection, or recognizing which claims merit special handling. Partnership training is necessary here, because the best medical bill solutions fit into a carrier's workflow and personnel patterns.

The challenge is how fast claims analysts and adjusters get up to speed. For that to happen quickly a medical billing solution has to include a mix of training methods. Having the ability to customize training for a carrier is a win-win for the carrier and employee. Allowing paced courses online and a combination of vendor and carrier-training courses to include carrier workflow are the most successful implementations. We also cannot forget the need for continuing education.

Back in the day, training consisted of face-to-face interaction or was made up of video presentations. Often the training had to be conducted all at the same time to maximize insurance carrier resources. Today, the training includes go-at-your-own-pace methodologies that allow the claim representatives to be trained while still keeping up with day-to-day activities. The most successful training and education programs are designed to be interesting, quick, on point, include the carrier's personality and requirements and are easy to use.

Rolling out a new medical bill review system or upgrading to newer versions is a major aspect of software and solutions implementation for carriers. The training is considered an integral part of the implementation and will not be a success without the partnering of carriers and vendors.

Major categories addressed to insure a successful transition and implementation of medical bill review solutions include:

Defining carrier workflow. For medical bill review, this entails evaluating every possible step and point of contact a medical bill travels at the carrier. From the mailroom to the provider payment, a complete understanding is necessary to implement and prove value. Often workflow analysis is done at the point of sale or during the pilot phase. Maximizing resources and workflow proves the concept and return on investment from the start.

Gap Analysis. If a carrier has an existing medical bill review product and is changing to a new solution or an upgrade is occurring, it is extremely important to train staff on the differences. This not only sets the correct expectation but prepares the claim representatives for any new edits or review criteria they may not be familiar with.

Coverage. Training in the use of medical bill review is coverage-specific. During the workflow analysis, the coverage types are discussed and mapped separately. Training is geared either to the first or third party claims representative's job function. The intent of medical bill review varies with coverage differences. First-party claims are workflow specific and require immediate action whereas bill review in third party is done in bulk and is used as part of a negotiation. These considerations and the carrier's preferences need to be trained by both the carrier and medical bill review staff.

Documentation. Carrier preference is gauged as to whether or not the vendor provides customized documentation or whether the documentation is part of the carrier's best-practice standards. Often the carrier chooses to integrate the vendor's documentation into a complete training strategy with details that are specific to the carrier's policy and practices. Either way, documentation will provide additional information regarding why processes are followed and can be used to train new employees and refresh experienced users.

Online Universities. A bill review vendor who provides an online university for software products is an excellent resource. Some carriers choose just to utilize these self-paced knowledge driven courses instead of face-to-face training classes.

The intent of most online universities is as an adjunct form of training. In other words, online universities are often used in addition to face-to-face training.

The most effective online universities are accessed and courses completed by claim representatives before the face-to-face training. This limits the time away from the claims desks, and training can be accomplished with little disruption.

Online universities can also be accessed later as retraining needs arise. This type of training is effective in centralized or decentralized locations where claim representative work remotely.

Webinars. Over the past several years, webinars have been utilized more and more as a cost-efficient alternative to face-to-face training. They not only provide convenience for remote employees, but also allow for live interaction with trainers, key carrier personnel and flexible schedules. Most webinars can be saved for future use. Webinars are used most often in conjunction with the online university training methods.

Face-to-Face. Face-to-face training is most effective after online university training and/or Webinars have occurred. Over the past five years, the medical bill review training programs when performed face-to-face took approximately two-and-a-half days to perform. Now, with the addition of go-at-your-own-pace online courses, face-to-face training can be limited to four hours. This is a step forward in providing efficient and cost effective programs.

The best way to know if you have hit "touch down" is to survey participants for specific training issues as well as include an event-driven survey. Specific questions to ask regarding the training are related to:

--Online university and content. Was the program easy to use? Was it valuable? Did it provide the information to get you started appropriately?

--Trainers. Both in the webinar and during face-to-face training; were trainers knowledgeable? Did they dispense appropriate information? Did they exhibit professional behavior?.

--Understanding your business. Did the vendor understand your business where the solution fit and how to train your claim representatives inclusive of workflow?

--Overall experience. Would you recommend the vendor to other companies, value of the software to your company and suggestions for change?

In today's environment of staffing fluctuations and the need to retrain and educate--training expertise performed well at the beginning, understanding what is to be expected and versatility of the chosen vendor is key to operating an efficient training program. One of the top reasons for attrition (voluntary and involuntary) at carriers is lack of knowledge and training. It is much easier to maintain knowledgeable staff from the start, than it is to constantly retrain new staff. The loss of knowledge will demonstrate itself in lower performance levels and cost over time.

We are in an evolution in the casualty claims industry and need the abilities of a versatile and experienced training team from vendors of medical bill review software to partner with casualty carriers. This experience and partnering of resources will allow best practices to be instituted and to become consistent and repeatable no matter what level of training is provided.

October 1, 2009

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