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By JACQUELINE PAYNE, the vice president of managed care operations at Aon eSolutions, overseeing the bill review and case management service and software products

"Many hands make light work," the saying goes, but when it comes to the efficient and accurate processing of workers' compensation claims, too many hands in each case can lead to confusion and affect the bottom line of the claim.

Let's break it down on how the system should work in the ideal world of workers' compensation as it relates to the treatment process.

--The treating physician examines the patient and determines treatment.

--The physician's office staff contacts the claims office for approval of treatment plan, but is redirected to a nurse case manager for preauthorization.

--The nurse case manager compares the treatment plan against industry-standard treatment protocols and either approves, denies or determines that it needs to be modified.

--In some states, a nurse does not have the legal authority to modify or deny treatment so it is then referred to a peer reviewer (typically a physician of similar specialty of the treating physician) for final determination.

--The decision is then communicated to the bill review department.

--The bill review department is responsible for reviewing submitted bills from the provider to state-mandated fee schedules, PPO contracts and certifications from nurse case managers. Bill review is typically outsourced to an outside contractor.

--Bill review then receives the invoice from the treating physician and compares it to the "note" from the nurse case manager.

--Approved treatment is only paid for ? denied treatment is not.

This is an eight-point plan at best. With so many parties involved, many disconnects can occur throughout the treatment approval process.

The nurse case manager or claims personnel might modify the treatment plan as presented by the treating physician. This might be communicated to the physicians' office staff but the treating physician will treat outside the plan, regardless. The bill review staff is unaware of the treatment modification and pays for the unauthorized treatment. Unfortunately, claims personnel many not catch the mistake until after the provider is paid.

Another source of communication breakdown could be electronic, specifically in the software systems. Assume that all parties communicated perfectly which each other throughout the process. However, the carrier, TPA or self-insured employer may be operating in three or more various software platforms. A risk management information system handles the claim, a nurse case manager system handles the preauthorization process and bill review has its own system to adjudicate bills. Even if the entire process is handled by one entity, multiple systems could be at work. Typically, the various systems do not "talk" to each other when it comes to treatment authorizations. There is a lack of data communication between the different software platforms

Without the proper communication systems in place, thousands of dollars are paid out unnecessarily. A typical example would be in physical therapy. If a provider requests 12 visits of physical therapy but only six were authorized by the nurse case manager. If it were not caught by bill review, those six visits, typically totaling $790, would have been paid out to the provider.

Another more expensive request is for inpatient stay on a back trauma without evidence of acute or progressive neurological findings. Treatment protocols typically deny the inpatient stay. If the nurse case manager does not communicate the denial to bill review, another $5,000 would be lost in savings. Expensive? Yes. A common occurrence? Yes.

How can you build the bridge of communication for treatment requests? Some prefer to hire an industry consultant. These professionals should complete a thorough analysis of the data communication between all parties and help establish client protocols to ensure the entities are in compliance. They should also provide a level of expertise during the RFP process for claims, nurse case management and bill review services. And most importantly, they should help build reports to ensure the communication is up and running. These reports should include all the treatment modifications and denials compared to what occurred in bill review.

Another solution is improved technology. The first step is to ensure that all systems are "talking" to each other. A software program that allows the claims system to receive and output communication to the nurse case manager and/or bill review would eliminate the potential for lost savings. The nurse case management and bill review system have some sort of automation of the decision making process--keeping it out of human hands. An automated data dump of communication.

The particulars of the treatment are broken out in detail including CPT and ICD-9 codes, dates, provider TIN's, to name a few. The more detail the data, the better the output of savings. A simple but yet highly efficient idea is to have claims, nurse case management and bill review all on the same software platform--a "one system" approach. This eliminates the need for data sharing and provides instant access for all parties of the goings on of treatment status.

Something to watch--many managed care vendors claim to be working on a single platform--but are they really? Look a little closer, dig a little deeper and ask more pointed questions. Even if it is the same company, they may be leasing various software systems or have built separate systems as others are added as an afterthought. Find out if they own or lease the software, obtain the name of the software, have them physically show you a demo of the system and how it interacts with other systems--from soup to nuts.

Most of us would agree that the treatment authorization process can be convoluted with potential for various communication breakdowns at any time. But with the right solution in place, you can make a difference to the bottom line. In the end, these cost savings will make an incredible difference.

November 1, 2009

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