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There is widespread anxiety though, about a litany of alleged provider misbehaviors that include errors in diagnosis, inordinate delays and aggressive billing.

All the while, medical spending per workers' comp claim is expected to surge. As in all things workers' comp, California appears to be headed for the worst news, with a projected annual growth rate of around 9 percent.

Let's look at how a regional insurer, Texas Mutual, is investing in information technology. This insurer knows its provider community well and has a track record of leadership in a state that has focused on improving relations between medical providers and insurers.

Approximately 12 years ago, it got out of the antique business of handling paper medical bills by using scanned copies.

Today, Kim Haugaard, Texas Mutual's vice president in charge of provider networks and medical operations, is promoting electronic submission of bills. Texas was the first state to encourage electronic billing. Haugaard estimates that e-billing, auto-adjudication of bills, and participation in the insurer's network lowers the turn-around time of bill payment by 33 percent.

His providers include not just the large occupational medicine clinic chain of Concentra, which embraced electronic billing years ago, but also single clinician offices with primitive systems. As of today, Haugaard doesn't think that provider e-billing will exceed 40 percent of medical bills at least in the near future. Within Texas Mutual's network, e-billing is more common.

Texas Mutual has been using a medical bill review platform which automatically flags bills that require pre-authorization or a special review. The medical auditor can quickly search for the pre-authorization approval and compare it with the bills. That person then can also dispatch the bill for study by a specialist, for instance an internal or external expert in hospital bills.

Haugaard is contemplating an enhancement for the bill review system to automatically reconcile a bill with its pre-authorization data.

The medical bill review system's ability to flag bills can help where the insurer suspends pre-authorization requirements for preferred providers, because it can easily find these treatments for a post audit.

Haugaard can also send bills based on their features directly into completely automated analysis and payment processing--auto-adjudication, which one bill review expert told me could work for 60 percent of workers' comp medical bills.

Left largely unaddressed to date are the extreme front-end and back-end of the business relationship. Providers who use e-billing can look up coverage data for the injured worker, but cannot get an automated pre-approval. Nor can they receive their payment electronically.

On balance, Texas Mutual has conceptualized the entire electronic pathway between providers and itself, and is constructing it with its vendors, step by step.

PETER ROUSMANIERE is an expert on the workers' compensation industry.

September 15, 2010

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