Workers' compensation medical bill review requires an innovative solution that removes guesswork
Unfortunately that pesky question pops up way too often during the course of the bill review process, according to Sam Gabal, senior solutions consultant at Aon eSolutions.
Gabal says historically, as part of the workers' compensation bill review process, medical bills are routinely sent out by claims examiners to a separate entity, either internal or external, for review and adjudication. On its face, using a separate bill review analyst is not the issue. But, due to inefficiencies and non-integrated data management, problems in the form of costly delays often can and will develop.
"Typically, claims examiners send the medical bills off and hope for the best," said Gabal, who is located in Aon eSolutions' Newport Beach, Calif., office. "Unfortunately, that situation can sometimes turn into a black hole, mainly due to a lack of real integration between the claims and medical bill review systems."
Why is this an issue? Because until now, the prevailing claims management and medical bill review integration model has offered a limited technology solution that schedules jobs on a daily basis from the claims system to the medical bill review platform, Gabal explained. While that is a form of integration, it is limited to batch files containing recent changes to bills, claims and provider records at particular stages of their specific workflows, without up-to-the-minute views or status updates of medical bills currently being processed.
"That is about the extent of the integration," Gabal said. "It is only meant to support at a basic level of what is needed for a claims examiner to do their work. It can be like passing information over a fence and waiting for it to reappear."
Gabal added that a substantive deficiency in the prevailing model is the lack of real-time coordination. Plus, if the medical bill analyst/team is ill equipped to manage the data it will eventually trickle down and negatively impact the claims team's effectiveness as well.
"The claims professional ultimately is responsible and there could be penalties for a slow pay," he added. "The prevailing model has those delays built into it."
An ideal solution for claims examiners would be an embedded workflow platform that can be used to manage the flow of medical bills throughout the bill review process, as well as answer ongoing questions related to bills and claims.
"Claims examiners need a view into the lifecycle of medical claims, a high-touch technology that offers them real-time capabilities, so they will be informed every step of the way after they send out their medical bills," Gabal said.
To meet that goal, Aon eSolutions offers iVOS, Aon's existing claims management system, paired with SmartAdvisor, the workers' compensation medical bill review solution offered by Mitchell, the industry medical bill review leader.
The iVOS/SmartAdvisor solution was designed specifically to provide for managing the entire bill review process through an integrated system. Claims examiners can access the entire medical bill history of a claim by logging into SmartAdvisor from within iVOS (All medical and non-medical bills are available via the User Document tab of iVOS to determine compensability).
Primary iVOS/SmartAdvisor features include:
- Via an automated workflow, examiners can have medical bills sent to bill review for processing (in SmartAdvisor) and non-medical bills sent to a designated workflow (in iVOS) for processing and payment.
- For bills sent to bill review, the Examiner can designate how the bill should be processed.
- Through designated pend queues in Claims Examiner Portal (CEP), examiners can access bills with missing vendor or claim records.
- Examiners can add new vendor or claim record in iVOS and release bill from the CEP pend queue back into the workflow for processing by bill review.
"It all happens within a single instance of iVOS," Gabal said, adding that the main benefits to having bill review truly integrated with claims administration are cost savings and ease of use for claims examiners.
"This solution gives them a much better view throughout the entire bill review process, so they can see what's going on at any point in time," he added.
For example, if an examiner wants to modify a bill being processed by specifying a different payment amount, or by selecting a different reduction reason code, or to have the bill processed as a denied bill, they can make the respective changes while reviewing the bill in CEP and approve it for payment, or input their desired changes into the Comment field and pend to the bill review team for them to make the changes. Once compensable medical bills are approved by the examiner, they will be posted to the permanent history in SmartAdvisor and exported to iVOS for payment.
Examiners can also review bills they have designated as denials to ensure the denial reason codes correctly reflect their intent. As with compensable bills, the examiner can choose a different denial reason code(s) and approve the bill or pend to bill review for them to make the change.
"Our solution is completely tailored to simplify the exchange between the claims examiner and the bill review analyst," Gabal said.
Most of all, Gabal noted, workers' compensation claims professionals will no longer have to ask the troubling question, "Where are my medical bills?"
"Our solution eliminates that frustrating dilemma," he said. "It blends two of the best technology platforms into a single, integrated solution. Claim examiners no longer have to waste valuable time chasing down medical bill review data or status updates. All they need to do is access our solution from their desktop.
"Medical bill review is something all claims managers must deal with, as well as an area of growing expense and cost containment," he added. "They say knowledge is power and our solution is a direct example of that idea in action. It offers a 'high-touch' experience that brings claim examiners much closer to the process, and closer to the medical bill review staff, because it is tightly integrated and available on demand."
(The above piece is part of our continuing Insights series designed to highlight key products and services to our readers. This paid-for Insights was written and edited by Risk & Insurance®
on behalf of our marketing partner. Additional Insights can be found on our Web site at www.riskandinsurance.com.)
October 8, 2012
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