Incorrect provider invoices cost WC industry a bundle, study suggests
The president and COO of Acrometis commented after the release of the company's study showing 81 percent of medical provider bills rejected are never resubmitted for payment.
The findings are based on an analysis of 10,000 invoices, of which nearly 25 percent were flagged and returned. Poole says the study points to the inefficiencies between medical providers submitting bills and workers' comp payers.
"As the number of bills presented for workers' compensation claims continues to rise, this increase directly impacts the efficiency of adjusters processing these claims," the report says. "One way to improve the quality of the claims process is to stop duplicate or incomplete bills from ever getting to an adjuster. And if these bills are found to be in error by the provider and never resubmitted, there are meaningful cost savings to be had as well."
The invoices in the study were rejected for a variety of reasons -- such as duplicate submissions or being sent to the wrong payer. With so many payers of health care, Poole says it is understandable that providers don't spend a lot of time figuring out where each invoice should be sent.
"I don't think providers are nefarious, I think it is the insurance system," he said. "The burden to the workers comp or particular insurance payer is to make sure they are only paying for things that are unique to them."
The answer for the workers' comp system is to ensure the improper bills are eliminated from the system before they ever get to a claims adjuster, Poole says. He advocates a using an electronic system, such as the Claimexpert platform developed at Acrometis.
"It checks every bill and every document ... it processes documents in a time-based fashion as if it were a human working through the process. By automating it, it's very high volume, high efficiency," he said. "Then it looks at the content inside the document."
For example, the system does a 'relatedness check' by assimilating the various procedure codes, accident description, body parts affected and the specific jurisdiction. "The underwriting pricing was developed based on rules of payment in a certain jurisdiction," Poole said. "We are making sure those payment rules are enforced on every document and the risk for which the payer is exposed are the ones they expected when they wrote the policy."
While larger companies with in-house resources might choose to develop similar capability, Poole says the type of system his company has created is designed for small- and mid-sized companies, especially those without IT departments or any company that chooses to devote their Capital resources to other tasks. Industrywide, he says too many companies still have their adjusters wasting time wading through bills that should have been eliminated.
"If you look at the provider industry, it's almost a cottage industry, many providers thus many tax ID numbers trying to be reimbursed by many payers," he said. "Where you have the payer community being rigid and disciplined, you force providers to become disciplined ... if the whole industry takes this type of approach and starts disciplining itself people submitting bills to get paid will change their behavior and you'll see costs to the industry come down."
Read more at the WorkersComp
April 1, 2013
Copyright 2013© LRP Publications