Workers’ Compensation Medical Bill Review: Neglected Truths

Did you know that (according to NCCI) medical expenses account for about 60% of average claims' costs? These costs clearly represent the greatest impact on an employer’s workers’ compensation total cost of risk and this average is expected to keep climbing. So naturally, maximizing savings opportunities through the medical bill review (MBR) process is a critical component of all comprehensive claims management programs.

An employer, insurance company or TPA that historically “outsources” managed care services and engages in an RFP will always seek MBR service vendors that have the largest medical savings opportunities for the lowest bill review fees. If your RFP process is comprised of comparing one MBR vendor’s results with another via a spreadsheet, your results will be profoundly inaccurate. There are neglected truths that you may never hear discussed surrounding the very complicated process of selecting an MBR vendor – every risk manager and CFO should be aware of these truths.

The typical RFP process focuses on a Quantitative approach comparing vendors’ average MBR savings by state combined with a “sample” number of medical bills and these metrics alone are meaningless. Risk managers and CFOs must move away from a Quantitative to a Qualitative analysis selection process.

Focusing on the Qualitative component of the bill review process trumps all other considerations. While a focus on the potential vendors’ keen abilities to facilitate the largest savings possible on key specialty, facility and out-of-network bills makes the selection process more difficult, it is critical to ensure your ability to maximize your medical bill savings.

The Qualitative business model is not just about negotiating discounts below fee schedule or trusting “all-in” DRG billing codes; rather, it is about verification of every component of each bill for accuracy; review of every code and charge billed; review and verification that all required documentation is provided; and review of utilization controls and compliance to identify additional savings.

Additional awareness points:

• Some states do not have fee schedules that apply to large bills (or include every component of the bill).
• Most large bills contain “gray areas or gaps” that are not able to be programmed by a bill review software platform.
• Most hospital bills contain billing errors and exceptions.
• Billing departments/companies will make every effort to maximize reimbursements through “gray areas” of billing.
• No bill review software platform alone can provide a solid cost-saving solution for specialty/facility bills.

Want to learn more about the most effective Qualitative (and limited Quantitative) questions to ask when seeking a new MBR vendor partner? Let our team assist you! We might just be that new partner you’ve been needing.

Lisa Gran is the founder of Splashlight. Email her at Lisa@splashlightsolutions.com.