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The single largest issue in workers’ compensation bill review is the need to better and more completely link medical management determinations to the actual payment and processing of medical bills, according to the Health Strategy Associates’ (HSA’s) 2012 Survey of Workers Compensation Bill Review.
“Payers are tired of paying for services that were specifically denied by utilization review, pre-certification or case management,” said HSA Principal Joseph Paduda.
“It is clear that most bill review systems are still a long ways from full, seamless integration with medical management and claims systems which obviously diminishes their effectiveness,” he said, noting that the integration issue also came up in HSA’s utilization review and claims systems surveys and its 2009 bill review survey.
“This is surprising,” he added. “Considering all the money invested in medical management and all the medical dollars paid out, it is incomprehensible that so many large and mid-tier payers have yet to reach full integration.”
Payers view bill review as significantly more important than provider networks, case management, utilization review, or other medical management services, according to the survey. They also indicated that bill review costs were lower than in 2009.
When asked to rank the importance of various attributes or functionalities of bill review systems, respondents gave “a business rules engine tied with Electronic Data Interchange (EDI) connectivity” the highest score. Their responses to other questions emphasized the need to use rules to streamline production, increase consistency, improve results, facilitate best practices, and ensure that rapid adoption of corporate policies and processes occur.
HSA’s 2012 bill review survey explored pricing, vendors, internal-versus-outsourced BR processing and other aspects of the industry that determines reimbursement for $30 billion in workers’ compensation medical care each year. Twenty-four decision makers and executives at insurers, third party administrators, large employers, and managed care firms participated in the survey. A survey summary is available at http://www.healthstrategyassoc.com/surveys.html.
About Health Strategy Associates
HSA is a national consulting firm serving insurers, employers and health care providers. Led by Joseph Paduda www.healthstrategyassoc.com/paduda.html, who also writes www.ManagedCareMatters.com, the firm specializes in helping clients control health care costs in workers’ compensation and group health.
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