Major Findings in 1st Annual Comp Bill Review Survey

Friday, May 22, 2009 | 0

By Joe Paduda

We at Health Strategy Associates have completed our First Annual Workers Comp Bill Review Survey and there are several highlights worthy of mention.

Bill review is considered significantly 'more important' than other managed care services by survey respondents (TPAs, carriers, managed care firms, and self-insured employers). While this isn't consistent across all respondents, most are of the opinion that bill review is where the proverbial rubber/road meeting occurs, and if UR or PPO determinations don't show up in bill review, they are irrelevant.

Which leads to the next finding: Most of the more sophisticated respondents are very, very cognizant of - and frustrated by - the difficulties inherent in integrating BR and other medical management systems, platforms, and vendors. There is a sense that not all UR determinations (numbers of visits for PT, hospital stay duration, epidural steroid injections) appear in the final payments, with many unauthorized services actually performed, billed, and paid.

(Note - this is consistent with the result of some, but not all, audits of client data performed by Health Strategy Associates)

Respondents decried the lack of understanding of the complexities of bill review, and the commoditization of the service, on the part of senior management and policyholders alike. Their sense is there is little to no appreciation of the difficulties inherent in staying on top of fee schedule and rule changes, increasingly sophisticated provider billing techniques, and impact of bill review on claims costs. Pressed to reduce costs and staff during this soft market, respondents are frustrated by their inability to convince C-level personnel of the relationship between effective (i.e. well-done and not cheap) bill review and ultimate claims costs and combined ratios.

The ratings of bill review vendors and application providers show respondents are quite current and aware of changes at the various suppliers. Vendors that would have been rated poorly as recently as a year ago are viewed more favorably today, with respondents very much open to considering bill review application vendors that would not have made their first cut 12 months ago.

There were notable differences among and between the various bill review vendors and application providers, differences that 'didn't appear until well into the implementation phase.' The perception among respondents was that these differences were due in part to a failure on the front end to be very clear and precise about semantics (what, exactly, is a 'bill', what is a 'rule', what is a 'duplicate bill', when does the clock start and end for turn around time, whose responsibility is it to ensure the DRG grouper complies with and is consistent with specific state regs, and on and on). As a result, costs, throughput, efficiency measures, 'savings' and other metrics had to be readjusted, causing more than a little agita for program managers.

Finally, some bill review applications and vendors were perceived to be better positioned to address likely changes in the overall health care system. Respondents viewed these vendors as more flexible, more adaptable, and more cognizant of the broader systemic issues and their potential impact on workers comp. One knowledgeable respondent noted "some of these vendors are so focused on comp that they aren't paying attention to current and likely future changes in Medicare physician and hospital reimbursement...and their systems just won't support some of the likely changes in Medicare-based fee schedules."


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Joseph Paduda's blog, managedcarematters.com, focuses on managed care for group health, workers compensation, auto insurance, cost containment, health policy, health research, and medical news for insurers, employers, and health care providers. Paduda is the principal of Health Strategy Associates.
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