Integrating Medical Bill Review for Unified Outcomes

Over the years, medical bill review processing for workers’ compensation has skyrocketed in complexity. From intricate bills combining mental and physical injury to those requiring extensive implant reviews, today’s medical bills are far more complex than in times past. This impacts not only bill payment but also the processes and efficiencies of multiple stakeholders involved in the claims process.

Given the significant role that medical bill review plays in shaping claims outcomes, it is essential to adopt a holistic approach that integrates all components of the bill review workflow. CorVel’s recent webinar explored how this integrated approach supports efficiency and optimal program outcomes.

Keep reading to take a closer look at the workflows that form the foundation of an integrated medical bill review program and their impacts on various stakeholders.

 Bill Review Process

1. Submission: Despite the rapid adoption of digital technologies, over 70% of providers still utilize paper or mail-in medical billing forms. However, as states like New York will soon mandate the use of clearinghouses for electronic submission, the standard for faster, cost-effective billing is gaining traction in the workers’ compensation space. This new requirement comes as no surprise as electronic transmission enables faster processing, giving way to receiving more accurate data.
2. Data Validation and Indexing: With over 40% of medical bills missing required information[1], rigorous validation is essential to prevent costly denials and payment delays. Key elements include confirming that the correct form is used, ensuring specific state required fields are present—such as the provider license number, facility or treating National Provider Identifier (NPI) number, and diagnosis codes—are accurate, and validating provider information. To improve these processes, bill review professionals are beginning to adopt AI-driven tools that streamline data validation, ensuring faster resolution for both providers and payers.
3. Audit and Analysis: Once a bill passes the data validation process, a more in-depth review commences, including (but not limited to) fee schedule application CPT guidelines and coding edits, as well as modifier review. Given the complexity of today’s medical bills, CorVel’s team takes additional care to incorporate claim status, diagnosis, and body part review to identify any non-compensable charges. For example, if a diagnosis code present on the bill notes an injury to the knee, yet the documented work injury is for the shoulder, CorVel’s process would flag this bill for further review to ensure that all procedures meet work-relatedness requirements.
4. Specialty/Clinical Review: On average, facility bills account for only 7% of total bill volume yet represent nearly 50% of recommended payments[2]. This significant discrepancy underscores the need for targeted reviews, especially as the complexity of these bills continues to increase. Additional flags for clinical expertise include surgical implant procedures. Reviewing implants involves an in-depth analysis of medical documentation to ensure that the documented implants match those used during the surgery and that state-specific reimbursements are properly verified.

While a comprehensive bill review process sets the foundation for optimal medical bill review outcomes, aligning with a managed care partner and integrating their preferred provider organization (PPO) into the process is crucial for long-term program success and efficiency.

Network Integration

Managed care organization (MCO) programs are available in many states to direct employees toward network healthcare professionals. The purpose of the MCO’s preferred provider organization (PPO) is to deliver high-quality medical outcomes while maintaining competitive reimbursement rates. These networks focus on helping injured workers return to their jobs by offering evidence-based, patient-centered care.

CorVel’s PPO network contracts directly with physicians and specialists, as well as multiple affiliate networks, to ensure comprehensive access to primary and specialty care.  Employing a “high-tech, high touch” approach, CorVel’s Network Solutions feature robust data integration, enabling network teams to quickly receive and respond to provider changes, ensuring billing accuracy.

In addition to these features, comprehensive medical bill review programs should also include the following attributes for optimal outcomes:

• Provider Education: Through regular outreach, network teams can keep providers apprised of new regulations and serve as a local resource when state laws are passed. Network teams are readily available to assist in resolving bill payment inquires and addressing contract questions.
• Customization: CorVel’s bill review services include the ability to set up customized rules triggering automated notifications. These alerts notify adjusters when employees have been treated out-of-network and can even provide guidelines on when payment can be approved based on client pre-approval.
• Advanced Technology: In addition to utilizing AI for data validation, sophisticated medical bill review programs will look to leverage AI’s predictive capabilities to better identify patient risk factors and anticipate treatment outcomes.

With network integration, employers can benefit from a connected care system made possible through strategic application of technology. This level of integration will be crucial as regulatory agencies push to make electronic medical bill review processes the industry standard.

Compliance Considerations

Changes in technology have also created headway for more formal compliance measures surrounding the bill review process. Examples of these include clearinghouse submission requirements, EOR required elements, timeliness guidelines, and state reporting requirements.

To date, most states do not have formal regulations mandating the electronic submission of medical bills or the acceptance of electronically submitted bills. However, e-billing regulations are expected to gain momentum with states including Minnesota, North Carolina, and Virginia already adopting electronic acceptance requirements. These anticipated regulations will further the goals of current bill adjudication timeframes, which range from 30 to 60 days, by enabling for faster bill review and payment nationwide. With a medical bill review partner, employers can not only leverage electronic platforms to avoid adjudication delays and get ahead of e-billing requirements, but also fortify programs to account for the full range of complex regulatory changes impacting the industry.

Additional compliance requirements include the Explanation of Record (EOR) which is sent to providers after a bill is paid, adjusted, or denied. EOR regulations vary by state but commonly include contact information for the bill review company, an explanation for any payment adjustments or denials, and a note on balance billing.

For a single bill, manually maintaining these information requirements is a challenging undertaking. This task becomes nearly impossible when scaled up to the thousands of workers’ compensation bills received by employers annually. The advantages of a sophisticated bill review platform are clear when utilized for automated data consolidation and are critical for state and federal reporting requirements.

Garnering Outcomes

From bill intake to compliance reporting, integrating each element of the medical bill review process creates an efficient and optimized program. CorVel’s Network Solutions team is helping employers realize the benefits of a holistic approach with key outcomes achieved to date. For instance, employers have seen 28% greater savings than industry average with CorVel decreasing overall medical spend on claims. In fully optimized programs, CorVel’s automated adjudication capabilities have saved adjusters over 10% of working hours annually, allowing team members to focus their time on direct service to injured workers. Lastly, CorVel’s regulatory expertise ensures employer compliance with new rules, minimizing the risk of fines and penalties associated with state requirements.

Learn more about our bill review services at https://www.corvel.com/services/workers-compensation/bill-review/.

[1] CorVel Internal Data

[2] CorVel Internal Data