Tustin, Calif. ― Medata, the originator of automated medical bill review for the workers’ compensation and auto liability markets, has broken new ground by fully integrating medical treatment and disability guidelines into its bill review system. Medata now offers industry-first access to evidence-based medicine (EBM) without clients having to acquire, integrate and maintain the entire database.
Medata’s new Guideline Direct© product eliminates the need to perform manual look ups by automatically inserting the appropriate guideline based on diagnosis and demographics. Medata launched Guideline Direct with Reed Group’s MDGuidelines©, the American College of Occupational and Environmental Medicine’s (ACOEM’s) APG-Codelink, and the Work Loss Data Institute’s Official Disability Guidelines (ODG).
Despite broad acceptance of treatment guidelines as a necessary component of cost containment, the management of Utilization Review (UR ) guidelines has been laborious and inconsistent due to the disconnect between UR and bill review, according to Medata’s President Cy King. “A true cost-containment program incorporates good medicine, paying the accurate amount for appropriate medical care, and makes available statistical data that validates the investment in the bill review and UR programs,” he added.
Guideline Direct enables Medata’s bill review system to compare frequency of use of medical procedures, expected disability durations and average duration trends without human intervention. There are hundreds of millions of potential different combinations of ICD-9 diagnosis codes and CPT codes that can now be automatically calculated by the system. Flagging potential problems early in the claim enables payers to focus on the claims likely to generate the highest costs and set reserves appropriately.
In addition to presenting the guideline data on the screen for use by examiners and bill review experts, the information is included on the Explanation of Review and, when suitable, sent to the treating provider to establish a common framework for provider treatment and accurate reimbursement.
Source: King Knight / Medata