By Paul Glover, Chairman and CEO, ISG Services, LLC
Maintaining a compliant and highly integrated medical bill review function is an essential part of any innovative service delivery model, especially in today’s highly-regulated workers’ compensation sector with so many participants and stakeholders in the ecosystem. The implementation and execution of a fully-integrated, best practices approach to medical bill review compliance requires leading technology and software applications, a team of highly skilled coding, clinical and regulatory experts, embedded decision support tools and cooperation among participants.
While we all recognize that investing in people and technology is a basic foundational need in today’s technology-rich environment, decision support tools and their importance are often overlooked. Without embedded decision support tools, the impact of a compliant model becomes unnecessarily cumbersome. Approximately, 80M workers’ compensation medical bills are generated annually in the U.S. Ensuring every medical service is reimbursed accurately requires customizable technology to identify and detect potential inconsistencies. Additionally, bill review experts should be utilized to validate the recommended reimbursement prior to adjudicating the bill. When assessing your bill review vendor’s degree of compliance, I encourage you to inquire how many compliance personnel, jurisdictional experts and software developers they employ as part of their best practices model.
Readily accessible compliance-based content for the end user is critical and a feedback loop to validate the accuracy of the workflow and potential leakage is just as important. As an embedded financial control delivery mechanism, our Compliance Library is a fully-transparent solution that assists our valued clients with processing almost 20% of the workers’ compensation industry’s medical bills with a tremendous degree of accuracy. The regulatory and compliance experts responsible for maintaining and delivering the data bank to our clients are, in essence, providing a prospective audit function, including both the calculation and justification of payment.
Another critical element to the utility of this functionality is “where” the content, alerts and services are delivered or made available. With the plethora of tools becoming available, access to those tools can be both confusing and inefficient. A tightly integrated set of services can deliver value directly to the applications where they are most relevant. An informational tool providing audit functions mapping adjudication results with compliance guidelines should be made readily available. Likewise, alerts and decision support services should be made available where decisions are made and cases are managed.
A few of the critical compliance-related best practices should include the following:
- A single repository for the most current regulatory rules and jurisdiction-based information on-demand, including state regulations, fee schedule administration, Medicare methodology, UCR alternative reimbursements, and bill review rules
- A web-based portal configurable to your entity’s payment process interfaced with the bill review software
- Availability of the most current content 24/7/365 at the end-user’s fingertips enabling the claims examiner, nurse, bill reviewer, and others to obtain real-time, accurate information to make the right decision the first time
- Easily accessible links throughout the bill review platform
- Notifications and alerts available to claims adjusters and bill review processors prior to adjusting or reconsidering medical bills
Along with some of the specific utility tools mentioned above, thoroughly analyzing your bill review partners’ compliance department structure is wise. After all, they are a critical member of your supply chain to ensure compliance with each state’s regulatory landscape. Don’t simply expect them to deliver a compliant solution, but inspect how they deliver a compliant solution. They must validate that the service performed was authorized, billed properly according to the venue and is reimbursed accurately the first time. They must also fully understand their staff’s professional credentials, their ability to monitor and deliver rule revisions to the end user in a transparent environment, and their organizational hierarchy to ensure a best practices approach to compliance. I look forward to a future article outlining the best practices approach to complete clinical integration within a bill review platform.
About Paul Glover
Paul Glover founded ISG Services LLC in 2008 and is Chairman and Chief Executive Officer. Prior to ISG, Mr. Glover has been a leader in the workers’ compensation managed care industry with roles in managed care, third party administration and insurance companies. Mr. Glover holds an A.B. degree in Economics from Dartmouth College and an M.B.A. in Finance and Accounting from Cornell University.
About the Compliance Library
StrataCare has made a substantial investment in people and technology to develop and maintain an embedded application within the StrataWare bill review technology platform, aptly named the Compliance Library. It is an interactive web-based repository including thousands of changes annually encompassing regulatory rules and jurisdiction-based information for workers’ compensation. The Compliance Library is comprised of substantial on-demand information, including state regulations, fee schedule administration, bill review rules, and topic based resources, such as the application of Medicare methodology and UCR as an alternative reimbursement source. In addition to easily accessible links throughout, notifications and alerts can be established to jurisdiction based information to inform decision makers prior to adjusting or reconsidering medical bills of new information that has become available that may affect reimbursement.
About ISG Services LLC
ISG Services LLC is the nation’s leading healthcare technology company with a suite of software and services that enable highly targeted data-driven interventions to achieve meaningful impact on outcomes and financial performance. ISG utilizes extensive data analytics to identify gaps in care, quality or integrity and applies the appropriate resources to ensure rapid resolution. ISG’s affiliates include the following well-known entities: StrataCare, the nation’s premier workers’ compensation bill review software and service provider, and Bunch CareSolutions offering innovative managed care solutions.