By Michael Josephs, CIO, ISG Services
With 45 jurisdictions in the Unites States using workers’ compensation fee schedules, and state regulatory agencies charged with maintaining and revising hundreds, or even thousands, of maximum allowable reimbursement levels for medical services, it is imperative that organizations ensure they are creating timely and accurate updates to the fee schedules underpinning medical bill review and cost containment strategies. The task of ensuring accuracy in a rapidly changing environment can create significant challenges and is costly when implemented manually. How does an organization ensure accuracy of fee schedule data when workers’ compensation fee schedule depth and scope of medical services continues to evolve as a result of the state regulatory, legislative and administrative processes?
In a perfect world full of evolving technology, it is easy to assume fee schedule inaccuracy is a concept of the past. However, a single small data entry error from one fee schedule provider can potentially cause thousands of dollars in overpayments for payors and TPAs, as well as increased administrative activity for all workers’ compensation participants. Now, imagine more than one fee schedule provider making at least one or more data entry mistakes across each jurisdiction. You get the picture.
Based on our experience, and because fee schedule changes do require manual entry of data at some juncture, fee schedules often contain errors that are not easily identified without the right tools. Therefore, it is critical to employ procedures, analytic s and quality assurance measures before, during and after the loading and testing of fee schedule data to ensure data integrity for medical bill review processing. We recommend you ensure that your vendor is conducting the following processes to yield complete accuracy of the data set: data load analysis, test bill management, test bill execution and regression testing.
Data Load Analysis
Fee file data validation involves the loading of tabular fee files and comparing fee schedule versions, allowing anomalies and significant changes to be detected. Often, when large groups of codes (e.g., procedure codes, place of service codes and specialty codes) are added or removed, there are errors or gaps in the original generation of the source data. Likewise, when large amounts of change in the base allowance computation are detected, we have found that it is often times a result of errors in the source data. Variances should be computed during data load analysis and flagged when differences exceed expected or jurisdiction established variance levels.
Test Bill Management
Since medical bills are somewhat like snowflakes (each one seemingly unique in terms of claims data, procedural coding, jurisdiction, diagnostic codes, utilization levels, etc.), the manual comparative approach to validating updates for state-directed fee schedules can be laborious and prone to human error. Creating suitable test bills manually will likely create time-sensitive challenges for adherence to fee schedule compliance given the short window of data availability and the fee file effective date.
As a result, it is critical that effective technology be leveraged to automatically generate a sufficient amount of test bills to ensure the accuracy of fee schedule updates. Test Bill Management automation should allow for bill copy and the automated generation of new data points on the bill to ensure optimal test coverage as it records the expected result. Once created, test bill sets can be reused for rapid validation of fee schedule updates from the same jurisdiction.
Test Bill Execution
With a sufficient set of test bills available to validate fee schedule updates, it is critical to automate the execution of the test bills, including the comparison of test results with expected results. Test Bill Execution automation should rapidly compare expected results against actual results for large groups of test bills. Differences should be automatically generated for analysis and potential communication with the data provider. The Test Bill Execution tool set should also have the capacity to override previously captured expected results with the updated values when appropriate.
And finally, fee schedule updates should only impact the intended bills. In order to provide suitable regression testing for unintended changes, it is necessary to maintain the ability to initially run very large numbers of bills (hundreds of thousands comprising different jurisdictional and compositional scenarios) against the candidate fee schedule update and compare the outcome with processing the same bills against the original fee schedule. These differences are then identified, analyzed and corrected accordingly if unintended changes are identified.
A well-engineered Fee Schedule Test Automation suite will enable the routine updates of tabular re-pricing fee files to be validated from a number of perspectives while mitigating the risks to timeliness and accuracy. As these updates are a foundational element of financial validation accuracy, the same quality standards should be applied in the generation of tool sets as is applied to bill review functionality. As various industry associations continue to report a steady increase in the rise of medical costs, the reimbursement portion of the equation and validated fee schedule uploading becomes more critical.
About Michael Josephs
Michael Josephs joined ISG Services in 2006 and has held the role of CIO since 2008. Josephs is responsible for the creation and delivery of ISG’s technology platform, which encompasses the areas of project management, information systems, technology infrastructure, release management, product management, application development, software quality assurance and technical services. Prior to joining ISG Services, Josephs served as director of technology development at E*TRADE Financial and was also the CIO for Triad Financial Corporation, a subsidiary of Ford Financial. He holds a Bachelor of Science degree in computer science from the University of Maryland.
About ISG Services LLC
Operating as the nation’s leading healthcare technology company, ISG Services offers a suite of software and services that enable highly targeted data-driven interventions to achieve meaningful impact on outcomes and financial performance. ISG Services utilizes extensive data analytics to identify gaps in care, quality or integrity, and applies the appropriate resources to ensure rapid resolution. Our valued clients process their workers’ compensation medical bills through the ISG Services affiliates including well-known affiliates StrataCare, the nation’s premier workers’ compensation bill review software and service provider, and Bunch CareSolutions, offering award-winning, innovative managed care solutions. For more information, please visit: www.stratacare.com or www.bunchcare.com.