By Tom Sebold, Vice President of Medical Review Services, GENEX Services LLC
After some 20-plus years in the workers’ compensation industry, I’ve noticed, and been a part of, considerable changes and innovations. We’ve come a long way as they say. But despite our progress, there remain some entrenched myths about several areas within workers’ compensation. Chief among them is that Medical Review is just a commodity; another box to check in the adjudication process.
Effective Medical Review, however, isn’t simply another step on the path to close or settle a claim. It’s not about auto-adjudicating a bill through the system. It’s not about state fee schedules and reductions. It should be designed and implemented as a strategy to drive cost savings, improve outcomes and minimize risk by identifying those claims that should be targeted for a higher level of technical review or specialty network services.
Achieving the goal of optimal Medical Review outcomes and savings isn’t difficult, but it does require an honest examination of current processes, and a willingness to more closely examine, and perhaps even debunk some long-held myths.
Here are the three most pervasive myths and misunderstandings that I frequently hear about Medical Review:
- 1. Bill review results vary little from company to company as savings are driven mainly from auto adjudication of various state fee schedules.
That’s a tricky one, because it is true if all you do is process the claim. However, when you combine the process with superior technology and experienced and committed bill review experts, you can start to see very different results across the Medical Review landscape. For example, technology allows for exception workflows to be put in place that drive the appropriate complex bills to the most qualified professional staff for in-depth review. This allows these professionals to generate significant savings by applying specialty review tools and more closely evaluating specific bills for inappropriate or over-utilization, as well as poor or improper use of prescription medications. A higher level of professional technical review not only drives additional savings, it also provides the ongoing evaluation and analytical overview that is needed to constantly improve results and allow for optimal billing practices.
- 2. We’re already doing all we can.
Many companies look at Medical Review and believe they are taking appropriate steps such as integrating claims management, managed care products, and bill review systems. However, that’s just step one in the process. It is also imperative that bill review service models (systems and data) have adequate integration with case management services (telephonic and field), pharmacy management, utilization review, and physician advisor services. This is critical to maximize potential savings in a program, but it is also important in identifying utilization issues or concerns with various medical and prescription treatments. It is especially critical in the hyper-sensitive environment around prescription drug over-utilization. If the various systems are not integrated, you can forget about impacting those critical claims where an injured worker and the treatment plan have gone down a dangerous path. The integration of every aspect of a claim is what truly drives results and savings.
- 3. We’ve negotiated all we can…and there’s no way to get more savings from hospitals.
Employers and carriers are often frustrated by challenges faced when negotiating discounts for hospital bills. But wait; don’t write-off those claims. Experienced Medical Review experts know how to integrate large bill negotiation services with signed agreements. Don’t use arbitrary discounts that are not based on math the hospitals will understand. The key to a solid approach to negotiating hospital discounts is to have accurate, timely and fact-based database tools to support your cost analysis, and that can put an end to contentious back and forth on pricing.
It is difficult for providers to argue with reductions to their services when you can show them exactly what their costs were for services, while also allowing for reasonable profit.
Not just understanding, but specifically targeting myths about bill review can pay big dividends. We recently implemented a new program that emphasized earlier and more focused Medical Review for a large national employer. They were initially skeptical that more could be accomplished, but they have become believers. Within the first quarter, (and this with a program that already had a very sophisticated overall approach to claims), we were able to secure additional savings of nearly five percent, representing hundreds of thousands of dollars.
If you haven’t examined your beliefs about, and current approach to Medical Review, now is the time to do so. The savings, and results will be well worth the effort.
About Tom Sebold
Tom Sebold, is the Regional Vice President, Western Region for GENEX Services, LLC. Tom joined GENEX in 1998, where he has held several leadership positions. Prior to being promoted to RVP, Tom was the Regional Manager for the Midwest Region. He holds a Bachelor of Science degree in Business Management and Marketing from Augustana College in Sioux Falls, SD.
About GENEX Services, LLC
GENEX Services is the trusted provider of managed care services that enables workers’ compensation payors and risk managers to transform their bottom lines. GENEX is the most experienced managed care provider in the industry, with more than 2,500 employees and 47 service locations throughout North America. The company serves 381 of the top Fortune 500 companies in the U.S. today. In addition, GENEX is the only company that delivers high quality clinical services enhanced by intelligent systems and 360-degree data analysis to consistently drive superior results related to medical, wage loss, and productivity costs associated with claims in the workers’ compensation, disability, automobile, and health care systems.
GENEX is a WorkCompWire Ad Partner.
This is not a paid placement.