By Jim Harris, Vice President, Analytics and Reporting, Genex Services
Today, insurance and claims organizations are considering switching bill review vendors for a variety of reasons and, increasingly, the ability to leverage data analytics is one of them. There’s a treasure trove of information embedded in the bill review process, and if you’re not able to mine that data for program insights, you may be missing out on valuable opportunities to impact your bottom line.
In this column, we look at five strategies that sophisticated vendors are deploying to elevate the bill review process to a strategic, data-focused initiative that can drive ongoing improvements for your workers’ compensation program.
Strategy #1 – Leveraging Historical & Trending Information
Historical bill review data enables you to see where medical spending has occurred. Using this information, you can develop an action plan to determine where and how costs can be reduced, how utilization can be improved, and how to ensure you’re using top-performing providers. You can also compare your medical spending against peers and industry benchmarks to identify other potential areas for improvement.
In addition, a year-over-year analysis can provide other insights, which may only be apparent when looking at data over a longer span of time. The analysis may indicate significant year-to-year volatility or one particularly bad year. It may show that a lot of injuries occurred at a certain location or a couple catastrophic claims dramatically drove up costs. In some cases, it may be better to carve out outliers to avoid skewing trending information.
Strategy #2 – Digging into the Data
An advanced bill review partner must have cutting-edge systems that enable you to look at data in different ways so you can assess the following types of areas:
- Medical Spending by Category. How much is your organization spending according to various categories, such as hospital costs, physical therapy (PT) and pharmacy? This breakdown can help pinpoint what’s driving your costs.
- Performance by Jurisdiction. Allows you to examine outcomes on a state-by-state basis, and compare these outcomes to state benchmarks – as well as data from peer organizations in the same region. This enables an apples-to-apples comparison, as you’ll be able to look at data from organizations affected by the same state-specific fee schedules and mandates.
- Performance within Defined Data Hierarchies. A vendor should set up data hierarchies, so you can run reports and drill down for detailed information. For example, an insurance company may define data hierarchies by types of insured groups and worksite locations. Counties and government entities might define hierarchies by agency, such as the Sheriff’s Department and Parks & Recreation. Within these groups, you might find other trends to address.
- Spending by Body Part. Understand developments by body part and determine if there’s an alignment with claims. For instance, increased spending on “ankles” could reveal a higher number of slip-and-fall injuries at a department store.
Strategy #3 – Optimizing Your Use of Physicians and Provider Networks
A data-driven vendor will perform an analysis to optimize your use of top-performing physicians and provider networks. It should assess your in-network referrals to determine how your organization is faring in terms of directing injured employers to network providers. The vendor must also use analytics to optimize your network strategy according to the geographic regions around your worksites.
Strategy #4 – Integrating Services for Deeper Insights, Deeper Value
Sophisticated vendors often offer multiple services in an integrated managed care program. For example, bill review can be offered in concert with case management or utilization review – or both. There are significant benefits to having one vendor manage all these components, as they are synergistic clinical tools that can improve care and save additional costs.
Another advantage is a broader, deeper set of data points, so there’s more information to analyze and act on. Integrated services would be coordinated on a seamless platform, which would enable additional benefits, such as clinical alerts, streamlined workflow between services, and seamless communication regarding non-certified treatment.
Strategy #5 – Predicting the Path of Care
Use of predictive analytics and machine learning is the new frontier. Using these technologies, a vendor can analyze millions of medical bills to identify patterns and predict future outcomes.
For example, predictive analytics can identify common characteristics that lead a claim down a certain path, whether it’s toward surgery or opioid addiction. The model would pinpoint the pattern, such as timing or combination of medical services, and this pattern would signify when a new case was likely to head down a similar path. Alerts would notify you when such scenarios were taking place, so you could take proactive actions, such as setting appropriate reserves, assigning experienced staff to the claim, and even referring the case to a nurse for clinical intervention.
Machine learning – a form of artificial intelligence – enables a system to learn without explicit programming. The system analyzes new streams of data and picks up on red flags earlier in the process – before a claim heads into risky territory. In this way, you’re able to cut it off at the pass before it becomes costly and problematic.
The Future of Bill Review: Intelligence in Action
Workers’ comp professionals are facing intense pressure to get spiraling medical costs under control. Today, a data-driven bill review company can help unlock the insights hidden in your bill review data. To assist in this endeavor, data platforms must be interconnected to apply analytics across bill review, case management and utilization review. With these powerful tools in place, bill review becomes elevated beyond a commodity service to a hot bed of business intelligence, empowering you to become a better-informed steward over your program and results.
About Jim Harris
Jim Harris is vice president, analytics and reporting at Genex Services. He is responsible for expanding the portfolio of reporting, analytic and predictive modeling tools for customers. With over 25 years in workers’ compensation, he provides organizations with the intelligence they need to continually improve program performance.
About Genex Services, LLC
Genex Services is the trusted provider of managed care services enabling workers’ compensation payers and risk managers to transform their bottom lines while enhancing the lives of injured and disabled workers. Genex is a managed care leader with more than 2,900 employees and 41 service locations throughout North America. The company serves the top underwriters of workers’ compensation, automobile, disability insurance, third-party administrators and a significant number of Fortune 500 employers. In addition, Genex is the only company that delivers high-quality clinical services enhanced by intelligent systems and 360-degree data analysis. The company consistently drives superior results related to medical, wage loss, and productivity costs associated with claims in the workers’ compensation, disability, automobile, and health care systems.
Genex Services is a WorkCompWire ad partner.
This is not a paid placement.