With separate and distinct state workers’ compensation jurisdictions, accurate medical bill review begins with managing the ever-changing regulations in each jurisdiction.
To process workers’ compensation bills in accordance with the various regulations adopted by each state, a bill review provider must be cognizant of current coding conventions and accurately apply the applicable state rules and regulations, even when they are disharmonious with current coding conventions.
Bill review should also incorporate and account for the following:
Many states have adopted treatment guidelines, such as ODG or ACOEM, to outline a standard clinical path they expect most providers to follow depending on the medical condition or injury. For example, there might be a typical number of therapy visits allowed without preauthorization or length of time after injury before certain procedures are allowed. Look for a bill review system that triggers alerts when the bill history is inconsistent with treatment guidelines.
Appropriate management of medical spend almost always requires some form of utilization management or preauthorization, even in states that have not formally adopted a given set of treatment guidelines. Your bill review provider should have a mechanism to incorporate these utilization management decisions into bill review. Preauthorized procedures or services should not be denied by bill review. Likewise, services denied by utilization management should not be paid. Payers should expect seamless integration of utilization management decisions into bill review.
Medicine is an ever-changing discipline, with new techniques and products hitting the market nearly every day. Procedures previously performed only on hospital inpatients are now being delivered in less intensive settings, such as outpatient hospital departments or Ambulatory Surgery Centers. Moreover, procedures previously performed only via open incisions may now be done through minimally invasive or endoscopic technology, often using robotics to assist. New devices, however, are often biologics that do not qualify as implants, which have traditionally been defined as hardware left in the body after a surgery. While many states carve out implants for special payments, most of this new technology has not been addressed in fee schedules. Therefore, a good bill review vendor recognizes these new products or services and, working with utilization management and adjusters, make appropriate payment recommendations.
CorVel’s proprietary PPO network and professional nurse review services provide the most comprehensive solution for your workers’ compensation medical bills. We have designated experts residing in and managing the processing of workers’ compensation medical bills in every state to ensure compliance with specific requirements, as well as an experienced clinical staff of registered nurses, medical directors, and physicians to ensure unnecessary treatments and associated costs can be avoided.
Our overall network solutions incorporate treatment guidelines, utilization review, and new technology to increase processing efficiencies and maximize savings opportunities, resulting in 28% higher savings than leading competitors.