Essential components of a successful medical bill review program include powerful software that captures every type of bill, high-quality provider networks, and professional review on complex bills to ensure every possible avenue for savings has been exhausted.
However, upon closer examination, the most consistent and verifiable long-term savings have come from the successful integration of these components. Integration in this context requires linking bill review software and data-driven workflow processes to high-performing PPOs with built-in quality standards.
Alternative programs often include a mosaic approach to achieve the best results, however, utilizing a partner with a truly integrated solution has been proven to yield measurable year-over-year savings. It also allows for comprehensive reporting of medical exposures with an underlying focus on long-term outcomes.
Carve Outs: Short-Sighted Solutions
Programs that focus on a single cost containment initiative such as diagnostics or physical therapy may promise significant discounts, but are they sustainable, and at what cost? Containing ancillary costs is necessary, but a strictly quantitative approach on one ancillary program fails to address the total cost of risk across all bill types. Other opportunities that may yield more significant savings could be missed. For example, oftentimes rising diagnostic costs can be contributed to multiple MRIs due to poor image quality or the lack of utilization review to determine appropriateness.
A sophisticated bill review platform offers a number of advantages over carve-out programs. Automated business rules are programmed into the system and can easily identify utilization patterns across various bill types. The rules can be tailored to a client’s specific business objectives and are consistently applied to every bill. Edits and alerts trigger cost and care interventions for the adjuster and whenever necessary bills are escalated to subject matter experts. An integrated platform results in greater savings over time as compared to the isolated savings offered by typical carve-out programs.
A strictly quantitative approach to individual ancillary programs fails to address risk across all bill types and misses opportunities for more significant savings.
Integration of Cost and Care
Not all programs offer a fully integrated solution and therefore must outsource services with multiple partners for bill review, PPO, pharmacy or other specialty networks. Many of these mosaic networks promise better utilization and greater savings as a result of unbundling. Unfortunately, because these services are contracted to different networks, significant challenges can emerge from the resulting disaggregated data. Are payors able to evaluate and report on these separate data sets to identify any underlying risk early enough to matter?
For example, most of these companies offer pharmacy benefit management (PBM) networks in addition to bill review, and purport to manage patient care as well as costs. PBMs have reported continuous improvements in financial results for more than a decade, creating a false sense of security that pharmacy services were being managed at the patient level. Meanwhile, more and more dangerous narcotics were prescribed, many being dispensed in the physician’s office, making timely intervention next to impossible. We now know that most PBMs failed to identify the narcotic problem until it was too late.
An integrated platform offering a complete view of patient care that tracks utilization patterns and costs as they occur could have identified this risk early on. The direct development and cultivation of a performance based network can also be highly advantageous. In this model, providers are held accountable to evidence based treatment protocols including the prevention of physician dispensing, producing better outcomes overall. Smart aggregation of all patient data during and after treatment accounts for better financial outcomes.
PBMs only have access to the transaction data they process; with no insight to outlier prescriptions such as physician dispensing.
Catastrophic Costs, Simplified
Slicing a complex, high dollar bill into parts audited separately creates a challenge for the facility. For example, overly aggressive cost cutting on an implant charge could diminish a positive outcome on the rest of the bill, cause provider pushback, or reduce the provider’s willingness for negotiations. These narrowly focused, aggressive tactics can potentially raise long term costs in return for short term savings.
Payors should focus on savings in a more comprehensive way. A holistic review of the bill includes an evaluation against the actual medical file by a surgically trained nurse and confirms every possible discount has been applied.
Working with a partner that leverages advanced technology with expert clinical review and has longstanding relationships with the provider community is recommended. By looking at a hospital bill in its totality, payors can rest assured that nothing slips through the cracks. This approach ensures that every possible avenue for savings has been exhausted—not just the cost of implants.
The Solution for Savings
A catastrophic injury equated to $5 million in hospital charges. A solid bill review platform and professional nurse review, combined with an established relationship with the provider, resulted in significant savings including a prompt payment discount.
The outcome was a $3 million reduction.
Unbundling a bill review program requires manually gathering and consolidating data. In many instances, the data can never truly be integrated into a complete information set. Even when various sources, departments, or units are bundled under a single parent company, it is difficult for payors to evaluate their results objectively and across the board. True data integration requires significant long-term investments, development of advanced technology, continued resources, and critical thinking. And the real test of its utility is whether it delivers actionable data in a timely way to manage risk consistently.
Beyond the integration of data and services, is the knowledge that a partner is integrated with your team and invested in your success. In the end, the holistic management of your program on both a technical and personal level can help achieve the results you expect—and the results your executives need to see, year over year.
Programs that try to manually piece together siloed data from multiple vendors often never experience the results received with a holistic program.
Your Integrated Partner
When CorVel introduced Network Solutions over 15 years ago, the vision was to integrate medical management, provider networks, bill review, and analytics into a single solution that would allow clients to proactively manage disability and improve outcomes against every measure. The intent was to move beyond the discount mentality that had been a driving force in the industry and to leverage technology to see real, measurable gains in outcomes. We accomplished this with an agile platform handling all bills and all charges with consistent, defensible savings.
Clients who have realized the power of Network Solutions experience improved workflows, proactive management of patient treatment, and industry-leading savings. The power of our data analytics and reporting tools, and the totality of our solution make decision-making easy and complete.
Today, more than 600 clients experience the benefits of Network Solutions, a holistic model where the sum of integration – and actual client results – is far better than the individual parts.