Inside Workers’ Comp Blog

Bill Review: Digging Deeper to Fight Fraud and Attack Overall Medical Spend

Posted by Tom Kerr on June 7, 2016

Most people don't think of bill review as a component of fraud detection in workers' comp, yet in this edition of Inside Workers’ Comp, Genex’s Tom Sebold says it sometimes plays an integral role in the process. Through a combination of technology and experienced staff members, a good bill review program can identify improper billing and utilization of medical services in workers' compensation.


Tom Kerr (TK): Welcome to Inside Workers’ Comp, a regular multimedia series in which subject matter experts discuss problems and offer solutions to top issues affecting our industry.

And in this edition of Inside Workers' Comp, we examine the role bill review plays in detecting workers’ comp fraud. With me today is Genex’s Tom Sebold. Tom, thanks for joining us.

Tom Sebold: I really appreciate it. Thanks for having me today.

TK: Tom, most people don't think of bill review as a key part of fraud detection in workers' comp. How is it involved in that process?

Sebold: I always look at it, that bill review provides a combination of technology and people to identify improper billing and utilization of medical services in the workers' compensation process. In my mind, a good system checks treatment and dates of service across all providers, signaling the customer when there may be a suspicion of fraud for closer claim scrutiny and investigation.

A good bill review will use a process of clinical edits or flags that provide a utilization review component designed to catch inappropriate treatment for a given diagnosis. These flags should be based on clinical guideline tools that generate specific alerts for claims examiners' review when frequency or duration thresholds are exceeded. I think that's very important to note.

Any inconsistencies in treatment versus the diagnosis should be identified, or when maybe there's an injured body part that does not match with the billed ICD 10 code. It should have a capstone table that flags that process and basically provides an alert back to the adjuster or claims person that might be handling that individual claim.

TK: So, when bill review red flags something that may appear fraudulent, what happens next?

Sebold: The first step is we look to see if we simply have a provider education issue. Is this truly a fraudulent issue, or do we just have a provider that maybe needs some outreach and some additional education on how to properly bill for the services that they are submitting to us?

It's easy to jump right to, "Hey, this is fraudulent," when, in fact, a lot of times workers' compensation is a very complex state by state driven process. Providers need, at times, additional education to understand what's appropriate to bill in the workers' compensation world.

If we don't see the change at that level, or we see a provider that falls into a pattern of billing issues, or a utilization that's inappropriate compared to professional levels, professional guidelines like ODG or ACOEM, then we may have to raise that issue to the individual claim staff, have a discussion about what are our next steps.

Is it a more of an outreach from the payer? Whether that's a self-insured employer, a TPA or an insurance carrier, where in conjunction with our assistance, we do an outreach to that provider or provider community and say, "Hey, we have an issue here. We're concerned about the level of services being billed for, or the level of services being provided for this type of care or treatment."

If we don't get that alignment or if we're not able to come to that alignment, the next step may be working with our business partners, our customers, in making an outreach to the individual state jurisdiction that's involved. That would be where we truly believe we may have something that is egregious or going beyond just an education standpoint.

TK: Thanks, Tom. In the next Inside Workers’ Comp, we’ll address the question: Bill review generalist vs. specialist. Is there a real difference? Until then, thanks for listening.

Price shopping is a good idea when looking to rent a beach house and a car to get you there, but when it comes to purchases that will impact your wallet for the long-haul, pinching pennies early on will likely cost you in the end. Same is true with bill review in workers’ comp, where the quality of a system can make a big difference in saving you from costly errors and fraudulent activity. Genex’s Tom Sebold explains the differences between bill review specialists and generalists and how to differentiate the real deal from a lemon.

Part 2

Price shopping is a good idea when looking to rent a beach house and a car to get you there, but when it comes to purchases that will impact your wallet for the long-haul, pinching pennies early on will likely cost you in the end. Same is true with bill review in workers’ comp, where the quality of a system can make a big difference in saving you from costly errors and fraudulent activity. Genex’s Tom Sebold explains the differences between bill review specialists and generalists and how to differentiate the real deal from a lemon.

 


Tom Kerr (TK):
Welcome to Inside Workers’ Comp, a regular multimedia series in which subject matter experts discuss problems and offer solutions to top issues affecting our industry.

I’m Tom Kerr, and in part two of our discussion with Genex’s Tom Sebold, we’ll try to uncover the true differences between bill review generalists and specialists.

So, Tom, let’s get right into it, what makes a bill review specialist “special?”

Tom Sebold:  Obviously, everybody in the marketplace realizes technology is becoming more and more important, but it's the people behind that technology that really, especially in a bill review setting, drive that additional reduction in your overall medical spend that you may experience.

Those specialists that examine specific types of bills — whether it be large hospital bills, whether it be surgical implant bills, or whether it's specific to pharmacy bills — they have that combination of experience, training, and then the knowledge of what's going on within specific subsets of bills.

In addition, it's very difficult to have a true fraud protection program, or something that can at least alert you to the potential of fraudulent activity within a bill review program, if you do not have those specialized people that have the education training and background to identify those issues.

TK: You had mentioned bill review specialists help reduce overall medical spend, but don’t they carry larger upfront costs?

Tom S.: I think there's a drive out there to look for a low‑cost provider in the medical bill review area. But really, where you drive the most cost savings is through incredible savings reductions within your bill review program.

You can drive some of that with technology, but you need that specialized team of people behind the technology to get that incremental two to five percent of additional medical spend reduction that really highlights a great managed care program.

TK.:  OK, so what are some examples of where customized bill review can make a difference?

Tom S.: It could be something like in a pharmacy program really focusing on physician‑dispensed medications, and having a flag that directs those types of bills to a group or team of people that can actually break those bills apart and identify areas of savings, areas of concern, provider education‑type issues and then, potentially, even potential fraudulent issues within that network.

It may be an employer that has extremely high and costly injuries. They need a real focus on hospital and surgical‑type centers. They want to have certain large dollar bills flagged to be broken down and really analyzed by that bill review professional.

That's really how you can differentiate your program. It suddenly becomes, instead of that fast, quick, "Hey, let's get it to a fee schedule reduction," now you're really breaking down a bill. You're really attacking the overall medical spend of a program.

Again, there are certainly options in the marketplace to go out and get an out of the box platform and generate some bill review savings, but I really believe the best programs are ones that specialize to the need of the individual customer and then drive and maximize the savings with specialized tools and reduce that overall medical spend for those individual employers.

TK: Thanks, Tom. In our next Inside Workers Comp we’ll discuss how case severity tools can make a difference in your work comp claims. Until then, thanks for listening.

   

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