Many payers’ bill review systems are still not electronically connected to medical management applications; bill review prices are lower than they were three years ago, and payers are increasingly interested in bill review applications’ rules engines.
Those are three of the key findings from the latest Survey of Bill Review in Workers Compensation, and result from answers provided by 24 respondents from payers large and small.
We last conducted the survey back in 2009, and waited three years to see how quickly the industry would evolve. In some ways there’s been a good deal of change; in others, not so much.
The connectivity issue is perhaps the most visible. While there’s no doubt more payers have done a lot to tie bill review to medical management systems, many are still relying on “manual” processes to ensure bills for unauthorized or denied care are not paid or otherwise handled correctly. This greatly increases the chance for error, thereby increasing costs and wasting the time and money spent in the UR process.
Prices have declined, both for outsourced bill review and for payers leasing vendors’ systems, this despite the consolidation among application vendors that’s removed several once-significant players from the industry.
What has changed is the focus on auto-adjudication and interest in rules engines, driven – according to respondents – by a quest for greater efficiency and consistency.
With prices for bill review coming down, it’s not surprising interest in efficiency and automation is up; the soft market and pressure on admin expense is certainly a factor as well along with the desire to more consistently – and accurately – pay medical bills.
I expect the Survey report will be available by the end of next week. More to come.

With a weekend to recover, here are the quick takes from the WCI Conference in Orlando.
The ‘Headline’ keynote – Kathleen Madigan – was terrific. Glad I didn’t have to follow her; my “Industry Keynote” didn’t inspire many grins or guffaws, but did generate some outright hostility from the physician dispensing/repackaging folks.
Good.
Liberty’s physician meeting was very well attended; word is there were almost a hundred physicians at the get-together, a credit to Jean Feldman, their local Florida managed care exec. Kudos to Liberty for reaching out to treating physicians to strengthen relationships.
Saw an interesting piece of technology from CORA rehab – an iPad-based tool that serves as a teaching tool, enables patients to record and document their home exercise, and communicates w the PT and others involved in the case. Will be in use in January; they’ve invested a great deal of thought into the app and it looks promising.
The emphasis on broadening the conference’s appeal to a national audience looks to be paying off. There were attendees from everywhere, including Hawai’i, and topics of interest to people from all around the country.
Progressive Medical’s analytics capabilities are pretty impressive – that’s the report from a couple folks who attended their luncheon.
One of the strengths of WCI is a bit of a shortcoming as well; the plethora of audience-specific tracks (regulators, judges, medical issues, claims, etc) means there are not nearly enough “cross-stakeholder sessions” where judges hear from doctors and regulators and vice versa. This is a medical-legal system, and the more perspective we have on the various pieces and parts of the “system”, the better.
Definitely a younger and hipper crowd than at other conferences, but that’s to be expected when adjusters make up a big percentage of the audience. I have no idea how women walk in those five inch heels, but there were lots who somehow managed. And what’s with all the shirt tails out?
I know, showing my (advanced) age…
Overall – a LOT of information available, many excellent sessions, plenty of opportunities to party in the suites; need more cross-stakeholder discussion and better attendance at some really solid presentations.

The Hartford wants to pay for what works, not pay for stuff that doesn’t and doesn’t want to argue.
That was the one-line statement from Medical Director Rob Bonner in his talk at the just-concluded WCI.
Bonner went on to discuss how the Hartford defines “what works” and how they evaluate treatment plans that deviate from generally-accepted standards of care/Evidence Based Medicine (EBM).
I reviewed my notes from Dr Bonner’s talk after several comments on yesterday’s posts lamented/complained/squawked/expressed outrage that insurers had any right to determine the medical necessity of treatments much less not pay for treatments deemed not effective.
When you consider the wide variation in practice patterns reported by WCRI’s Dr Rick Victor yesterday, the weakness of the commenters’ arguments become crystal clear.
Notably, Dr Bonner said guidelines don’t work for all patients in all situations; treatment outside of guidelines may be appropriate but only if treatment within guidelines has failed.
Bonner concluded with a very interesting discussion of how payers should – and the Hartford does – look at guidelines and the interaction with providers based on guidelines. It is clear they are central to the way the Hartford medically manages WC claims, and that the use of guidelines is based on driving to better outcomes. It is equally clear that the onus is on the treating doc to develop a treatment plan that gets to a defined result if and only if standard EBM guidelines don’t work, with “work” defined as functional improvement.
I’d add that insurers have this thing called “fiduciary responsibility” that requires them to pay only for services that are deemed appropriate and necessary. That doesn’t include procedures that have been demonstrated to show no positive impact on outcomes; examples may include some cold therapy devices, passive motion machines; certain drugs and surgical procedures.
I’d also add that some insurers are “bad actors”; denying treatments arbitrarily, losing documentation, and generally doing whatever they can to avoid paying as much as possible. That said, in my experience these crappy companies are in the minority.
What does this mean for you?
Practice within guidelines, and if you don’t, be prepared to show why it makes sense to do something different and describe where the treatment is headed.