Today, in the
United States, the cost of medical care is rapidly growing. These increasing costs, especially in
workers’ compensation, are putting more and more pressure on the payers of these
costs (i.e. insurance companies, self-insured employers, etc.) to keep them
under control. Oftentimes, payers will
turn to a specialist, such as Alpha Review Corp. (ARC) to review these medical
bills.
On its surface, medical bill review may seem like a very simple process. In reality, it is much more complicated. Every state has its own set of rules and guidelines which determine not just what code(s) should be used for which procedures, but what fee is to be charged for that particular code. Additionally, some codes include procedures which are also accounted for separately in other codes and should therefore, not be used together. For these reasons, among many others, it is increasingly difficult for a payer to effectively review their own medical bills before payment.
Once the decision
is made to look for a new bill review company, many times test bills or a short
pilot program is used to compare different bill review companies. Test bills can be an effective way to compare
some features of different companies such as PPO savings, specialty review
programs (i.e. nurse or physician review, complex bill review, etc.) and
overall fee schedule/RACD savings.
Beyond simply comparing the final savings number, some questions need to
be asked to find out exactly what they consider savings such as:
- Are duplicate bills included in savings?
- How are reconsideration request accounted for?
- What types of savings are included in the final number?
Once a true
“apples-to-apples” comparison can be made between all companies, other factors
must be examined. Often, one of the main
factors is price. It can be tempting to
“spreadsheet” all the potential vendors and simply sort them on price and pick
the cheapest one. However, there are too
many factors that go into determining the best fit for a bill review
partner. Factors such as turnaround
time, customization of workflows, responsiveness, etc. Perhaps the most important factor is the most
difficult to quantify and that’s the confidence and overall comfort level that
is felt with the potential vendors.
No doubt, price is
certainly a factor. Return on Investment (ROI) should be the
highest priority. Using highly trained, certified reviewers yields
significantly higher ROI. While a seemingly inexpensive per bill or line
rate may seem like a bargain by reducing claim expense, claims paid may
skyrocket.
While price is
always going to be one of the factors that go into making a decision, it should
not be the only one. There are many
other things that need to be considered and cheapest does not always equal
best. If you have any questions or would like
additional information, please contact Alpha Review here.
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