Managed Care Integration

With the arrival of new claims system options, using the latest cloud-based technology and “low-code” architecture, the opportunity to integrate systems has never been better.  Add to that the eminent impact of AI in the workers’ compensation claims process, which will only drive more innovation.

This is not a bad time to ask yourself if you are taking advantage of all of the integration opportunities available to you.  Sure, you will need to integrate your bill review and other managed care services into your claims systems, but what is the nature of that integration?  Is it traditional EDI-based integration, or are you able to use API or web services-based integration?  

Particularly for bill review, integration with the utilization review (UR) process is foundational to most all managed care programs.  If you think of cost in its most basic economic terms, it is a function of volume multiplied by price.  In this scenario, the UR services control the volume of care, and the bill review process control the price, and those two elements must be integrated to maximize savings.

This integration has some inherent challenges however.  For starters, UR is primarily notes driven, and bill review is data driven, making it difficult to use automation to connect those processes.  If the UR company is exporting UR notes to the bill review processors, that staff must stop and read the notes, potentially increasing the turnaround time for bill review (a metric payers closely monitor). Also, the clinical staff conducting the UR services typically has little visibility or influence to what or how the provider will bill for the services rendered, further complicating things.

There are however a few bill review companies in the marketplace that have an automated “Code Range” based process, that can automate the bill review/UR integration process.  This process authorizes services within a range of procedure codes by the UR staff, enabling the bill review system to capture the procedures as data within that codes range, and apply the UR decisions (especially denials) into the bill review process, maximizing the value of the UR service.

What is the bottom line?  This an unprecedented time to increase productivity and savings by leveraging existing and new technology into your managed care programs.  To that end, make sure you have an understanding from your vendor partners about how technology and automation is being used today, and have them articulate their roadmap for the future.