Hours, days, and sometimes weeks or more can be required for a payer to review and audit a medical itemized bill (IB). From outpatient procedures to long hospital stays, there are millions of insurance claims submitted for review daily. The process is time and resource consuming, yet it is essential to the payer-provider relationship of disbursing appropriate reimbursement. While outsourcing the IB review process is an option that many in the healthcare system utilize, insourcing the process has never been more possible than with today’s technological advances. If you’re a payer in search of how to bring your IB review process in-house, here are some things that you need to consider:
Evaluate Your Team and Resources
One of the first assessments to make when considering the move to insourcing your medical review process is to evaluate your team’s talent and their bandwidth to handle the workload. Shifting from outsourced solutions to insourcing may seem like an insurmountable task. However, with today’s technology, you don’t need a large team of people to perform IB reviews in-house.
For years, the standard procedure for the review process has been for the payer to request the itemized bill directly from the provider. Once the payer submits the request (usually via mail), the provider is tasked with complying with the request and submitting the IB. The provider must then locate the IB within their EMR and/or the financial system, then either fax, mail, or upload via a portal to the payer for review. It then takes a team of skilled resources to work through all of the IBs, line-by-line. The turnaround time for review varies, but often, many factors push the review time out to days and weeks. With extended hospital stays, one IB could be hundreds of pages long and take up to a month or more for one person to manually review.
When paired with a solution like CAVO® Predict, your staff doesn’t need an advanced skill set, as automation and artificial intelligence guide the process. On average, health plans with 1 million members traditionally need 15 people to manage reviews. However, with our CAVO® solution, that same health plan now only requires five people to do the work. No matter the size of your staff, if you have talent that knows the healthcare system and can be trained on today’s IB review technology, you can insource your review process, saving time, resources, and money.
Choose the Right Workflow and Technology
With the right workflow and technology solution, even a small team of people can manage a robust in-house IB review process. Technology doesn’t completely remove the need for human engagement in the IB review process, but it does minimize much of the administrative burden, as well as reduce the subsequent administrative costs. Instead of spending hours searching for key line-items to adjust or deny and then re-keying it into Excel documents or workflow systems, automation can seamlessly deliver the needed data into the organizations’ workflow.
Additionally, finding a solution that provides formatting and structure from manually generated IB images implements consistency in the data format, allowing users to quickly share findings with providers- including specific line items and reasons for rejection. This structure reduces provider abrasion by minimizing required EMR access and subsequent credentialing, ultimately leading to a faster time to appropriate reimbursement.
With technology like our CAVO® platform, the IB review time is greatly minimized. By utilizing our cutting-edge Optical Character Recognition (OCR) technology, CAVO® can extract data from an imaged IB and map it into your current processes and systems, delivering the most accurate IB information in the industry. Our CAVO® platform provides an astounding 5x Productivity Lift. This means that by leveraging our solution platform, one person can do the work of at least five people.
Consider Your Claims Selection
Another component to bringing your medical IB review process in-house is to consider your claims selection. Will you bring all IBs in-house, or will you select some for insource, while others will remain outsourced? You may determine which claims you insource vs. outsource based on a dollar threshold. For instance, you may outsource larger claims due to the time required to review the IB. There are three things to consider when determining your claims selection:
- Your available staff and bandwidth
- Your payer-provider policy and pay audit agreements
- Your workflow and supporting technology
One of the major advantages of utilizing our CAVO® platform is the ability to identify non-allowable charges within the IB. The IB data can be organized by revenue codes, DOS, and more by utilizing the sort and filter functions. Bulk adjustments can be made based on consistent reason codes that the user assigns. This process decreases the administrative burden, allowing for a much quicker review of even large claims.
It’s Not As Difficult As You Might Think
The opportunity to bring your IB review process in-house is just that: an opportunity. What used to be a system that required a large group of people who are overworked and overburdened with the pressure of millions of dollars on the line is now being driven by technology that generates a massive lift in production with more efficiency and better accuracy. Keeping the considerations above in mind, your team can efficiently get more work done while saving money.