Risk Managers and workers’ compensation claim managers normally know the purpose of medical bill review is to reduce medical bills to the state fee schedule or to the previously agreed amounts with the medical provider network. A good medical bill review company provides many more services. Unfortunately, many workers’ compensation insurance professionals do not understand all the services a medical bill review company can offer.
Upcoding Charges Higher Fee Than Injury Justifies
The adjudication process where the medical bills are compared to the state fee schedule or medical provider network schedule is the first step. The medical bill review company should also review whether or not the coding of the bill is correct. “Upcoding” is where the level of the medical care is coded at a higher level than was delivered, or where the medical care delivered is at a higher level than the injury justifies. Upcoding is used by the billing departments of medical providers sometimes in error, sometime on purpose.
Either way, if upcoding is not caught by the medical bill review company, the cost of medical care is higher than it should be. Good medical bill review companies will not only compare the bill’s coding to the state fee schedule or the medical provider network schedule, it will also review the coding to determine the appropriateness of the coding and “downcode” the bill when appropriate.
State Fee Schedule Comparison Only First Step
It is important that the medical bill review company utilize the specific state fee scheduled where the injured employee was treated. Employees who travel constantly, for example truck drivers and salespeople, often have an accident in one state, but need medical treatment near their home. The medical bill review company needs to have the flexibility to utilize the appropriate fee schedule and not be locked in to the state where the injury occurred.
