Control Costs: Utilization Review and Medical Bill Review

In claims management loss reduction is a constant priority. Previously, insurance adjusters accomplished this through their expertise and use of resources when settling cases. Two strategies that have proven to be highly effective and increasingly popular are utilization review and medical bill review. In this article, we will explore how insurance adjusters can streamline costs by utilizing these powerful techniques in conjunction.

Understanding Utilization Review:

Utilization Review is a comprehensive process facilitated by trained professionals such as UR nurses who compare treatment plans with the industry standard. This way adjusters can identify what services can be avoided or reduced without compromising the quality of care. This method ensures that only essential services are approved, minimizing unnecessary costs to the insurance company and ultimately benefiting policyholders.

The utilization review process helps prevent fraudulent claims, control costs, and:

• Ensures compliance with insurance policies and regulatory requirements, preventing unnecessary reimbursement
• By identifying potential risks, errors, or gaps in treatment plans. Therefore, mitigating liabilities and reducing the risk of future litigation.
• Minimizes the potential for overutilization and wasteful spending, optimizing the allocation of insurance resources.

Why it’s Beneficial for Insurance Adjusters:

According to Insurance Business America, the insurance industry is facing a 430,000 shortage of adjuster positions. Outsourcing to the same vendor for UR (utilization review) and Medical bill review needs will relieve adjusters of manually comparing fee schedules and scrutinizing bills.

Understanding Medical Bill Review:

Adjusters use medical bill reviews to verify that the services billed for were provided and that the charges are reasonable and customary.

Medical bill review is an additional layer of cost reduction that compliments utilization review. After a treatment is deemed medically necessary, insurance adjusters use a medical bill review to analyze the billing and coding of medical services rendered.

Medical Bill review can help by:

• Identifying coding errors
• Eliminating duplicate charges
• Finding inflated fees
• Adjusters can negotiate more favorable rates with healthcare providers, ensuring that the insurer pays a fair and accurate amount for the services provided.

This process safeguards against billing discrepancies and helps control costs, ultimately leading to savings for both the insurer and the insured.

Benefits for Your Policyholders:

The integration of utilization review and medical bill review not only benefits insurance companies, but it also has significant advantages for policyholders. By reducing unnecessary treatments and ensuring accurate billing, insurance adjusters can help keep insurance premiums affordable. Additionally, policyholders can have peace of mind knowing that their insurance company is actively managing costs while maintaining the highest standard of care.

Maximizing Resources:

• Cut the need for your insurance adjusters to manually audit every medical bill and its corresponding changing fee schedules
• SaaS model and cloud access eliminates costly infrastructure and internal resource commitment
• Eliminate reporting errors and delays with automatically updated fee schedules
• In-house experts provide fast responses and precise bill adjudication due to their extensive experience.

The science behind it is Medical Bill Review providers have mapped all ICD diagnosis codes to their exact and equivalent body part codes, enabling claim data to be evaluated systematically and bills to be identified for review. They allow examiners to quickly determine compensability based on data received in the claim record.

Two Distinct Processes With One Common Goal

Utilization Review primarily focuses on evaluating the medical necessity and appropriateness of care provided to patients, while Medical Bill Review concentrates on assessing the accuracy and completeness of medical bills and claims for reimbursement.

By carefully assessing treatment plans and scrutinizing medical bills, adjusters can identify unnecessary expenses, negotiate fair rates, and ultimately provide cost-effective insurance solutions.

Assign a utilization review and medical bill review all in one place through Ethos.