If your organization is experiencing workers’ compensation claims leakage and paying more than you should for claims, you are not alone. That’s because every claim involves multiple systems and the input of numerous people, departments, and vendors. At each of these points, there are opportunities for claims leakage and overpayment. It’s happening in your organization, and in thousands of others across the country.

Here’s the problem: After a workers’ comp claim is submitted, a subject matter expert performs a utilization review. At this time, some procedures are approved and others are denied. However, denied services are often performed anyway. And because the bill review process can’t identify which services were approved and which weren’t – based on the codes on the bill – the whole bill gets paid.

Another breakdown in the system occurs when a claim is submitted for a valid injury. The injured worker is treated by a medical professional, who also treats a non-work-related physical condition at the same time. Afterwards, the provider submits all costs to the carrier. Without a way to effectively identify which costs are associated with the claim and which are not, the whole bill gets paid.

In a third problematic scenario, a claim comes through for a worker’s injury. The claim is determined to be valid, so it gets paid. The issue here is that the amount spent to treat the injury is excessive, due to unnecessary tests having been performed.

In each of these cases, claims leakage or overpayment happened because volumes of data housed in multiple locations could not be correlated effectively. Sure, manual examination may catch some of these issues before the whole bill gets paid. But manual reviews are time-consuming and prone to human error. Since few organizations can build time into the process for manual review at each step of the way, some opt for spot-checking; but that won’t eliminate all of the leakage either, only what is found during the individual spot checks.

What is lacking in these examples is true claims system integration – the only way claims leakage and overpayment can be prevented.

When your claims system is properly integrated, your organization will reap these benefits:

• All those error-prone, labor-intensive tasks within the claims handling and bill review processes are automated.
• Each submitted bill is evaluated for relatedness before being routed automatically to the correct bill review process. This avoids the inconsistencies that arise during manual routing.
• A truly integrated system verifies high-fidelity information, such as whether a service is appropriate to a claim and is compensable.
• Inappropriate coding relationships are identified BEFORE reimbursement.
• The clinical data from utilization reviews – including approvals and denials – are correlated with detailed billing codes.
• All non-compensable medical costs are eliminated.

Every organization needs to reduce or eliminate both loss and loss adjustment expenses while improving overall profitability. Claims system integration is the answer! To automatically stop paying for unauthorized or non-compensable services, Acrometis has claims system integration tools that can be easily inserted into your organization’s existing systems.

For more information about claims system integration, visit Acrometis.com or call 855-282-1476 today.