Compmed Advantage - Bill Review

BILL REVIEW

With more than two decades of bill review and workers’ compensation cost management experience, the CompMed Partnership has the solution to workers’ compensation medical cost-management problems. We host many of the industry’s leaders with our bill review application and process over 15 million bills on our system annually. The CompMed Partnership's proprietary Bill Review system is centrally maintained and managed, allowing for consistency in bill processing and fee schedule updates across all bill-processing locations. In fact, the CompMed Partnership has a total of 250 FTEs nationwide, dedicated to our bill review operations.

We have extensive experience with bill review workflows and can assist the Client in developing a customized process to increase processing efficiency while increasing overall savings with our integrated cost management programs The CompMed Partnership's proprietary Bill Review system automatically re-prices to state fee schedules, calculating modifier reductions such as assistant surgeon or multiple surgery reductions and Network re-pricing.

The CompMed Partnership's proprietary Bill Review system is delivered as an Application Service Provider (ASP) model. Our clients’ benefit from receiving updates to the state fee schedule almost immediately and our track record in fee schedule maintenance is the best in the industry. The CompMed Partnership loads these changes twice a week. To notify our clients of changes to the fee schedules and their availability within the CompMed Partnership's proprietary Bill Review system, we employ multiple avenues to communicate with our clients. The CompMed Partnership will provide Client with a monthly report that details any changes to fee schedules on a state-by-state basis. We send e-mails to our clients that identify fee schedule and functionality changes to the bill review system as they are programmed twice a week. And we offer a client portal that combines multiple CompMed Partnership and regulatory resources into a single client-specific web resource.

The CompMed Partnership employs a multifaceted approach to gathering fee schedule information. First, we develop and maintain relationships with state agencies to keep apprised of changes in fee schedules. Additionally, we use Internet web sites, publications, industry contacts and state mailing lists to keep current with state fee schedule activity and obtain fee schedule information.

Upon receipt of a new fee schedule, the CompMed Partnership assesses the information for revisions and validates the automation of rules and pricing that have not changed in a fee schedule. Fee schedule pricing and rules that do not change remain automated in the system and, consequently, do not require activity by the CompMed Partnership. For those portions of the schedule requiring updates, the CompMed Partnership maintains and updates a state fee schedule database of pricing files, procedure files, diagnosis files, Explanation of Review (EOR) messages, and other various tables, and uses a variety of reference files including CPT, ICD-9, and HCPCS to implement fee schedule regulations. Fee schedule data is updated in the proprietary bill review system within 30 days of receipt and fee schedule rules are updated within 60 days.

The quality processes the CompMed Partnership has in place to managed fee schedules on a national basis, will provide Clients with excellent fee schedule response, ensuring that bills are processed against the most current guidelines available.

The CompMed Partnership routinely measures the timeliness of updates to validate the loading of fee schedule data. Prior to each update, the information is tested in a model office environment to ensure accuracy. The CompMed Partnership also regularly performs Quality Assurance tests on the data to validate the loading process.

The CompMed Partnership’s proprietary Bill Review system automatically reprices to usual and customary values if a fee schedule does not exist, calculating modifier reductions such as assistant surgeon or multiple surgery reductions and Network repricing. States that have not adopted an official fee schedule are given an area plan that contains usual and customary rules, regulations, and pricing.

Usual and customary information is purchased from Ingenix and is updated quarterly and integrated into the proprietary bill review system. The information is updated via computer tape quarterly and is available to all system users when it is loaded into production.
Clinical Rationale

There are edits in the proprietary bill review system that are supported by clinical logic that has been developed by clinical experts within the CompMed Partnership. The primary basis for the clinical edits are the National Correct Coding Policy Manual (NCCPM), Current Procedural Terminology (CPT), and the American Academy of Orthopedic Surgeons (AAOS). A rationale statement has been written for each clinical edit to describe the reasons that the system is recommending a change in payment. These rationale statements are also available to our clients to assist the adjuster with explanations as to why a specific bill has been reduced.

Our proprietary system precisely detects unbundled, mutually exclusive and incidental procedures. Our clients routinely receive enhanced savings through the identification of inappropriate treatment intensities for a given diagnosis or treatments that exceed the needs of an injured worker.

Identification of provider billing anomalies is as much a part of the proprietary bill review system as is the pricing of procedures. Various parts of the system work together to assist the processor in creating the maximum savings possible on any individual bill.

Unbundled procedure codes are identified in our proprietary bill review system, according to state-specific guidelines and medical policies. Procedure unbundling occurs when two or more procedure codes are used to identify a service when a single, more comprehensive procedure exists to describe the entire service performed. When unbundled services are detected, our proprietary bill review system automatically bundles the procedures to the correct procedure code. Occasionally, the correct code is not present on the provider’s bill. In these cases, our proprietary bill review system will automatically add the correct procedure code and price accordingly.

Incidental procedures that are commonly performed as a part of a larger procedure are edited in the system. For example, if an injection procedure is billed in conjunction with a tendon repair, the proprietary system will identify the injection procedure as an incidental procedure and deny the charge.

Mutually exclusive procedures are those procedures that should not be performed during the same visit. The system will automatically identify mutually exclusive procedures and recommend payment only for the most clinically intensive procedure performed.

Fragmented procedures are also identified by our proprietary bill review system. A fragmented bill is a bill which the provider submits only a portion of the services. The secondary billing includes additional services on the same or different date of service. Our proprietary bill review system performs edits and audits on a line-by-line basis and uses other service lines on the bill and in the history database to determine appropriate adjudication.

Procedure to diagnosis relationship edits examines diagnosis codes that are not related to the procedures with which they are billed. A series of edits were created to alert the processor of billing inconsistencies in the areas of radiology and surgeries involving the musculo-skeletal system. These edits can be assigned a severity to disallow services or suspend bills for manual review.

Outpatient utilization monitoring is a feature that utilizes a statistical database which contains over 2,000 diagnosis codes and the corresponding number of visits, by percentile, that represent the norm. The client can choose the percentile and the system will identify the number of visits exceeding the parameters. The system can be set to simply print a message on the explanation of review, or can suspend the bill for further review.

The CompMed Partnership adheres to annually published Current Procedural Terminology (CPT) through utilization of the following coding systems:

CPT (Current Procedural Terminology)
ICD-9-CM (Diagnoses and Procedures)
DRG (Diagnostic Related Group)
HCFA Place and Type of Service Codes

With the exception of the CPT, which is maintained by the American Medical Association, the Healthcare Financing Administration (HCFA) defines most coding systems. There are some instances where the use of these codes is not possible, as is the case with California Medical-Legal bills. Other unique services in California require the CompMed Partnership to define a code to process these services. The CompMed Partnership fully documents these procedures as part of the state fee schedule guidelines we provide to our clients.

The CompMed Partnership has an on-going clinical edit review process coordinated by a steering committee. Clinical edits and rationales are under constant review, especially when procedure codes updates are released. In addition, when state fee schedules updates are released, clinical edits are evaluated against fee schedule rules and regulations and any conflicts are resolved as part of the fee schedule implementation process.