a trend already well underway as more
state regulatory bodies embrace their
own guidelines or those from ODG and
the American College of Occupational
and Environment Medicine (ACOEM).
There is a good reason why guidelines
are gaining traction. When they are integrated into payors’ workflows, claims
handlers can more quickly determine the
most effective treatment for something
like back injuries, or the optimal number
of physical therapy appointments required
for recovery from a torn rotator cuff. Still,
many payors lack processes for applying
the guidelines. As a result, they’re able to
make only sporadic use of them.
What’s the best approach for adopting
evidence-based guidelines? Payors’ first
steps are to examine how to interface with
the guidelines and then build data feeds
that incorporate them organically into
their processes. How can payors make the
information they contain more actionable? Establishing the answers will help
lead to the lower costs and quicker case
closings that researchers are documenting.
2. Implement medical necessity
reviews (MNRs) for all claims.
Sounds impossible, we know. After all,
MNRs have traditionally been used in
mandatory utilization review states, on
defined sets of procedures or at the claim
handler’s discretion. But data-driven, evidence-based guidelines make wider use
of MNRs financially feasible.
MNRs are an important tool so payors
can stop claims leakage, or the difference
between the amount paid and the amount
that would have been paid had best practices been applied. Leakage occurs in
surprising places. It can be greater for
routine injuries than the high-value cases
typically flagged for MNR.
Digital technology helps payors apply
medical expertise to claims in affordable
ways that enable its broader use. For in-
stance, payors may create OCR-based
solutions that review medical records for
treatment outliers and identify co-mor-
bid and pre-existing conditions such as
smoking and hypertension, which impact
claims outcomes. Medical bill data can be
used to identify services that are unre-
lated to a claim’s approved injury or that
exceed the guidelines. Instead of relying
on adjusters to pore over stacks of docu-
ments, digital systems can handle it.
The result for payors is identification
of candidates for early intervention and
better allocation of resources to mitigate
3. Rethink your approach
to medical expertise.
Although it seems counter-intuitive
at first, incorporating more medical ex-
pertise can limit medical costs without
increasing claims allocated loss adjust-
For example, nursing expertise adds
valuable clinical insight into cases, but
traditional approaches to it can be expensive. In our work with payors, we
found fewer than 20 percent of indemnity cases utilize nurse case management
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