Linked In Dismantling the beast - Sedgwick

Dismantling the beast

The art of rooting out complicated cost-building tactics and re-pricing complex bills

The healthcare industry has an uneven compensation system. Healthcare providers, by necessity, utilize complex pricing systems and strategies that inflate costs for employers in workers’ compensation. These tactics are deployed to compensate for lost income for services provided in group and private healthcare. Without a systematic and consistent medical bill review program, employers are at high risk to overpay for medical treatments, products and services.


Employers should not be burdened with overcompensating for an imperfect healthcare system when paying for occupational injury care. Risk managers must ensure that exhaustive medical bill re-pricing processes are in place to protect their organizations from overpaying for necessary occupational injury care.

Medical bill review is not as exciting a topic as, say, strategies to counter the opioid epidemic or the impact of behavioral health on workers’ compensation. But effective medical bill review is the cornerstone of an effective overall risk and claims management program. It is important to fully eliminate the risk of even one complex and high-cost bill escaping expert scrutiny and re-pricing. One missed bill could wreak havoc on an employer’s loss budget.

Once the medical bill review process for detection of every complex and high-cost bill is established, the risk manager needs to make sure the right team of multi-disciplinary experts is in place. Medical bill review expertise must include highly skilled and knowledgeable clinicians providing oversight for complex, questionable and costly bills. Clinicians review pricing line-by-line and examine accompanying documentation of care. Nurses also identify non-applicable and inappropriate fees for the treatment documented and re-price complex bills to a reasonable rate. These experts then must document the reasons why services are being re-priced, as well as the regulatory and treatment guidelines they may fall under, to help the billing provider better understand and accept payment rationale.

Consider these three proven bill review strategies:

  1. In one common area of inflation, for example, surgical implant cost is often beyond reasonable and appropriate rates. A reliable and proprietary database exists to help bill reviewers accurately re-price charges associated with surgical hardware. Risk managers must ensure their medical bill review services are utilizing this surgical implant pricing database and implement tactics for maximum re-pricing.
  2. Providers want fast compensation for services provided. That preference for rapid reimbursement allows the effective medical bill review team to create criteria for express reimbursement. If a medical bill meets the scheduled cost criteria, the provider is offered reimbursement within a set amount of days for agreement to compensation discounted to a reasonable rate. Express reimbursement is a fair, reasonable and consistent strategy to secure additional discounts below fee schedule, usual and customary and PPO network reductions.
  3. Finally, the most costly and complex bills should always be pulled for specialty review and negotiation services, in which highly trained, specialized negotiators access targeted bill re-pricing information and agree to discounted compensation with the provider. Documentation of the negotiated agreement is accurately and consistently written to prevent a provider from later disputing the payment.

Employers receiving consistent, justifiable and well-documented complex bill review discounts have behind-the-scenes bill review systems, processes and skilled experts in place who work to re-price every bill at reasonable and appropriate rates. Risk managers: check the pulse of your medical bill review service. Ensure that it provides excellent clinicians, specialty reductions for items like surgical implants and skilled and knowledgeable negotiators to address the most complex bills.

Mary Beth Sanford, Managing Director

Back to Blog
Back to top