Workers Compensation Medical Bill Review Services

The Vendor is required to provide for workers compensation medical bill review services.
- The professional health care review is to ensure that services are related to the covered work injury and that the carrier is reimbursing for medical necessity and appropriate medical care. Carriers are to review the quality and quantity of medical services, based on accepted medical standards.
- Determine the accuracy of the procedure coding on the bills.
- Ensure the amount billed does not exceed the maximum allowable payment allowed by the rules.
- In-patient hospital care
- Total claim medical payments exceed $20,000.00.
- Any cases where it is suspected there is inappropriate care taking place.
- Medical bills are reviewed by licensed, registered, or certified health care professionals.
- The application by others of criteria developed by licensed, registered, or certified health care professionals.
- The licensed health care professionals are to be involved to address reconsideration requests from the medical providers.
- Non-clinical staff
• Non-clinical staff (R 418.101204 (5b)) may be used in the application of criteria developed by licensed, registered, or certified health care professionals in the review process. They may not gather data that requires evaluation or interpretation of clinical information.
• Their duties must have oversight by a licensed health professional.
• They must be properly trained in the principles and procedures of structured clinical data, scripted clinical screening, and maintenance of confidentiality of patient-specific information.
- Peer Review
• Peer review may be performed when the claims are initially submitted.
• Peer clinical review is usually done in cases where clinical determination to approve claim payments cannot be made by initial clinical review.
• Either a carrier or the physician may request a peer review if the outstanding claim issues are not resolved through the written reconsideration process.
• Peers must have suitable occupational injury or disease expertise, or both, to render an informed clinical judgment on the medical appropriateness of the services provided. They must be in the same licensure category as the ordering provider or a doctor of medicine or doctor of osteopathic medicine.
- Any bills with date of service before the date of injury, the vendor is to contact the appropriate Technician directly to confirm the date of injury to assist in processing the payment timely.