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Harness The Power of Nurse Reviews for Third Party Bodily Injury Claims

Medicare reimbursement for providers continues to move toward the value-based care models, which center on patient outcomes and how well healthcare providers can improve the quality of patient care. Thus, providers treat the entire patient, not just the presenting injury or disease. As such, physicians are now asking more questions about the patient’s medical history and thus documenting and treating more complex medical conditions than in years past. For hospitals, reimbursement may be impacted by the number of patient readmissions in a specified period. Therefore, when an auto accident patient presents to the ER, the patient may be subjected to tests and procedures to address unrelated conditions (comorbidities) to decrease the likelihood of future readmission. These additional treatments and procedures are often presented in 3rd Party demand packages and passed on as loss-related costs, thereby inflating medical specials.

While treating the whole patient helps deliver a better patient outcome, it creates a significant challenge for insurance adjusters. Claims professionals are looking to accurately reimburse injured parties for their loss injuries and associated treatment while filtering out pre-existing or non-accident-related conditions and convoluted medical procedures presented in lengthy demand packages. CCC Casualty’s Third Party Reviewer Program helps your adjusters make sense of these complex conditions and their associated treatment to aid in fairly and accurately adjudicating these bodily injury claims.

To add more complexity to this growing problem, the age of the US population is shifting, with Baby Boomers expecting to become 21% of the population by 2030 (source: The Graying of America: More Older Adults Than Kids by 2035 ( ). The number of third-party injury claims for those aged 61 and over continues to rise, with 2022 showing the most significant increase over the past four years.

Common chronic conditions in older patients that may be present after an automobile loss include back and neck pain from osteoarthritis, chest pain from chronic obstructive pulmonary disease, and confusion/disorientation from dementia. These conditions appear in the medical records and billing presented to our customers, with head injuries dramatically increasing in 2022.

A Shift is Happening

Starting in 2021, there was a significant decline in the average number of total procedures presented in third party claims, going from a high of 115 procedures in 2020 to just under 90 procedures at the end of 2022. During that same period, the average medical bills submitted per injured party rose from $23k to a high of $26k in Q3 of 2022. Medical inflation is partially to blame for these rising costs, but expensive hospital bills at the front end of the claim are also a significant driver.

The current data suggests an increased focus on the front end of the treatment cycle, where higher-priced radiology procedures such as CTs and MRIs are being ordered, higher-level evaluation and management charges are increasing, and inpatient stays are rising. This trend will continue as more and more providers adopt value-based care models in the future.

Let us reduce the noise

To help your claims professionals, our nurses identify non-loss-related injuries and treatment through careful review of the medical and treatment records. In addition to the thorough review of the treatment rendered, a certified coding professional reviews the medical bills to assess whether the billing comports with industry-standard coding guidelines and whether the billing is supported by the treatment notes. While the treatment may have been medically necessary, the level of service or procedure code(s) billed may be inappropriate per accepted coding guidelines. The resulting output of the Reviewer report arms the claims professional with the necessary information to feel confident in raising arguments on medical necessity and appropriateness of billed charges. This two-pronged approach to reviewing these complex packages, along with our comprehensive supporting report, has resulted in our customers who utilize our Reviewer program seeing an additional 30-35% of accuracy realization compared to our Analyzer Bill Review product.

Isolate complex files through our customized Reviewer Algorithm

Our intelligent rules engine offers new configurable rules to flag demand packages for professional review that have a higher likelihood of treatment without causation and/or medical necessity. In addition, we have developed analytics dashboards to inform carriers in setting their configurations, quantifying opportunities, and tracking KPIs in real-time.

For more information on customizing your Reviewer Algorithm or to schedule a demo, please reach out to your CCC Account Team.

Source for all charts/graphs: CCC Crash Course 2023