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Bill Review Companies PPO or MPN Networks Worth Their Fees?


Bill Review Companies – A Hot Topic in Risk Management

The Bill review companies and their PPO or MPN network  created a large amount of positive buzz until recently.  Some have come into question over the past few months.

One of the most popular requests we receive is to analyze an employer’s Workers Comp Preferred Provider network (PPO) and bill review charges.  This is usually an add-on service to some of our other review offerings.

Picture Of Business Colleagues Bill Review Companies Disscussion

Bill review and medical network charges are becoming hot topics of discussions between Risk Managers various public and private employers.  Bill reviews are usually based on the existence of a fee schedule in a certain state.

The different types of charges for fee schedule states are based on:

  1. Header or per bill fee
  2. Fee per line processed
  3. % of savings
  4. Network – PPO Fee
  5. Combinations of the first four

Risk managers for self insured public entities are now even breaking out bill review and medical network charges separately from the TPA fees.   This may be a good idea in some cases as the mixture of TPA claim processing fees can be confusing.

Many risk managers are now beginning to bid the medical processing fees as a separate Request For Proposal (RFP) or at least allowing bill review and PPO networks to bid separately from the TPA claims processing bids.

There is sorely missed area in the evaluation of a bill processing company for WC and their associated networks.   The provider effectiveness measurement is actually what most adjusters use and not whether a provider is in a certain network.

The targeted amount for most Workers Comp PPO’s is a reduction of 15% of the bottom line bill which is #4 on the above list.  If one medical provider has a great history of returning workers to gainful employment, does the 15% reduction really matter?

A great surgeon for example may end up saving much more on the claim than the 15%.  One of the most disconcerting things that we see in files is when the adjuster has NO decision on the medical provider as it is pre-chosen by the network and location.   This removes all loss reduction strategies on the medical part of the file, which of course affects the indemnity part of the file.

Picture Of Doctor Bill Review Companies With Medical Files

The best of both worlds is to have the most efficient and effective medical provider for Workers Compensation be in the medical bill provider’s network.   If the treating physician is able to return employees to work with no delays, the adjusters can keep the indemnity and medical reserves in check.

I did not mention the U&C (Usual and Customary) charges for the remaining states without a fee schedule.  I will cover those next time.

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One Response


James J Moore - Workers Comp Expert

Raleigh, NC, United States

About The Author...

James founded a Workers’ Compensation consulting firm, J&L Risk Management Consultants, Inc. in 1996. J&L’s mission is to reduce our clients’ Workers Compensation premiums by using time-tested techniques. J&L’s claims, premium, reserve and Experience Mod reviews have saved employers over $9.8 million in earned premiums over the last three years. J&L has saved numerous companies from bankruptcy proceedings as a result of insurance overpayments.

James has over 27 years of experience in insurance claims, audit, and underwriting, specializing in Workers’ Compensation. He has supervised, and managed the administration of Workers’ Compensation claims, and underwriting in over 45 states. His professional experience includes being the Director of Risk Management for the North Carolina School Boards Association. He created a very successful Workers’ Compensation Injury Rehabilitation Unit for school personnel.

James’s educational background, which centered on computer technology, culminated in earning a Masters of Business Administration (MBA); an Associate in Claims designation (AIC); and an Associate in Risk Management designation (ARM). He is a Chartered Financial Consultant (ChFC) and a licensed financial advisor. The NC Department of Insurance has certified him as an insurance instructor. He also possesses a Bachelors’ Degree in Actuarial Science.

LexisNexis has twice recognized his blog as one of the Top 25 Blogs on Workers’ Compensation. J&L has been listed in AM Best’s Preferred Providers Directory for Insurance Experts – Workers Compensation for over eight years. He recently won the prestigious Baucom Shine Lifetime Achievement Award for his volunteer contributions to the area of risk management and safety. James was recently named as an instructor for the prestigious Insurance Academy.

James is on the Board of Directors and Treasurer of the North Carolina Mid-State Safety Council. He has published two manuals on Workers’ Compensation and three different claims processing manuals. He has also written and has been quoted in numerous articles on reducing Workers’ Compensation costs for public and private employers. James publishes a weekly newsletter with 7,000 readers.

He currently possess press credentials and am invited to various national Workers Compensation conferences as a reporter.

James’s articles or interviews on Workers’ Compensation have appeared in the following publications or websites:

  • Risk and Insurance Management Society (RIMS)
  • Entrepreneur Magazine
  • Bloomberg Business News
  • WorkCompCentral.com
  • Claims Magazine
  • Risk & Insurance Magazine
  • Insurance Journal
  • Workers Compensation.com
  • LinkedIn, Twitter, Facebook and other social media sites
  • Various trade publications


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