Technology doesn’t make mistakes, right? Right? Well…let me get back to you after my internet starts working again, I call to figure out why I can’t log into my bank account online all of a sudden and after my mechanic tells me why my windshield wipers only work when the left turn signal is blinking and I hold my right hand out the window. I think you get the point. Technology does indeed make mistakes. Quite frequently actually, but how many times have you been told by companies in the Work Comp service industry they have replaced human eyes with a computer algorithm – because computer programs don’t make mistakes like humans. Hmm…sound of the bubble bursting. Let’s just say, the next client I meet who tells me their Bill Review or PBM vendor’s computer software has never made a mistake will be the first!
Fast or Right? 
Speed, aka “efficiency”, is a primary pillar of the technology is superior to humans argument. “We can process a million bills per second” or something like that. My Dad used to always say, “do you want it done fast, or do you want it done right?”. Hard to argue with Dad these days. Somewhere along the way, the world and certainly our little niche industry made the switch from using technology to support humans to using humans to support technology. Well, things definitely move a lot faster these days so I can’t argue with the argument of pure speed. Efficiency is another thing altogether. Work Comp vendors used to succeed based on the quality and experience of those handling the operations and work directly with the clients. Today, it is more of an IT race and who can build a bigger, “better” infrastructure for processing things the fastest. Too much industry knowledge has been sucked out of the equation. Sure, industry know-how goes into building those algorithms but anyone who has ever sat in or adjacent to a claims desk knows how nimble one has to be when adjudicating claims and programs just can’t be updated frequently or quickly enough to keep up with what goes on in the trenches. There is no true substitute for an experienced, well-organized adjuster handling a claim and there is nothing quite like an experienced, organized set of human eyes backing them up on medical bills or pharmacy scripts. Using a solid technology platform to support those humans is where you start to maximize the true value!
“What the Heck is This?”
Another pillar of the technology argument is the ability to combat questionable/unethical/fraudulent billing practices. “Our proprietary rules know what to look for and will kick the bill out for human review” is what I’ve heard. Yes, the rules might know what to look for today, but what about tomorrow? See, the unscrupulous providers or billing companies who employ these tactics are very aware of what gets flagged and what doesn’t and that is why they keep developing new ways to get around those rules. It becomes a game of one computer system designing billing rules to get around another computer system’s rules to catch them. All is well and good until the next wave of new billing tactics comes along and the existing software is blissfully unaware of what to look for while those millions of bills per second are freely flowing through the system and your medical spend is taking hit after hit, second after second. And, sadly, you won’t even know it because there will be no change to your “savings” reports or notations of dollars lost.
Waiting for an update . . .
The next time a new billing practice comes along and your partner lets you know their rules are updated, maybe take a look back at the previous few months and see how much money went out the door while waiting for that to happen! An experienced, well-trained human knows what a bill should look like and isn’t programmed to be so narrowly focused. I can hear our bill reviewers sometimes say out loud “uh, what the heck is this?” when some new tactic shows up on a bill to try and get paid more than is allowed. They won’t need to be reprogrammed every couple of months to learn how to spot new things. They already know what’s right and everything else gets extra attention until it’s determined to be legitimate or not.
Churning and burning bills may be the only way to go for companies so large they can’t realistically review each bill in the timeframe needed. I would argue that’s not true either but I don’t see many willing to make the change. For all the other work comp payers – and especially self-insured employers – who need to focus on saving every dollar possible, don’t forget the benefits of a well-trained, experienced human helping you achieve your savings goals. After all, you are a well-trained, experienced human yourself!
Dan Ziemer
