1. Fee Schedule Quality Control
Michael Josephs, Chief Information Officer, StrataCare, a Xerox Company
Co-Author: Dimitri Robert, Vice President of Technology Delivery, StrataCare, a Xerox Company
As Published in WorkCompWire, Leaders Speak, December-2013
Did you know that there are 45 states in the U.S. that maintain a workers’ compensation fee
schedule and that each state’s legislature approves revisions to the maximum allowable
reimbursement within these tabular pricing guidelines on a regular basis? Therefore,
organizations need to make certain they are creating timely and accurate updates to the fee
schedules that underpin medical bill review. This process of rapidly ensuring accuracy can
create significant challenges and is costly when addressed manually.
Based on our experience, state fee schedule data, which is provided by a myriad of sources,
often contain errors. Therefore, it is critical to employ procedures, analytical tools and quality
assurance measures for loading and testing fee schedule data. Doing so promotes accuracy and
timeliness, and ensures the most up-to-date re-pricing rules are utilized in medical bill
payments. We recommend you ensure that your vendor is conducting the following processes
to yield complete accuracy of the data set, including: adequate testing validation, test bill
execution, data load analysis, and regression testing.
Testing and Validation Coverage
Since medical bills are somewhat like snowflakes (each one seemingly unique in terms of
procedure, jurisdiction, diagnostic codes, utilization levels, etc.), the manual approach to
validating updates for state-directed fee schedules can be laborious and prone to human error.
Creating suitable test bills manually will likely create challenges with the timeliness of the
updates from a compliance perspective, especially given the short windows sometimes
provided between data availability and the effective date.
As a result, it is critical that effective technology be leveraged to automatically generate a
sufficient amount of test bills to ensure the accuracy of fee schedule updates. This Test Bill
Management automation should allow for bill copy and the automatic generation of new data
points on the bill to ensure optimal test coverage as it records the expected result. Once
created, these test bill sets can be reused for the rapid validation of fee schedule updates from
the same jurisdiction.

2. Test Bill Execution
With a sufficient set of test bills available to validate fee schedule updates, it then becomes
critical to automate the execution of these tests, including the comparison of test results with
expected results whenever feasible. Test Bill Execution automation rapidly compares expected
versus actual results for large groups of test bills. Differences are automatically generated for
analysis and potential remediation with the data provider. This Test Bill Execution tool set
should also have the capacity to override previously captured expected results with the
updated values when appropriate.
Data Load Analysis
Another point of validation involves the actual loading of tabular re-pricing guidelines. as
anomalies and significant changes can be detected when compared to previous versions during
the load. Often, when large groups of codes (e.g., procedure codes, place of service codes and
specialty codes) are added or removed, there are errors in the original generation of the source
data. Likewise, when large thresholds of change in base allowance computation are detected, it
is often a result of errors in the source data. These thresholds should be computed during data
load analysis and flagged when differences exceed expected levels.
Regression Testing
And finally, there is always the challenge of making sure fee schedule updates impact only
those bills intended. In order to provide suitable regression testing for unintended changes, it is
necessary to maintain the ability to initially run very large numbers of bills (hundreds of
thousands comprising different jurisdictional and compositional scenarios) against the
candidate fee schedule update and compare the outcome with processing the same bills
against the original fee schedule. These differences are then identified, analyzed and corrected
accordingly if unintended changes are identified.
The creation of Fee Schedule Test Automation tool suites enables the routine updates of
tabular re-pricing guidelines to be validated from a number of perspectives while mitigating the
risks to timeliness and accuracy. As these updates are a foundational element of financial
validation accuracy, the same quality standards should be applied in the generation of these
tool sets as is applied to bill review functionality. As various industry associations continue to
report a steady increase in the rise of medical costs, the reimbursement portion of the equation
and validated fee schedule uploading becomes more critical.
About Michael Josephs

3. Michael Josephs joined ISGServices in 2006 and has held the roleof CIO since2008.Josephs is responsiblefor the
creation and delivery of ISG’s technology platform, which encompasses the areas of project management,
information systems,technology infrastructure,releasemanagement, product management, application
development, software quality assuranceand technical services.Prior to joiningISGServices,Josephs served a s
director of technology development at E*TRADE Financial and was also theCIO for Triad Financial Corporation,a
subsidiary of Ford Financial.He holds a Bachelor of Science degree in computer sciencefrom the University of
Maryland.
About ISG Services LLC
Operatingas the nation’s leadinghealthcaretechnology company, ISG Services offers a suite of software and
services thatenable highly targeted data-driven interventions to achievemeaningful impact on outcomes and
financial performance.ISGServices utilizes extensive data analyticsto identify gaps in care, quality or integrity, and
applies the appropriateresources to ensure rapid resolution.Our valued clients process their workers’
compensation medical billsthrough the ISG Services affiliates includingwell-known affiliates StrataCare,the
nation’s premier workers’ compensation bill reviewsoftware and serviceprovider, and Bunch CareSolutions,
offering award-winning,innovativemanaged care solutions.For more information,pleasevisit:
www.stratacare.com or www.bunchcare.com.