Medical bill review workflow: How to streamline P&C and workers’ comp claims
At a glance
The medical bill review workflow ensures every claim-related bill is validated, compliant, and accurately processed.
Breakdowns in this process lead to payment delays, revenue leakage, and compliance risks.
Automation strengthens intake, coding validation, approvals, and payment handoff across P&C and workers’ comp claims.
Moxo enables secure, automated bill review workflows that reduce errors and deliver faster, audit-ready outcomes.
Simplifying medical bill review for better claims management
Managing property and casualty (P&C) and workers’ compensation claims can be a complex process, especially when it comes to medical bill reviews. Inefficient workflows often lead to delays, errors, and increased costs, impacting both insurers and claimants. By streamlining the medical bill review process, you can enhance accuracy, reduce turnaround times, and improve overall claims management. This guide explores practical strategies to optimize your medical bill review workflow for better outcomes.
The hidden cost of inefficient bill review
Insurance carriers and TPAs process thousands of medical bills every month. Studies suggest up to 15% of workers’ comp bills contain coding or compliance errors. These errors can inflate claim costs, extend cycle times, and create re-open risks.
Manual workflows are especially vulnerable. Bills arrive by email or fax, are scanned and keyed into systems, and then move through disconnected approvals. Like running a relay race without a baton, information gets dropped mid-hand, causing bottlenecks and leakage.
A structured medical bill review workflow turns this chaos into a controlled, auditable process. By integrating automation, portals, and secure communication, insurers can reduce cycle times, ensure compliance, and deliver better claimant and provider experiences.
Intake & capture
The bill review journey begins with intake. For P&C and workers' comp carriers, this means dealing with a high volume of medical bills arriving in various formats: scanned PDFs, electronic submissions (like EDI 837 files), faxes, and even handwritten CMS-1500 or UB-04 forms. The traditional, manual approach requires staff to re-key information from these documents into core systems. This process is not only slow and tedious but also highly susceptible to human error, which can lead to payment inaccuracies, compliance issues, and delayed claims processing.
This is where automation comes in. Technologies like Optical Character Recognition (OCR) and Intelligent Document Processing (IDP) are designed to automate data extraction.
OCR converts images of text (like a scanned bill) into machine-readable text data.
IDP takes this a step further. It uses AI and machine learning to not only extract the text but also understand its context—identifying and classifying key fields like provider information, CPT codes, diagnosis codes (ICD-10), dates of service, and billed amounts.
With an automated intake process, bills are digitized, classified, and validated with minimal human intervention. Intake becomes less about clerical work and more about managing the exceptions that the system flags for review.
Analogy: Think of intake like an automated sorting facility for mail. Every "package" (document) is scanned, its destination (claim file) identified, and its contents (data) logged before being routed to the right place. A manual error at this first step means the package gets lost or delayed.
Real-world scenario: A regional TPA handling workers' comp claims introduced IDP for their bill intake. This single change cut manual data entry by over 40% and reduced data errors by 60%. As a result, adjusters could focus on high-value tasks like reviewing complex bills and negotiating settlements, significantly improving overall throughput.
Coding & fee schedule checks
Next up is validation, where medical bills are meticulously checked for coding accuracy and adherence to fee schedules.
Coding validation: This step involves verifying that the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and Diagnosis-Related Group (DRG) codes on the bill accurately reflect the medical services provided. It ensures the treatment documented matches the diagnosis.
Fee schedule application: Once codes are validated, the charges are compared against official state fee schedules, which dictate the maximum allowable reimbursement for services. These schedules can vary significantly by jurisdiction, making this a complex but critical step in managing costs.
Errors at this stage can lead to significant financial leakage, such as double payments for a single service or outright claim denials. For example, a workers' comp knee surgery billed with an incorrect CPT code could result in an overcharge of thousands of dollars. Beyond the financial impact, misaligned codes can delay provider payments and frustrate injured employees waiting for care approvals.
Automation can streamline this entire process by cross-referencing codes against treatment plans and applying the correct state-specific fee schedule logic, flagging discrepancies for review. This not only prevents over-billing but also creates a transparent audit trail, ensuring every payment decision is compliant and defensible.
Approvals & exceptions
Even the best automation can’t handle every scenario. Some bills will always need a human touch because they exceed payment thresholds, are missing necessary documentation, or raise compliance questions. That’s where approvals and exceptions come in.
Traditionally, handling these exceptions meant endless email chains and phone calls between adjusters, nurse reviewers, bill review staff, and managers. With so many parties involved, tracking down information and getting approvals was slow and inefficient. Delays were inevitable, leading to stalled claims and frustrated providers.
In a modern medical bill review workflow, this process is automated. Custom rules flag exceptions and automatically route them to the right reviewer based on criteria like dollar amount, injury type, or jurisdiction. The system manages the entire process:
Smart routing: Bills are automatically sent to the correct person or team for review.
Centralized communication: Reviewers can communicate and share documents within the platform, eliminating confusing email threads.
Automated nudges: Built-in reminders, escalations for overdue reviews, and real-time status updates keep processes moving. No bill gets lost or stalls in limbo.
Example: A workers' comp insurer implemented automated routing for bills over $10,000 and escalations for any review lasting longer than 48 hours. Result: Exception cycle times fell by 35%, which not only reduced claimant wait times for reimbursements but also helped the insurer avoid late payment penalties (learn more about workflow automation).
Payment handoff & audit
Once approved, the reviewed bill flows into payment systems for final processing. Here, auditability and accuracy are critical. Every payment amount must precisely match the reviewed and approved bill, with strict role-based access controls in place to protect sensitive health data and ensure compliance.
Key considerations at this stage
Accuracy: Discrepancies between the approved bill and the final payment amount can lead to costly disputes and administrative rework. A system that automates the transfer of approved amounts into the payment platform minimizes the risk of human error.
Audit trail: A structured, unchangeable audit trail is non-negotiable. This log should capture every action taken on the bill, from initial review to final payment, including who made changes and when. This is essential for resolving disputes, meeting regulatory requirements (like HIPAA/PHI safeguards), and preventing fraudulent activity.
Preventing leakage: Leakage often happens at this stage. A mismatched invoice, an unauthorized last-minute adjustment, or a duplicate payment can easily slip through without a robust, automated workflow. By embedding secure processes with clear audit logs, carriers can ensure payments are both faster and more transparent, avoiding costly downstream conflicts.
A modern workflow platform like Moxo can secure this handoff, creating a seamless, auditable link between your bill review and payment systems.
Build it in Moxo: A step-by-step modernization
Flow builder (forms, file requests, approvals, eSign)
With Moxo’s no-code workflow builder, insurers can digitize intake, route approvals, and capture eSignatures in one place.
Controls (branches, decisions/milestones, thresholds/SLAs)
Decision points ensure exceptions are routed correctly. SLAs and thresholds maintain compliance and prevent backlog.
Automations & integrations
Moxo integrates with policy admin platforms, claims cores, CRM, and payment systems. This ensures smooth handoffs and less manual reconciliation.
Magic links for external participants
Policyholders, brokers, and providers can join workflows securely without needing accounts. This keeps processes client-friendly.
Management reporting
Dashboards track cycle times, straight-through-processing rates, and leakage recovery. Reports segment by line of business, region, or severity.
Governance
With SOC 2, HIPAA, and role-based access, Moxo ensures PHI remains secure. Audit trails provide regulator-ready evidence exports.
Bringing it all together
A strong medical bill review workflow reduces leakage, enforces compliance, and improves both provider and claimant experience. Intake, coding, approvals, and payment must connect seamlessly, with PHI safeguards baked in.
Platforms like Moxo make it possible to build this workflow without custom coding. For insurers and TPAs, that means fewer errors, faster payments, and measurable ROI. Ready to see it in action? Book a demo with Moxo today.
FAQs
What is a medical bill review workflow?
It is the structured process of validating, coding, approving, and paying medical bills in insurance claims.
Why is medical bill review important in workers’ comp?
It ensures coding accuracy, applies state fee schedules, and prevents leakage. With Moxo, it also protects PHI and speeds up processing.
Can automation really reduce errors?
Yes. Automation flags missing codes, applies compliance rules, and routes exceptions instantly, reducing manual oversight.
How does Moxo handle PHI compliance?
Moxo provides HIPAA-compliant, SOC 2 certified portals with role-based access and audit trails.
Can external providers participate in Moxo workflows?
Yes. With secure magic links, providers, brokers, or policyholders can submit and track bills without needing full platform access.
