Medical Bill Review: Verifying care, validating costs

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Record date: 7/17/26
Air date: 9/23/26

Medical bill review is about much more than processing medical bills. It's a critical tool for supporting appropriate care for injured workers and managing Workers' Compensation costs.

In this episode of our Claims in action: Driving better business outcomes podcast series, host Catherine Marciniak, Head of Property & Casualty Claims at Zurich U.S., sits down with Jesi Pabley, Head of Managed Care and Vendor Services at Zurich U.S., to explore the role medical bill review plays in Workers' Compensation claims management. Their conversation unpacks common misconceptions about medical bill review, explains how medical expertise and data-driven insights support better claim outcomes and highlights the importance of integrating bill review with broader managed care strategies.

Listen now to learn how a comprehensive approach to medical bill review can help organizations improve outcomes and better manage loss costs.

In this miniseries, other episodes include:

9/9/26: Road to recovery: Workers’ Comp and Managed Care

Guests:

Jesi Pabley
Head of Managed Care and Vendor Services
Zurich U.S.
Connect on LinkedIn

Jesi Pabley is Head of Managed Care and Vendor Services at Zurich U.S., where she leads the organization's Managed Care, Claims Vendor Management, and Claims Payment functions. With more than 18 years of Workers' Compensation and insurance leadership experience, Jesi specializes in operational excellence, medical management, vendor strategy, and creating innovative solutions that improve outcomes for injured workers while delivering value for customers and broker partners. Jesi has a proven ability to lead cross-functional initiatives, drive profitability, and develop high-performing teams. Since joining Zurich in 2011 as a Workers’ Compensation Claims Professional, Jesi has held a series of progressive leadership roles in Claims, including her most recent role that she has held since 2022.

Host:

Catherine Marciniak
SVP, Head of Property & Casualty Claims
Zurich U.S.
Connect on LinkedIn

Catherine Marciniak is the Senior Vice President, Head of Property & Casualty Claims for Zurich U.S., leading teams responsible for delivering exceptional claims outcomes while driving operational excellence across the organization. Based in Schaumburg, Illinois, she is recognized for her collaborative leadership style, commitment to developing talent, and ability to navigate complex business and claims challenges with clarity and purpose. She is known for building high-performing teams, fostering strong cross-functional partnerships, and bringing both resilience and authenticity to her leadership.

(PLEASE NOTE: This is an edited podcast transcript, capturing speakers with natural speech patterns that may include incomplete sentences and/or asides, grammatical errors, verbal shorthand and some statements that may be less clear in print.)

EPISODE TRANSCRIPT:

CATHERINE MARCINIAK:

Medical costs remain one of the most important drivers of Workers' Compensation claim severity. Medical bill review is often misunderstood as a simple repricing exercise, when in reality, it can involve medical expertise, jurisdictional knowledge, provider insight, data analysis and a really strong understanding of how treatment decisions affect claim outcomes and our loss costs.

Welcome to Future of Risk, presented by Zurich U.S. We explore the changing risk and resilience landscape and share insights on challenges facing businesses today.

I'm Catherine Marciniak, Zurich U.S. Head of Property & Casualty Claims. In this episode of our Claims in action miniseries, we’re focusing on medical bill review. And our guest Jesi Pabley, Head of Managed Care and Vendor Services at Zurich U.S., is going to help me take a deeper dive into medical bill review and how it fits into the broader claims cost management story.

MARCINIAK:

So, Jesi, thank you for joining me today and welcome.

JESI PABLEY:

Thanks for having me, Cathy. I'm really excited to join and have the opportunity to talk about medical bill review.

MARCINIAK:

Excellent. We had one of your peers on our first episode, Neil DeBlock. I think I referred to him as a veteran in the work comp space and you're right there alongside of him. How long have you been in the work comp space and medical bill review?

PABLEY:

I've been in workers comp for I think about 20 years. Um, I don't like to really say that number. <laugh> You might age me a little, but yeah, and I've been within managed care for the last five years.

What is medical bill review?

MARCINIAK:

Excellent. Well, hey, I'm right there in that group with you because I think I've worked with you almost all 20 of those years. <laugh> So we're all veterans. So, let's dive in and I thought maybe it would be a good place to start if we kind of just laid it out in plain English. How would you define medical bill review?

PABLEY:

Medical bill review can be thought of as complicated potentially. But really, think about it when you go to the doctor and you've had a visit and they submit the bill to your insurance. It's very similar. And medical bill review is really the process of after that visit, we receive the medical bills from the providers and we are looking at medical necessity. We're looking at appropriateness to make sure that the care is actually related to the claim. We're also in our Workers' Compensation environment looking at compliance to make sure that that bill is meeting billing requirements, you know, jurisdictionally as well as Zurich's requirements for billing. And I would say a common misconception with medical bill review is that it's fully automated and then it just applies a state fee schedule or a usual customary rate along with PPO discounts.

And that's really not the case. There's so much more to it. The majority of our bills here at Zurich are actually reviewed by someone with medical billing expertise and that includes certified coders and nurses. And we also have a number of other strategies that we use because we want to pay only what we owe and what our customers owe. So, some examples, I won't get into everything, but some examples are duplicate logic, reviewing to ensure that the medical documentation supports the treatment that's being billed and really looking at, you know, certain treatment to make sure it's appropriate.

The connection between medical bill review and managed care

MARCINIAK:

And I feel like that's probably one of the most difficult parts of that review is how do you discern what's related to this injury or accident that happened at work versus what might be a pre-existing symptom that the injured worker might have? So, it's a lot more complicated, I think, than what people believe, just like you said. So, I'm interested. I know you've had an opportunity, right, to listen to our first episode with Neil. So how does that... And I thought he did a fabulous job. <laugh> How does that medical review connect to the Workers' Compensation and the managed care conversation that I had with him? I know there's probably quite a bit of overlap, but just curious your thoughts there.

PABLEY:

Yeah. I think you hit the nail on the head when you were talking about how we need to have information on the claim for us to actually do the medical bill review piece correctly, right? So that means a lot of collaboration with Workers' Compensation and the teams and just ensuring that we're balancing the injured worker and their care with the cost containment strategies to manage the medical costs.

How integrated managed care strategies help control loss costs

MARCINIAK:

And how does medical bill review help to control those loss costs for customers?

PABLEY:

I would say a key piece of this is that medical bill review is a piece of a puzzle. It's a piece of our integrated managed care strategy. So medical bill review alone isn't going to control the loss cost. It is, but along with our medical management, our utilization review, pharmacy and our return-to-work strategies.

MARCINIAK:

I like how you phrased that as a piece of a puzzle or like just one of the many levers that we have to pull when we're looking at controlling lost costs for our customers.

PABLEY:

Our customers really rely on us for our expertise because managed care isn't something that they do every day. So I think, again, looking at those specific insights, that's really important to them and they find a lot of value in that specific information for their book of business.

MARCINIAK:

I think that's a huge point because if you’re a large hotel chain, probably not what you're spending a lot of your time on is being an expert in managed care. You’re an expert at being a hotel chain. Hospitality. That's right.

PABLEY:

And their needs are different too, right, than a construction customer. And I think a lot of it is workers' comp is extremely jurisdictional. It's very much important where the business is.

How medical bill review data strengthens managed care strategies

MARCINIAK:

So, can you help me understand, from a customer's perspective, how can the medical bill review data help to strengthen their managed care strategies?

PABLEY:

As you can imagine, we have a lot of data. We have a lot of medical bills coming in and we're looking at that to look at patterns and trends in medical costs, provider behavior. You had talked about Neil's podcast as well. And I think he also talked about looking at frequency of modalities - Yeah. Uh, versus looking at total cost of care. So I think that's really important. We also have two managed care consultants on our team and they can actually look at specific data for our customers and provide targeted recommendations. So, while our program-wide metrics are really important, I think it really helps our customers to be able to see what's happening on their program.

MARCINIAK:

Oh, I love that. And I love that we have those two dedicated employees on staff for us within the managed care area. How do they share that information with, let's say, like, our risk engineers? And is that a continuous conversation that we're having? And how do we get them that data so that they can help us in developing some of those strategies alongside of our customers?

PABLEY:

Well, oftentimes it is a lot of that, again, internal collaboration. I know I keep using that word, but it's so important. Just making sure that we are doing everything we can to communicate internally to support our customers and make sure we're mitigating appropriately those loss costs. So, they do work very much with our customer relationship management experts as well as underwriting and risk management. And they really are the experts in managed care. And, you know, a lot of times, managed care seems very overwhelming, but when they dive into these reports and the data, they have a lot of insights that they can share with our customers. For example, recently, they had looked at some data for a customer and they were able to recommend that they participate in a managed care organization. And they also were able to suggest that, while it was a state where we can direct care, they were able to give some recommendations for that initial care of, you know, maybe referring an injured worker to an urgent care facility versus an emergency room.

MARCINIAK:

Our risk engineering group here in conjunction with working with our managed care team, they are sharing that data. They're talking about that data. And then that's what we're equipping our risk engineers and our underwriters and our customer service executives to go and have those very customer-specific level conversations based on, yes, their data. But then I also think the data across the entire industry and the certain segment that that customer base might fall into. So, I think we leverage our data really, really well, and it's probably one of our strengths.

Turning medical bill review insights into cost-saving actions

MARCINIAK:

I'm curious if you have any recommendations or suggestions on what customers could ask us as their insurance provider or could ask their broker, or shoot, even some of our larger customers have their own internal team. If they wanted to strengthen how medical costs are being managed, what's something that a customer could ask to find that out?

PABLEY:

A lot of what I've said so far is really asking how medical bill review is integrated within claims handling and managed care, all the other services that we're utilizing, to look at the treatment as well as the costs. So medical bill really should not be sitting in isolation. And I also think it's about the data. What's available and how is it being leveraged to identify opportunities? And I think another piece that I want to mention is there are studies out there that estimate that as many as 80% of medical bills submitted by providers contain errors. Now, those errors run the gamut, right? But I think that really shows why it's so very important to have medical bill review and all the strategies that we're implementing to make sure that we're looking at those 80% of medical bills, especially.

MARCINIAK:

And it's funny you bring up the 80%, um, likely have some type of error on it. Are we typically looking at coding fat fingering going in, inverting, like, code numbers? Or what types of errors are typical on a medical bill that we flag and identify?

PABLEY:

We're looking at all of that. We're looking at something as simple as a duplicate bill. Yeah. The provider continues to bill, some of it may be intentional, some may not, right? So making sure we're identifying those. We're also looking at what we call upcoding. So, you know, if you go in for a visit but the provider charges for a more complex visit, that's where we're looking again at that medical documentation to say, "This only supports a lower-level visit and that's what we're going to reimburse." And that's how I would say with those strategies, we've achieved a 67% average medical bill savings across our book.

MARCINIAK:

That's pretty good. And you hit on something that I think is just a nice little plug for us as we start to look at our next episode, which is going to be focused on fraud. And that's a comment that you made around, you know, duplicate payments or duplicate billing entries sometimes done intentionally. So, I think we'll dive into that a little bit more in our next episode with Delpha. Thanks for teeing that up for me, Jesi.

PABLEY:

Yeah. And Cathy, that's a great point. I think we work really closely with investigative services. We're looking at that potential fraud and suspended providers. And to your point, Delpha will dive into that further.

Looking ahead at Workers' Compensation cost and treatment trends

MARCINIAK:

So, looking ahead, right, because I know we can learn a lot from the past, but we also need to look ahead and see what trends are on the horizon. So just from your role and where you're at, what trends in medical billing and healthcare costs should our customers be watching out for? And certainly, what are we watching out for?

PABLEY:

There's genuinely too many to highlight, so I'm just going to try to list a couple of them. Right now, in the last couple of years, we've really been looking at medical costs and inflation. And those provider billing behaviors that we really can't control. Something that we've been hearing in the industry is a concern about potential cost shifting with changes that are coming in Medicare and Medicaid. So we are watching that as well. I will also say, I know Neil had talked about, again, that frequency of care and modalities versus looking solely at total cost of care. And, you know, we have several other things that we're thinking and looking at, including pharmacy where we're looking at the use of GLP-1s and migraine medications and workers' comp.

MARCINIAK:

Yeah. The modality came up a couple of times in, in our podcast with Neil. And I know we had mentioned too, like, that was one of the biggest topics this year in May at the NCCI conference. So it was good to hear that we were kind of already on the lookout for that, both here at Zurich and industry wide. So, um, awesome insight. Well, Jesi -

PABLEY:

Yeah, I think it - Sorry. Go ahead. I was just going to say, I think it's an interesting take too, because for as long as I've been in workers' comp, we've looked at the cost. We haven't really looked at the frequency. So, I appreciate that. I think the industry is trying to get creative with the way we're approaching Workers' Compensation and the medical costs.

MARCINIAK:

Awesome. Well, Jesi, I'm going to thank you for joining me today and explaining how medical bill review fits into our broader work comp and managed care story. I think it's a really important story and I think you hit on a lot of key facts. So just thank you again for your time and your expertise.

And thank you for listening. In our next episode, we’ll lift the veil on claims investigations and how it helps make sure claims dollars are paid for legitimate losses and not on fraudulent claims. Our guest will be Delpha DiGiacomo. She's our Vice President and Head of Zurich Claims Investigative Services at Zurich U.S. If you like the show, leave a comment or review wherever you get your favorite podcast or drop us a note at media@zurichna.com. This has been Future of Risk presented by Zurich U.S.