Factors that drive claim costs in Workers’ Compensation are many. Among them are the type of injury, the claimant’s job, age and other health factors, as well as psycho-social factors. Psycho-social factors may be the most elusive in terms of predicting claim cost because they tend to be subjective, intangible and not well documented in the data. However, another potentially powerful predictive cost factor is injury severity.
What is severity?
The concept of severity in Workers’ Compensation begs definition because it refers to claim cost. The term severity is defined in the dictionary as seriousness, gravity, significance, magnitude, acuteness, badness, or awfulness.
When the term severity is used, most people assume the discussion is the dollar cost of the claim. However, this discussion of injury severity, while it leads to total dollar cost of the claim, is about one very significant component of claim cost—injury severity. How serious is the physical injury?
Until now the best way to determine the severity of an injury was to ask the doctor. One of the three-point contacts initiated at the outset of an injury is the treating doctor. The interviewer wants to get a sense of how serious the injury is during that exchange. However, any response from physicians will be a subjective comment, making it useless for predictive purposes. Obtaining a standard measure of injury seriousness from responses of treating physicians is impossible.
Physicians describe injuries and illnesses in terms of ICD-9 (International Classification of Diseases, 9th Revision ). In fact, ICD-9’s are the only acceptable norm for describing medical conditions in medical records and billing procedures. The problem is most adjusters in Workers’ Comp cannot interpret them. Even medical case managers cannot decode ICD-9’s without looking them up individually. Consequently these very powerful information nuggets have typically been ignored in medical management and for predicting cost. To complicate matters, physicians ascribe multiple IDC-9’s to a claim.
By way of describing the injury, physicians assign ICD-9’s initially and add to them throughout the course of the claim. ICD-9’s are required on the bill to describe the injury or illness and justify billing for medical procedures and services delivered. Nevertheless, the ICD-9’s in a claim often multiply and migrate over the course of the claim. New providers who become involved in treating the claimant add new ICD-9’s. Sometimes ICD-9’s are added because comorbidity is documented. Also, ICD-9’s may also be added to insure the bill will successfully navigate bill review. The reasons for adding ICD-9’s to the claim are many, which is reason enough to pay better attention to them.
The primary diagnosis?
People often ask, “How do I determine which ICD-9 is the primary ICD-9?” One answer is to note the date the ICD-9 is added. Those entered toward the beginning of the claim might be most revealing—but not necessarily. The diagnostic category might be more revealing. Do all the diagnoses relate to musculoskeletal conditions of the low back? In practice, doctors may select from eighty to one hundred different diagnoses to define low back injuries.
One diagnosis does not a story tell
In point of fact, identifying a primary diagnoses may not be important at all. Any one diagnosis must be taken in context with the others assigned to the claim. Several ICD-9’s might be used to describe strain of multiple related body regions. This still begs the question, how serious is the injury, but it also raises the question of what other information is living in the medical diagnoses?
Of course, one extremely severe diagnoses, such as a severed cervical spinal cord, should automatically kick the claim into the high risk class. On the other hand, while a low back strain by itself may seem benign, when it is combined with the fact that the claimant is over 65 years old or diabetic, or both, it also portends high risk. That same mild low back strain should be followed closely when the physician has also identified the claimant as obese. In other words, all diagnoses in the claim must be assessed in context with the other diagnoses present. Together they tell the whole story and can have an exponential effect on cost and outcome.
The MedMetrics solution
MedMetrics has solved this problem by assigning a severity (seriousness) score to individual diagnoses—the Injury Severity Score. Each diagnosis found in a bill is scored individually for severity. When a diagnosis is scored extremely severe, the organization is notified immediately. For multiple diagnoses, the accumulated diagnostic scores are totaled. If the composite score reaches a certain level, the organization is notified. Comorbidity and age are factored into the combined scores.
MedMetrics electronically monitors an organization’s bills, scores the diagnoses, and alerts its client of those diagnoses that are extremely serious. Additionally, the organization is notified when the accumulated diagnostic scores exceed a certain level. Claims adjusters and medical case managers can step ahead to manage the claim proactively.
Injury Severity Scores are a powerful, concurrent medical intelligence and management tool for claims adjusters and medical case managers. Moreover, Injury Severity Scores can be added to the available intelligence for setting and adjusting reserves. Finally, MedMetrics Injury Severity Score is a measure of bodily injury, an applicable intelligence tool for all personal injury claims!
Learn about other medical analytics tools that recharge managed care in Workers’ Compensation.
1 ICD-10 will be implemented in October, 2012.