How to Find Quality Providers in Your Data, a White Paper

by Karen Wolfe

Identify and avoid the poorly performing doctors
Accurate Provider information is critical to managing Workers’ Compensation networks, claims and costs. In fact, provider performance data analysis is the most powerful way to recharge managed care—identify and avoid the poorly performing doctors! Yet most provider records in systems maintained by payers, networks, and others contain errors, outdated information, or are missing key data elements.

Good data
Imagine the difficulty of evaluating provider performance analytically (the most fair approach) when the correct provider cannot be identified in the data. On the other hand, imagine the cost control muscle gained by knowing the best-in-class providers based on good data!

Most claims systems do not capture needed information about providers. Moreover, most system administrators do not include among their tasks upgrading or maintaining these records. Even network administrators often neglect their provider data. While this sad condition is no longer acceptable, it is somewhat understandable from an historic viewpoint.

Historic perspective
Until recently, Workers’ Comp payers essentially viewed providers as simply another type of vendor. Many still do. The only important data collected for vendors was name, address, and tax ID number. There was no reason to care about such details as specialty, state medical license number or National Provider Identification (NPI). Systems were designed to handle only the basic information needed to pay bills and send 1099’s for tax compliance at the end of the year. But that is changing rapidly with the shift to quality-based provider networks.

Provider performance evaluation is essential
People in Workers’ Comp now realize that just any provider in their networks will not do. The focus has veered sharply toward quality and outcomes. Attending that swing is the critical need for accurate and comprehensive provider data.

Defining good data
Many, if not most provider files in systems are incomplete and they are riddled with errors. The files do not contain basic, but essential data elements. Even more confounding is that they do not distinguish between pay vendor and service vendor.

Pay venfor and service vendor
Pay vendor is a term that defines the entity in receipt of the payment. The pay vendor is the clinic, hospital, or group. The service vendor is the individual treating physician or other professional provider. Distinguishing between them is crucial but most systems do not permit such differentiation. Still, that is just the tip of the iceberg.

Record proliferation
Record duplication is a huge problem. Please refer to our last article, “Medical Fraud by Identify Proliferation" for details about how provider records get duplicated in systems, thereby causing analytic confusion. Deliberate data obfuscation by providers is one cause and careless data entry procedures are also to blame.

Data entry procedures
Slipshod data entry procedures are often automated by organizations. For instance, many computer systems are designed to create a new record for providers with each new bill. That, along with the presence of slightly or very different formats for names and addresses, can cause a plethora of provider records representing the same individual or service entity. This data management behavior severely impedes medical cost management progress.

Provider Performance Suite
MedMetrics can help. In implementing analytic tools for clients, MedMetrics has encountered numerous systems. Virtually all of them have demonstrated the problems described here. To assist our clients, MedMetrics has developed proprietary methodologies to scrub data, merge duplicate records, identify provider types, and assign medical specialties using logic algorithms based on the available billing data.

MedMetrics experience and know-how uniquely position it as the leader in evaluating provider performance in the Workers’ Comp industry. MedMetrics Provider Performance Suite of services includes powerful technical services and simple online software tools. The Suite includes:
Provider Performance Suite
• Data Integration
• Provider File Cleansing and Optimization
• Quick-search Provider Performance Ranking
• Provider Performance Validation Studies
• Provider File Maintenance

MedMetrics’ exclusive suite of services and online software tools offer payers, managed care service providers, and networks a quick and affordable avenue to excellence. Sloppy, incorrect, and inadequate knowledge of providers and their performance is no longer acceptable. Yet, identifying quality providers in Workers’ Compensation is vital. For MedMetrics clients, knowledge of provider performance evaluation and scoring is achievable, affordable, and available now.

Whether they are called outcome-based, evidence-based, performance-based, value-based, or quality-based networks, selecting and monitoring providers for the new networks is imperative. To learn more, visit MedMetrics and to learn how, contact KarenWolfe@MedMetrics.org