Your Data can Spot Creeping Catastrophic Claims

by Karen Wolfe

 “One of the biggest cost drivers in Workers’ Compensation is seemingly “average” claims that take a turn for the worst and result in several years of medical treatment and disability.”[i]

Too often seemingly innocuous claims lay under the radar, unnoticed until the damage is done. Mark Walls in this article does an excellent job of pointing to several conditions that should serve as indicators of impending trouble. He discusses issues such as return to work, comorbidities, and psycho-social factors that can contribute to claim deterioration. His ideas are good and there are many more indicators that can be added to the list to recognize creeping calamity.

More indicators

In fact, there are many subtle tip-offs in claims that could lead to effective prevention if noticed earlier. Delayed injury reporting and treatment is one. We know from industry research that a delay between the date of injury and first medical treatment is a predictor of claim complexity, regardless of the reason. Speculation regarding motivators of delay in filing a claim or to seeking medical treatment may not be as important as actually identifying the situation early and intensifying scrutiny of the claim. The opportunity is to discover claims with migrating intensity early, thereby avoiding unnecessary cost.

Knowing is not enough

Unfortunately, knowing what conditions in claims might lead to trouble is not quite enough. Trying to apply the knowledge without a defined process has variable results. Manually identifying claims with perilous conditions is an inconsistent and inefficient endeavor because mere humans simply cannot do it well. Professionals, busy with a myriad of tasks, cannot monitor claims consistently enough to detect insidious conditions. Better process tools are needed and, happily, they are available.

Computer-aided medical management
Technology can be made a powerful work tool in Worker’s Compensation. A specially designed computer software program will monitor current claim data combined with historic data continuously, something mere humans cannot do. A custom computer program will detect trouble every time and notify the appropriate person in the organization so that focused intervention is mobilized.

A software program designed to spot combinations of data elements that portend risk and cost is a powerful cost control tool. It continually searches the data without human involvement. When an adverse situation is discovered, it automatically notifies the right persons.

Work-in-progress tool

Computer-aided medical management programs are designed to be work-in-progress tools that inform the claims management process in real time. They are driven by combinations of data elements that when they appear together in a claim, portend developing risk. Importantly, the computer-aided management tool must continually monitor current and historic data to uncover risk from the broad spectrum. For instance, ICD-9’s in a clam are data elements that can reveal impending trouble in near real time when monitored by a specialized program.

ICD-9 ‘s as windows into risk
ICD-9’s (The International Classification of Diseases, 9th Revision), the medical description of the injury or illness in a claim, can disclose much more than previously thought. ICD-9’s are documented in each bill submitted by treating medical doctors and other providers. They are windows into claim complexity at the start, but they are also powerful real time predictors of impending trouble.

Migrating claim severity
One true thing about claims is as they migrate from medical only status to increasing complexity they accrue ICD-9’s. As the situation deteriorates, more medical providers enter the picture, more medical services are provided, and more ICD-9’s are added to the data. Stated simply, monitoring current and accumulated ICD-9’s will reveal those claims that are unstable and migrating downward. A system designed to monitor ICD-9’s for severity (seriousness) will spot migrating claims.

Smart systems
A system designed to monitor ICD-9’s is a smart system containing information about how serious individual ICD-9’s are. Like pharmacy programs that alert for unsafe drug combinations, an ICD-9 scoring system will alert for dangerous combinations of comorbidities, age, and accumulated diagnoses. A claim is dynamically and continuously scored for severity and the right persons are notified automatically.

Smart systems that monitor current and historic data for combinations that portend complexity and cost can significantly recharge managed care initiatives. They are the next generation business solutions that are available now for those who are serious about controlling costs.

To learn more about MedMetrics smart systems, contact karenwolfe@medmetrics.org.
 

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[i] Walls, Mark. Creeping Catastrophic Claims—How to Spot Them and Stop Them. Business Insurance. June, 12, 2012. http://www.businessinsurance.com/article/99999999/NEWS080105/120609913

Teach Your Data to Fight Opioid Abuse

By Karen Wolfe

Workers’ Compensation research, networking communities, and press are overflowing with information about Opioid overuse and how it is negatively impacting claim costs and outcomes. Information about the problem abounds. Opioid abuse is clearly recognized as a serious problem in the industry, clearly evidenced by recent research.

Industry research
An example of recent research on the topic is from Alex Swedlow at the California Workers Compensation Institute (CWCI), “An association was found between greater use of Opioids and delayed recovery from workplace injuries.” Swedlow says it’s not so much that the drugs themselves are costly, rather, it is the collateral damage that accompanies their use.

A recent study from NCCI (National Council on Compensation Insurance, Inc.) is entitled, “Early Narcotic Use Is Indicative of Prolonged Use.” Findings showed that high use of narcotics in the first quarter following injury indicates a higher than average probability of narcotic use in subsequent periods.

The list of studies and articles is long. In fact, a Google search for “Opioid abuse in Workers’ Compensation” draws nearly 100,000 results. Now that the problem is well-defined, the focus shifts to correcting it.

Fixing the problem
MedMetrics recently conducted a small study for EK Health and their Next Step program. The Next Step program leverages EK Health’s many professional medical resources to address complex claims where the injured worker is addicted to prescription medications. They effectively apply expert peer to peer consulting to assist treating physicians in weaning claimants from their prescribed drugs. The EK Health Next Step program is uniquely effective in bringing those old and very complicated claims to closure.

While the EK Health Next Step program is a powerful tool, it could have even greater impact on costs and outcomes if implemented earlier in the course of the claim, well before so much damage and costs have played out. Early awareness and intervention by referral to the experts could have exponentially positive effects.

Identifying risky claims early
Busy claims adjustors are not accustomed to identifying early Opioid use in claims. In fact, hey often do not have the means because many claims systems do not capture prescription detail. Moreover, Pharmacy Benefit Management data, another source of critical information, is usually a separate system and is not readily available to claims adjustors. Consequently, they are unaware of narcotic prescriptions. However, they and others who might intervene could be made aware through computer-aided medical management, by teaching the data to find the problem.

Computer-aided management tools
Industry research and data studies serve to define and clarify the problem, but they can also illuminate a very practical means to resolution. The research contains tips and actual predictors of risky claims. A derivative of research is the knowledge of what to look for in the data.

For instance, the NCCI study identifies a predictor that when narcotics are used for pain early in the course of the claim, it can be indicative of impending trouble. Armed with this well-founded intelligence, the problem can be proactively addressed from the beginning of a claim by continually searching for the prescriptive indicators in the data.

Monitor current data
Concurrent data monitoring is a powerful cost control methodology to identify early Opioid use. By monitoring current data for Schedule II drugs prescribed, claims can be automatically flagged and referred for more intense scrutiny. Claims with this critical information will not be overlooked when using computerized data monitoring.

Likewise, providers who prescribe the drugs outside the accepted medical guidelines such as ACOEM (American College of Occupational and Environmental Medicine) can be monitored electronically. The system can identify providers known for higher Opioid prescription rates. When those physicians are involved in a claim, the system sends an alert to the claims adjustor, medical case manager or other key persons. The system can also send a notification to the prescribing physician.

Notifying the prescribing physician in near real time can serve as a potent preventive tool. It puts physicians on notice to let them know they are being observed.

IT resources
Creating vigorous computerized medical management tools such as these is an IT function. Technicians are required to develop the programs under the guidance of the business leaders who understand medical indicators. Unfortunately, many organizations suffer from scarce IT resources and such initiatives are not implemented. Therefore, outsourcing to a company that specializes in developing computerized medical management tools is the right answer.

To learn about MedMetrics medical management data monitoring, contact Karen Wolfe at 541-390-1680 or karenwolfe@medmetrics.org.