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.
[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
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