FAQ: How to Find the Primary Physician in Claims

by Karen Wolfe

A frequently asked question in Workers’ Compensation medical management is, “How can one determine which is the primary physician in a claim?” The reason for the question is usually an attempt to assign accountability for the outcome of claims. However, the question, if asked slightly differently, can provide much more valuable information.

The wrong question

Whether or not the correct question is asked, gathering information about treating doctors is essential. Knowing all the treating doctors in a claim is important and they can be easily found through analytics (data analysis). However, determining the primary doctor is misleading.

The notion of primary physician suggests assumptions that are inaccurate: that the primary physician has control of a claim. Rarely does one physician have full control. But one physician might have the most influence. Therefore, a more telling question is, “Who is the predominant physician in the claim?”

Predominant physician

The predominant physician in a claim is the one who has had the most influence on claim cost and outcome. That information can also be found in the data.  However, predominance cannot be measured in dollars billed or paid to physicians. Specialists, especially surgeons, will surface using dollars as the identifying metric. Those identified may or may not be the most influential in the course of treatment or outcome. Predominant physicians are the ones who encounter the injured worker most frequently.

Influence and Impact

An indicator of physician predominance in the data is how frequently they were face to face with the injured worker. Frequent encounters with the same physician will significantly influence the course of the claim, leading to positive or negative results. It is one measure of medical provider performance.

The treating physician who is seen more frequently by the injured worker will impact return to work, recovery, and often directly influence whether the claimant seeks litigation. Identify the best physicians using predominance in the claim data as one factor. Rather than directing injured workers to any physician in the network, select the doctors with better results, especially those who have greater influence in claims with positive outcomes.

New networks

Traditional discount networks do not evaluate provider performance regarding claim cost and outcome. Employers and their claims administrators are now undertaking that task and redesigning their networks by carving out the best performers. The only sure way to do that is to examine the data, especially provider performance data measured by multiple indicators. One of the indicators that should be evaluated is physician predominance in claims.

A groundswell is occurring in Workers’ Compensation, a dramatic shift from traditional medical provider discount networks to quality, outcome-based networks. Increasingly more organizations are evaluating their providers in networks and carving out the best-in-class doctors. Creating a “designer” network of the best doctors by analyzing the data guarantees improved claim outcomes.

Karen Wolfe is the founder and president of MedMetrics®, LLC, an Internet-based Workers’ Compensation analytics company. MedMetrics applies analytics and technology to evaluate medical provider performance, to significantly strengthen medical management in Workers’ Compensation, and to link the analytics to operations by means of user apps, thereby making the analytics actionable.

 

Moneyball and the Art of Workers' Comp Medical Management

by Karen Wolfe

Recently I watched “Moneyball”, the movie for the third or fourth time. The story is compelling, as is the book by the same name that preceded it.[1]

Moneyball is based on the concept called sabermetrics, defined as "the search for objective knowledge about baseball." The central premise of Moneyball is that the collective wisdom of baseball insiders, including players, managers, coaches, and scouts over the past century is subjective and flawed. The book argues that the Oakland Athletics general manager, Billy Beane took advantage of analytic, evidenced-based measures of player performance in order to field a team that could compete successfully against far richer teams in major league baseball. During the 2002 season, the Oakland ‘As’ won enough games to make the playoffs in spite of a meager salary budget and "inferior" players.

Even though the two industries are diametrically dissimilar, distinct parallels can be drawn between Moneyball, a story about the Oakland Athletics baseball team and Workers’ Compensation Medical Management.

Similar Resistance to analytics

One comparison that can be drawn between the two is resistance to adopting analytics as a knowledge tool. Baseball insiders and managers opposed Beane’s analytics, sometimes vehemently. Long-held beliefs among baseball insiders promoted measures of performance such as stolen bases and batting averages. Beane’s metrics debunked the old methods, revealing unrecognized strengths in lesser-known, more affordable players.

Similarly, Workers’ Compensation leaders have relied on traditional medical provider networks and personal preferences to select medical doctors. If doctors are in a network and offer a discount on medical services, all is good. Yet, industry research has shown that not all doctors are equal. Doctors and other medical providers who understand and acknowledge the nuances of Workers’ Compensation drive better outcomes. It’s a matter of finding those doctors.

Finding best performers

The purpose of Moneyball sabermetrics is the same as Workers’ Compensation medical metrics—to find the best performers for the job. The way to do that in baseball is to analyze the data defining actual performance in terms of outcome—games won. In Workers’ Comp the data must be scrutinized to find doctors who drive positive claim outcomes. In both cases, a variety of metrics are used to support the most effective decisions.

Performance indicators

As in baseball, the goal in medical management is to apply objective information to decision-making using evidenced-based measures of performance. For both industries, cost is a factor. However, in Workers’ Compensation, the cost of medical care must be tempered by other factors:  What is the duration of medical treatment? What is the return to work rate associated with individual doctors? What providers are associated with litigated claims?

As in baseball, the list of indicators for performance analysis is long. However, the sources of data differ significantly.

The data challenge
In baseball, all the data necessary for analysis is neatly packaged in games played. Statistics are gathered while the game is in progress. In Workers’ Comp the data that informs medical management resides in disparate systems and must be gathered and integrated in a logical manner.

Essential data lives in bill review systems, claims adjudication systems, pharmacy (PBM) systems and can also be found in utilization review systems, peer review systems, and medical case management systems. The data must be integrated at the claim level to portray the most comprehensive historic and current status of the claim. Data derived from only one or two sources omits critical factors and can distort the actual status or outcome of the claim.

Once the data has been integrated around individual claims, meaningful analysis can begin. Indicators of performance can be analyzed with new conclusions drawn about the course of treatment and medical provider performance. Moreover, concurrently monitoring the updated claim data leads to appropriate and timely decisions.

Data positioned as a work-in-progress tool

In baseball, the data is used as a work-in-progress information tool. Decisions about the best use of players are made daily, sometimes hourly. Workers’ Compensation medical management can do the same. Systems designed to monitor claim details and progress can alert the appropriate persons when events or conditions portend complexity and cost.

Industry status

Analytics in baseball is not exclusive to the Moneyball Oakland Athletics. All of major league baseball now relies heavily on its use. Unfortunately, there are still only a few visionary “Billy Beane’s” in Workers’ Compensation medical management. Yet, applying analytics for cost and quality control is simple, affordable and can be adopted quickly by all.

Karen Wolfe is the founder and president of MedMetrics®, LLC, an Internet based Workers’ Compensation analytics company. MedMetrics applies analytics and technology to significantly strengthen medical management in Workers’ Compensation and to link the analytics to operations by means of user apps, thereby making the analytics actionable.

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[1]Lewis. M. Moneyball: The Art of Winning an Unfair Game 2003. The film “Moneyball”, starring, Brad Pitt was released in 2011.

 

How to Find the Best Doctors for Workers’ Compensation

a White Paper
By Karen Wolfe

Caution: This is called a White Paper because it specifically recommends MedMetrics’ solution.

A poorly performing medical provider is costly, particularly when the patient is an injured worker. For injured workers, certain unique administrative processes must accompany medical treatments and procedures. Even doctors who are highly regarded in their medical specialty may generate negative results in the world of Workers’ Compensation.

Medical doctors might treat the injury with medical expertise while causing complexity for claimants and their employers. For instance, not supporting return to work initiatives drives costs and is known to contribute to extended disability. Continued referral to specialists to find the ultimate answer rather than declaring Maximum Medical Improvement (MMI) can result in claim stalemate rather than resolution. Moreover, frustrated patients often seek legal assistance, further compromising outcome. In other words, finding doctors with knowledge of Workers’ Compensation is essential to cost control and improved outcomes.

Some say finding the good doctors is difficult. In fact, finding the right doctors can be easy when MedMetrics does the work. The process is simple.

 

The data are transferred to MedMetrics from organizations’ disparate sources of claims data, bill review data, and pharmacy benefits management data (PBM). Claimant-identifiable information is not included so confidentiality is not an issue. MedMetrics does the heavy lifting by giving the organization's IT a list of data items to put into a file for transfer.

MedMetrics imports, integrates, and analyzes the data, then scores providers’ performance based on the facts found in the data. Results and rationale are easy to search and available online any time. Moreover, it’s affordable.

License fees are sized to the organization. The organization or the payer benefits immediately by being able to find the best-in-class doctors any time. Headaches and significant dollars are saved.

Karen Wolfe, BSN, MA, MBA is the founder and president of MedMetrics® LLC, an Internet-based Workers’ Compensation analytics company. MedMetrics focuses on analyzing the medical portion of claims, including medical provider performance evaluation and scoring, with continued monitoring. MedMetrics offers its clients online apps that link analytics to operations, thereby making them actionable.

How to Make Workers' Compensation Analytics Actionable

by Karen Wolfe

Analytics demystified

Much is said about the savings value of analytics, yet few in Workers’ Compensation have actually implemented them. Analytics are often misunderstood, making the idea itself daunting. Even those who have implemented analytics lament they really do not know what to do with them.

Simply stated, analytics means analyzing the data for the purpose of gaining new understanding of the business process, identifying or maximizing revenue streams, and uncovering cost drivers in the system. That other industries use analytics is well known. The food industry, for instance, has made their use of analytics quite obvious. A brief examination describes how analytics can be simple.

Monitoring transactions

Supermarkets and grocery stores have long monitored purchase transactions with customers. Customer purchases are automatically documented at the register. That is the raw data. When those transactions are analyzed in context with other data, such as inventory turns and factors such as season and weather, conclusions can be drawn about how buying behavior changes when outside conditions occur. It can even be assumed (predicted) the buying patterns that have occurred in the past will be similar in the future when similar conditions occur.

Analytics made actionable

The food industry views data analyses as a work-in-process operational tool. While monitoring purchases, weather conditions are consulted electronically for all locations. Based on combined conditions occurring in a region that are known to effect buying patterns, the computerized distribution system is alerted and redirected. Periodic high demand inventory is immediately diverted to the affected region.

Data analysis is translated to operational intervention. The outcome is increased sales revenue and satisfied customers resulting directly from data analysis and monitoring with appropriate and timely action.

Translated to WC Managed Care

Similar to the supermarket industry, the Workers’ Compensation industry collects data continually. Also similar is the fact that different systems are used for different purposes, but all are related to the operation. In Workers’ Compensation the central operation is the claim.

Bill review systems document medical bills received and recommend payment based on data analysis (analytics). Claims systems document medical bills paid, indemnity paid, work loss, legal actions and other factors, all related to the claim. Still more data is collected related to pharmacy, utilization review and others. Amazingly, the rich data is rarely converted to operational tools.

Opportunity cost in Workers' Compensation
Unfortunately, most in Workers’ Compensation neglect to integrate and monitor their verdant data to identify cost drivers and opportunities to mobilize action early to thwart or limit potentially high risk and costly situations affecting claims. Integrating and concurrently monitoring the data from the disparate sources, can identify conditions and events that portend risk and cost—not dissimilar to monitoring storms and inventory in the food industry.

Link analytics to operations

In the supermarket example, analytics are linked to operations by mobilizing changes in distribution. Current information received on the ground programmatically alters the operational process. Similarly in Workers’ Compensation, informational alerts sent to appropriate persons gives them the jump on potentially adverse conditions in claims. Adjusters and nurse case managers receive specific information regarding new conditions in a claim and mobilize action. The critical information is derived from analysis of the integrated data and automatically delivered to the right locations for action.

Early intervention saves

In the food industry the distribution system is notified when adverse conditions occur in a specific location. The analogy in Workers’ Compensation is the right person is notified when adverse conditions occur in a claim. For instance, when known high risk conditions occur in a claim, that information is automatically transmitted to an appropriate person. A simple example is when multiple prescriptions of Opioids are found in the currently monitored data, a nurse case manager is electronically notified to take action.

Analysis of current, integrated data can be programmed to automatically create alerts to appropriate persons who take action, thereby making analytics actionable.

Infrastructure and efficiency

Besides gaining dollar savings and claim outcome value from analytics and technology making analytics actionable, other positive results are gained. A formal infrastructure is created for medical management, thereby optimizing efficiency. The Workers’ Compensation industry can dramatically benefit from making analytics actionable.

Karen Wolfe is founder and President/CEO of MedMetrics®, LLC, an Internet-based Workers’ Compensation analytics company. MedMetrics provides the apps to make analytics actionable.

How to Tap the Secret Power of ICD-9's

by Karen Wolfe

The medical portion of Workers’ Compensation claims now meets or exceeds 60% of claim costs. That fact alone should easily convince payers to focus on the rich medical information in their data. Very powerful information residing in claims data is virtually untouched—diagnostic codes in the form of ICD-9’s. The problem is few in the industry really understand ICD-9’s or in what ways they could inform powerful medical management.

ICD defined

ICD-9 codes are not unique to Workers’ Compensation. ICD-9’s are the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). They are a standardized method of describing injuries, illnesses, and related issues worldwide.

ICD is the classification that codes and classifies mortality data worldwide. The ICD-CM is used to code and classify morbidity data from inpatient and outpatient records and doctor’s offices.

The purpose of the ICD and of WHO (World Health Organization) sponsorship is to promote international comparability in the collection, classification, processing, and presentation of mortality statistics. New revisions of the ICD are implemented periodically so that the classification also reflects advances in medical science.

ICD’s in standard billing forms

Those who bill for medical services in the U.S. are required to use one of two CMS (Center for Medicare and Medicaid) standard forms, the HCFA-1500 (Health Insurance Claim Form) for outpatient and UB-04 Unified Billing) for hospitals and other facilities. Both standardized forms require the medical provider to list ICD-9’s appropriate to the medical procedures for which they are billing. The verdant data derived from these forms should be analyzed and incorporated into managed care processes.

Unwieldy and ignored

Bill review organizations and payers capture data from the standardized billing forms in their systems. Nevertheless, while the ICD information is documented in systems, it’s use usually stops there. ICD-9’s are difficult to interpret.

ICD-9’s on bills are displayed in the form of codes, not descriptions of injuries and illnesses and they number in the thousands. Individuals cannot remember the codes, nor do they have the time to look up codes for interpretation. Instead, they simply ignore them.

Secret power of ICD

Incremental essential knowledge resides in ICD-9 codes that can be translated to powerful medical management. When they are monitored electronically and concurrently, they reveal and inform.

ICD-9’s reveal migrating claims

For instance, migrating claims accrue ICD’s. Migrating claims are those that are not going well, are becoming more complex and costly, often an insidious process that is missed by claims adjusters and medical case managers until considerable damage is done. What happens in migrating claims is the injured worker is not recovering for some reason and is referred to multiple specialists. Each specialist adds new ICD-9’s to the claim.

As a claims migrates, and the number of ICD-9’s associated with it mounts.

Computer monitoring

Using a computerized system especially designed to monitor ICD-9’s is a powerful knowledge solution. Alerts are sent to appropriate persons when the number of ICD-9’s in a claim increases beyond a designated point. Migrating claims cannot be missed and intervention is early, therefore far more effective.

ICD-9’s are predictors

Another way to tap the secret power of ICD-9’s is to score them individually for medical severity, the seriousness of the injury or illness. Each claim then contains a total ICD-9 score in the system for medical severity. As ICD-9’s are added during the course of the claim, the claim ICD score increases. As a claim migrates and accumulates ICD-9’s, an appropriate person is automatically notified by the system. Migrating claims cannot go unnoticed.

Claims with high ICD-9 scores are predictors of risk and cost. Claim ICD-9 scores can be monitored from the outset and throughout the course of the claim.

ICD-9’s scores level the playing field

The claim ICD-9 score reveals the seriousness and complexity of a claim. Medical doctors managing difficult claims can be differentiated from those handling less arduous claims, thereby creating fairness in measuring provider performance.

Many indicators are used for claim monitoring and provider performance including medical cost, frequency and duration of treatment, indemnity costs, return to work and multiple other factors. The claim ICD medical severity score automatically predicts trouble and alerts the appropriate medical managers.

Moving on—ICD-10

The ICD-9 contains thousands of codes. Moreover, the ICD-10 revision will more than double the number of codes, making its information value exponential. ICD-10 is slated to be activated in October of 2014.

Karen Wolfe is President and CEO of MedMetrics®, LLC, an online Workers’ Compensation analytics company. MedMetrics analyzes data and provides “apps” online to link analytics to operations, thereby making them actionable. MedMetrics also monitors concurrent integrated data to detect potentially high risk or high cost events in claims and automatically alert the appropriate persons.

 

How to Tap the Power of Rx Monitoring for Opioids

by Karen Wolfe

In a nutshell

Much has been said about the cost of Schedule II pain medications in Workers’ Compensation. Rebecca Shafer, JD recently summarized the stunning financial impact in this way: “The average lost time work comp claim in the U.S. without the use of opioids cost $13,000. When an employee is prescribed a short-acting opioid like Percocet, the average lost time claim cost triples to $39,000. When an employee is prescribed a long-acting opioid like oxycontin, the average lost time claim costs explodes to $117,000, an increase of 900% over the average lost time work comp claim without the use of any opioids.”[1]

Do nothing

Obviously, doing nothing about this problem is not an option. Moreover, cost is not the only issue. The lives of injured workers, their families, and fellow workers are affected by long term use of Opioids used in the treatment of pain. The probability of return to pre-injury status after long term treatment with Opioids is meager. 

Analyze prescription practices
The first step in solving or mitigating the problem is to analyze the data to profile medical doctor prescribing history. Those who continually prescribe Opioids of any type, and particularly those who prescribe long acting Opioids should not be a part of any medical provider network. A proactive strategy should be used to eliminate such doctors from the network and direct injured workers to best practice doctors.

The best doctor solution

Direct injured workers to best practice providers. Avoiding  over-prescribing doctors will solve the problem. Pretty simple.

Automatic trigger

Nevertheless, in situations where avoiding the perpetrators is impossible or they are unknown, another approach is available. Ms. Shafer recommends, “If you do not have a nurse case manager assigned to all of your lost time claims, the issuance of a prescription to the injured employee for any narcotic should be an automatic trigger to assign the nurse case manager.”[2]

The catch

The catch is, what is an automatic trigger or how is the information about prescriptions conveyed to nurse case managers?

The most expedient way to spot Opioid prescriptions and impending disaster is through concurrent electronic data monitoring.

Proactive medical management

The trick is to always know when a narcotic is ordered and to monitor the type and subsequent prescriptions. Manual monitoring is time consuming and costly. It is also inaccurate as important information is easily missed. Instead, apply the power of technology through concurrent electronic data monitoring. Deliver automatic alerts to nurse case managers. The nurse will take it from there to discuss the treatment plan with the doctor, provide the doctor with evidence of poor results with continued Opioid use, and refer to peer review when the doctor is resistant.

Responsible Opioid use

The question might be posed, “Should Opioids ever be prescribed for pain?” The answer is yes. Opioids, can be very effective pain relievers and injured workers deserve relief from acute pain. However, responsible prescribing and monitoring prescriptions is essential to avoiding the disaster of addiction.

Data made a work-in-progress information tool

Systems designed and to monitor prescriptions and automatically alert the appropriate person when Opioids are prescribed are available. Alerts can be adjusted to the number and type of prescriptions, thereby establishing consistent standards of care. Read more about how to make data a work-in-progress information tool for proactive computer-intensified medical management How to Optimizethe Nurse Case Management Advantage.

Karen Wolfe is President and CEO of MedMetrics®, LLC, an online Workers’ Compensation analytics company. MedMetrics analyzes data to score provider medical performance and provides “apps” for quick look-up of best practice providers by medical specialty and geo-zip,. MedMetrics also monitors concurrent integrated data to detect potentially high risk or high cost events in claims and automatically alert the appropriate persons.

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[1] Shafer, R. Workers Compensation Claim Costs Skyrocket with Use of Opioids ©2013 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

[2] Ibid.

Part III California SB 863, a Guide to Building and Monitoring Networks with Intelligence

by Margaret Wagner and Karen Wolfe

California has defined how medical networks in Workers’ Compensation should be structured and managed. Part I and Part II of this series described how California’s SB 863 LC 4616 (b) (2) and LC 4616 (b)(3) takes medical provider network directives to a new level. The key imperative is, “Every MPN must establish and follow procedures continuously to review the quality of care, performance of medical personnel, utilization of services, facilities, and costs. However, a few additional key points should be considered when selecting and monitoring medical providers for the California MPN or any network.

Beyond legislation

Escalating problems in the industry with Opioid overuse and abuse, as well as physicians who are dispensing medications from their offices are additional factors that must be considered. While the California SB 863 legislation does not address these issues, the data should be scrutinized to identify physicians who demonstrate unfavorable prescriptive practices. Analyzing the data to evaluate physician performance in that regard is essential to vetting physicians for membership in a network. It is also crucial to monitoring networks going forward.

Opioid over-prescribers

Workers’ Compensation literature is replete with information about Opioid overuse and abuse with its disastrous human and resource waste. Unfortunately, measures taken to curb inappropriate prescribing behavior are few and vary widely across the country.

Simply stated, the best way to reduce Opioid abuse is to avoid Opioid over-prescribers. Analysis of the data will identify the perpetrators. They should never be a part of a Workers’ Compensation medical network.

Back to California - CURES

California has a program that approaches the problem by monitoring patient utilization of prescribed Schedule II drugs and making that information available to authorized prescribers and distributors (pharmacies) of controlled drugs.

California’s program is called CURES (Controlled Substance Utilization Review and Evaluation System, and PDMP (California Prescription Drug Monitoring Program). [1] The California Department of Justice, has a Prescription Drug Monitoring Program (PDMP) system which “allows pre-registered users including licensed healthcare prescribers eligible to prescribe controlled substances, pharmacists authorized to dispense controlled substances, law enforcement, and regulatory boards to access timely patient controlled substance history.

The California Attorney General's Office said that if doctors and pharmacies have access to controlled substance history information at the point of care it will help them make better prescribing decisions and cut down on prescription drug abuse in California. The role of the CURES/PDMP entrusts that well informed prescribers and pharmacists can and will use their professional expertise to evaluate their patients’ care and assist those patients who may be abusing controlled substances.

The state’s database known as the Controlled Substance Utilization Review and Evaluation System (C.U.R.E.S) contains over 100 million entries of controlled substance drugs that were dispensed in California. Each year the CURES program responds to more that 60,000 requests from practitioners and pharmacists. The online CURES/PDMP system will make it much easier for authorized prescribers and pharmacists to quickly review controlled substance information via the automated Patient Activity Report (PAR) in an effort to identify and deter drug abuse and diversion through accurate and rapid tracking of Schedule II through IV controlled substances.”
 

Submission of Controlled Substance Data

Pursuant to Health & Safety Code Section 11190, and Business & Professions Code Section 1170, all licensees who dispense Schedule II through IV controlled substances must provide the dispensing information to the Department of Justice on a weekly basis in a format approved and accepted by the Atlantic Associates Inc.(AAI),and the DOJ. Similarly, pursuant to California Health and Safety Code Section 11165(d), dispensing pharmacies and clinics must provide weekly dispensing reports to the DOJ on Schedule II, III, and IV prescription drugs.

For purposes of creating an intelligent MPN, insure any physician under consideration for an MPN in California is a member of CURES/PDMP. That notwithstanding, the data should be monitored continuously to determine actual performance.

Physician-dispensed medications

Another prescription abuse issue not addressed by the California legislation is physician-dispensed medications. While it is portrayed as a patient convenience, and probably is, the medications are prepackaged and extraordinarily costly. Once again, this practice can be monitored in the data. Bills reflecting drugs dispensed by the treating doctor are not monitored by Pharmacy Benefits Managers (PBM), rather, they appear in normal provider billing.

Networks with Intelligence

All medical provider networks serving any jurisdiction should analyze integrated data, meaning all data associated with claims. Integrated data is sourced from claims level systems, bill review systems, PBM systems, and other such as utilization review to understand the broad spectrum of claims and all individuals, organizations, and events touching them. The goal is to select best-in-class doctors by objectively identifying excellent provider performance.

Margaret Wagner is President and CEO of Signature Networks Plus, Networks with Intelligence™. She is considered an expert in network selection, monitoring and management, thereby creating Networks with Intelligence for clients. MWagner@signaturenetworksplus.com

 

Karen Wolfe is President and CEO of MedMetrics®, LLC, a Workers’ Compensation analytics company. MedMetrics scrubs and enhances provider data in systems, integrates the data from organizations’ disperse systems, then analyzes, scores, and monitors medical provider performance. MedMetrics also offers online “apps” that link medical analytics to operations, thereby making them actionable. karenwolfe@medmetrics.org

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[1] http://oag.ca.gov/cures-pdmp

 

Part II California SB 863, a Guide to Building and Monitoring Networks with Intelligence

by Margaret Wagner and Karen Wolfe
 

California has defined how medical networks in Workers’ Compensation should be structured and managed. Part I of this series described how California’s SB 863 LC 4616 (b) (2) and LC 4616 (b)(3) takes medical provider network directives to a new level. The key imperative is, “Every MPN must establish and follow procedures continuously to review the quality of care, performance of medical personnel, utilization of services, facilities, and costs.

California SB 863

The emphasis on network review is a chief imperative of SB 863, effective January 1, 2013. Many directives in the bill require continuous data monitoring to discover provider and network compliance and non-compliance. Some of the directives that require continuous attention are:
·       Chiropractors are limited to a 24 adjustment maximum LC 4600(c).
·       MPN’s must have geo-coding of network physicians, updated every four years to insure access requirements are fulfilled.
·       LC 4616 (b)(2) and LC 4616 (b)(3) state every MPN must establish and follow procedures continuously to review quality of care, performance of medical personnel, utilization of services, facilities, and costs.
·       Anyone can complain, initiate an investigation, and petition to suspend or revoke an MPN.
·       Injuries while under unapproved, non-MPN care are no longer compensable!
·       Multiple conditions of escaping the MPN, non-MPN payment, and disputes must be monitored.
·       Home Health Care must be prescribed by an MD or DO.
·       MPN’s are approved for four years from date of the most recent application or modification.

Provider performance analysis

Medical provider performance must be analyzed and monitored not only for compliance with SB 863, but also for acknowledgement of the nuances of Workers’ Compensation in the treatment process. Work loss and disability payments, return to work and modified work, claimant legal involvement, along with frequency, duration, and costs of medical services should be analyzed and scored for individual providers, groups, and facilities, whether in California or another jurisdiction.

Provider data issue

A problem confronting many organizations is their medical provider data is insufficient, making accurate analysis impossible. Unfortunately, most provider records in claim systems and bill review systems is severely lacking in quality and comprehensiveness.

Until now, these records were used only to pay bills, consequently, name, address, and FEIN (Tax ID) were adequate. Now, however, because of SB 863 and increased attention to the medical portion of claims nationally, much more information is needed.

Duplicate records

Most systems contain duplicate provider records. Slight differences in data entry create multiple records for the same provider, each associated with different claims. Under those conditions, provider analysis is inaccurate and incomplete. Such duplicate records must be scrubbed and merged before beginning performance analysis.

Medical specialty

Medical specialty or specialties should be included in provider records in the data. Those providers certified in a specialty should be compared with others who are similarly certified. Without the provider’s specialty, analysis of performance is non-specific and often misleading.

For instance, pain management doctors’ performance should be compared to that of other pain management doctors, rather than dermatologists or internists. Pain management physicians often receive cases when they are growing more complex and already costly. Analyzing providers of similar specialties is a matter of comparing “apples to apples”.

Differentiating Individuals

Medical providers who are members of groups or facilities should be analyzed and selected for networks individually even if the group or facility is approved. Some believe all members of a group should be included in the MPN when the group is approved. Actually, individual members might be problematic and automatic approval should not be guaranteed.

Currently many doctors and other providers submit bills under a single Tax ID. Measuring collective performance quality is not acceptable for a network with intelligence. The way to differentiate individuals is to analyze their unique performance using specific identifiers such as the state medical license number or NPI (National Provider Identification).

Networks with ROI

Whether complying with California SB 863 or building Workers’ Compensation medical networks anywhere in the country, developing quality networks will return huge savings. Medical providers, especially doctors who score poorly in comprehensive data analysis drive complexity, high costs, and poor outcomes.  Those should be avoided and injured employees should be directed to best in class doctors to receive the best medical care with the best medical and employment outcomes. The business of developing and managing Networks with Intelligence should be given high priority.

First steps

The first step in building quality medical networks is to scrub and enhance medical provider data in the organization’s systems. The next step is selecting best practice providers based on integrated and comprehensive data associated with the claim. Developing and monitoring medical networks requires analytical knowledge and technical skill. Because internal resources are often limited, a practical solution is to outsource to the experts for provider performance analytics and continuous monitoring.

Margaret Wagner is President and CEO of Signature Networks Plus, Networks with Intelligence™. She is considered an expert in network selection, monitoring and management, thereby creating Networks with Intelligence for clients. MWagner@signaturenetworksplus.com
 

Karen Wolfe is President and CEO of MedMetrics®, LLC, a Workers’ Compensation analytics company. MedMetrics scrubs and enhances provider data in systems, integrates the data from organizations’ disperse systems, then analyzes, scores, and monitors medical provider performance. MedMetrics also offers online “apps” that link medical analytics to operations, thereby making them actionable. karenwolfe@medmetrics.org