Tips for Building a Medical Provider “A” Team

by Karen Wolfe

The “noise” in the Workers’ Comp industry about increasing medical costs is not subsiding. If anything, the chatter is swelling into a crescendo and much of it is relevant and important. Recent conferences such as the Workers’ Compensation Research Institute (WCRI) underscored the continuing problem of Opioids. Also of concern at the conference was physician-dispensed drugs.

Studies show when Opioids are prescribed inappropriately and when physicians sell patients medications directly from their offices, claim costs increase and outcomes deteriorate. However, while discussion of the topic increases, new initiatives in the industry designed to target the problem are scarce.

Source of the problem

The source of these two major cost problems is certain treating doctors. Doctors are the ones licensed to prescribe drugs and some are abusive. Probably only a few of the doctors are perpetrators, but the trick is to know in advance which doctors they are. Particularly for organizations that have employees geographically spread, this is a continuing challenge.

Networks are not a safe haven

Payer organizations have been lead to believe their networks are their safe haven. If an injured worker is sent to a network provider, a discount on medical services can be assured. Unfortunately, networks are known to contract with every physician and ancillary provider alive, without consideration of the provider’s Workers’ Comp knowledge, interest, or medical integrity. Nor are quality, overall cost, and outcomes considered.

Networks do not vet physician performance. They allege savings based on discounts off medical bills, but the number of bills is not measured. Most networks have not stepped up to apply analytics to provider performance so payers must look elsewhere.

Networks lack necessary data

The only practical way to evaluate provider performance in order to select the best is to analyze the data. The problem for networks is they do not have the scope of data necessary to fairly evaluate performance. They receive medical bills, discount them, take a cut, and pass them back to the payer. But medical bills alone are not adequate for evaluating provider performance.

Data from multiple sources is needed

To understand a provider’s performance, claims level data is also essential. It is needed to evaluate the uniquely Workers’ Comp nuances of return to work, indemnity costs, legal involvement, claim duration, timing, and other key factors.

Opioid data, another source

In the case of Opioids, the best source of data for evaluation is from the Pharmacy Benefit Management program (PBM). The PBM data set contains the detail of what drug was prescribed and when, who prescribed the drug, and where it was filled. However, Indicators of physician dispensing will not be found in PBM data.

Physician dispensing data

Physician dispensing will appear as an item on a normal bill from the treating doctor. The degree to which it is camouflaged will vary and it may or may not be noted by the bill review system. Many bills are summarized by the time they reach the claims adjuster, so adjusters cannot discern which bills are physician-dispensed drugs. Analysis of the data is the best approach, not with the goal of avoiding payment, but to avoid the physician altogether.

Networks are a platform for analysis

Payer organizations should use their network providers as a platform for selecting their A Team. By analyzing the data, the best practice providers will surface and injured workers can be directed to them. Unfortunately, most organizations do not have the necessary resources to accomplish that task.

The solution

The best solution is to invite a third party that specializes in analyzing Workers’ Comp data and identifying the best practice medical providers in your data. Avoiding doctors that prescribe Opioids and those that dispense medications from their offices will save thousands of dollars on any given claim—more than enough for ROI on the third party service. Savings can be measured in reduced claim costs and far better outcomes compared to claims where the perpetrators of these abuses were involved. Identifying the best medical providers and directing injured workers to them are powerfully effective cost containment initiatives.

Karen Wolfe is president of MedMetrics which specializes in medical provider performance analytics with easy user search tools. We analyze your data for you to score providers based on multiple indicators. Visit MedMetrics to learn about MedMetrics Provider Performance Suite of information services, including detailed Provider Performance Analysis and Master Provider Index, a quick search for best practice providers by specialty and geo-zip. For questions, contact karenwolfe@medmetrics.org.