Fact
Significant
dollars can be saved by getting injured workers to the best doctor. Evidence supporting
this fact is the mounting Workers’ Comp industry research clearly stating treatment
by well-informed and well-intentioned medical doctors results in lower costs
and better outcomes.
Belaboring a point
As
repeatedly stated in this series, many doctors in networks are not
well-informed or well-intentioned regarding management of Workers’ Comp
claimants. As a consequence of their involvement, claim results are lacking,
costs are high, and outcomes are precarious. This series of articles, “Tips for
Building a WC Medical Provider A Team”, is intended to describe how to identify
doctors who know the ropes in Workers’ Comp using indicators in the data.[1]
Beyond
the indicators discussed in the previous articles in this series, additional
salient data elements are available in the data to broaden the scope of medical
management evaluation. What makes this approach so feasible is that solid knowledge
of who demonstrates best practices is revealed in the data. However, to find
that knowledge, some operational processes and the data itself need refinement.
Access to the data and its quality must be addressed.
Getting to the knowledge in the data
Regrettably,
access to the data by the right persons is often a problem. Those who know best
what to look for, the business and clinical professionals, cannot use current
data in a practical, work-in-progress manner. The reasons are many.
First,
relevant data resides in separate databases that must be integrated to
understand all activity in a claim. Moreover, in most organizations, provider
records are simply inaccurate and incomplete. Until now, the need for them was
for reimbursement purposes only, not performance evaluation. Yet another problem
is that provider records are frequently duplicated in the data, making it
difficult to accurately evaluate individual medical providers’ treatment
process and results.
Data silos
Critical
data for analyzing medical provider performance is still fragmented in most
payer organizations. While people have long complained about data silos in
Workers’ Comp, little has been done to correct the problem. If anything, data
sources have increased. Pharmacy databases have been added, for instance. Yet
the databases are not integrated on the claim level, thereby portraying the
claim as a whole. Data silos too often lead those who are attempting to
evaluate provider performance to rely on a single data source.
Single source analysis
Relying
on one source of provider performance data is foolhardy. Nevertheless, bill
review data is often used, but by itself is inadequate to tell the whole story.
Claims level data is also critical to weigh return to work data, indemnity payments,
and legal involvement associated with claims and ultimately, to individual
doctors. None of these data items are found in bill review data, yet these are
essential to complete analysis of provider performance. Because in Workers’
Comp, doctors drive the non-medical claim costs as well as the direct medical
costs, these data items are essential to evaluating the quality of their
performance.
Data quality
The
problem of data quality can be even stickier. Traditionally, medical provider
records are kept in the claims database, along with records of other vendors for
payment purposes. All that is needed for bill payment is a name, address, and
tax ID. Unfortunately, the same provider is frequently added to the database
when a new bill is received. This outdated database management practice leads
to slightly different records added for the same provider.
Data optimization
To
evaluate medical provider performance, more information about individual
providers is needed such as accurate physical addresses. PO Boxes will suffice
for mailing checks, but injured workers cannot be sent there for treatment.Merge duplicate records
Tax ID’s are still important for reimbursement and 1099 purposes, but often multiple doctors are represented by one Tax ID. To evaluate provider performance, individuals must be differentiated in the data. State medical license numbers and NPI (National Provider Identification) numbers are needed. Frankly, some doctors deliberately obfuscate the data by operating under multiple Tax ID’s and multiple NPI numbers. Consequently, provider records must be merged, scrubbed, and optimized before any analysis can begin.
What to do
For
most organizations, choosing best practice providers by analyzing the data is
challenged by the shortage of accurate and complete data. Therefore, those wanting
to control costs by choosing the best providers should obtain provider
performance analysis and scoring from a specialty third party, one that is
expert in data integration from multiple sources, as well as provider data
scrubbing and optimization.
When
behaviors of doctors are analyzed using clean, integrated data, the well-informed
and well-intentioned in Workers’ Comp will rise to the surface.
Karen Wolfe is the founder and president of
MedMetrics®, LLC. MedMetrics specializes in medical provider data integration, optimization,
and analysis of performance for Workers' Comp. Additionally, MedMetrics leverages analytics and
technology to provide powerful “apps” online that strengthen medical management
for effective medical cost control. Visit MedMetrics to learn more or contact karenwolfe@medmetrics.org
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