Remember Y2K?
“January
1, 2000, that is the day that was to change all of our lives. That was the day
that the computers on which we all depended would fail us. That was the day
that all of our luxuries of daily life would crumble, and we would be once again
forced to live without electricity, running water, heat. The great Y2K scare is
what it was called. The scare was that all of our computer systems around the
world would cease to function on December 31, 1999.”[1]
They did not.
Drawing a parallel in WC
The
hype and fear of Y2K were paralyzing for some and organizations spent large
sums of money to reprogram computers in preparation. Indeed, there is far less anxiety
about the veracity of medical provider data in Workers’ Comp claims and bill
review systems. Yet, medical provider records in Workers’ Comp are just as
lacking as the year date in systems prior to 2000 and the ramifications could
actually be consequential.
Opportunity cost
The
Y2K issue prior to the late 1990’s was caused by limited disk space that was
conserved by using only two digits for the year. The number of bytes that would
fit on a screen and in the memory of the machine was limited. On the other
hand, the cause of limited medical provider data is simply a matter of
traditionally paying the bill efficiently. Only name, address, and Tax ID is
needed. However, inadequate and inaccurate medical provider data is opportunity
cost for the industry.
New applications
No
longer is the industry interested in using medical provider information for
bill payment only. Provider records in systems are key to evaluating provider
performance beyond direct fees for service. Medical providers impact return to
work, indemnity costs, claim duration, and other factors. The indicators can be
found in the data.
Who knew?
Medical
provider records have recently risen to the level of essential information for
quality and cost control. In order to evaluate individual medical providers, medical
groups, and facilities, the data in provider records must be non-duplicative,
accurate, and complete. Yet, most databases contain multiple records for the
same, and presumably the same provider. Moreover, the records are incomplete,
especially regarding unique identifiers such as state license numbers or NPI
(National Provider Identifier) numbers that distinguish individuals.
Duplicate provider
records
One
of the major problems found in most Workers’ Comp data is duplicate medical
provider records. Duplicates are a problem because the records for an
individual are dispersed over multiple records and can only be evaluated
separately rather than collectively. The cumulative data for a provider cannot
be assessed until duplicate provider records are merged.
Duplicate
provider records occur for many reasons. Some organizations simply add a new provider
record to their database when a new bill is received, without checking to see
if the provider already exists in the data. This is simple to correct
administratively, by requiring data entry persons to check the data for the
existing provider. A more reliable solution is to create systems with search
and select utilities that limit “add” authority. However, duplicate records
occur for other reasons as well.
Duplicate
medical provider records can also occur when the same provider is added to the
database, but the name is spelled differently, a different suffix is used, and
when initials or abbreviations are entered differently. Computer systems read
these as different and allow adding the new one. Similar address inconsistency
has the same result. Using Ste, Ste., and Suite might result in three separate
records for the same person or entity. The solution is using basic record search
and select from a drop down list. Moreover, correcting the existing data by
scrubbing the database is worth the time and cost.
Optimize medical
provider records
Tax
ID, so important to paying a bill is nearly useless when evaluating medical
provider performance because multiple persons often use the same Tax ID. Establishing
a critical mass of data associated with one provider is difficult, and
duplicate records simply dilute the information further. Certainty about
individual identity is critical and the only way to achieve that is with state
license numbers.
License numbers
Unfortunately,
NPI numbers, established by the CMS (Centers for Medicare and Medicaid
Services) are abused by some. Notorious medical providers apply for and receive
multiple NPI numbers. State license numbers are the most reliable and should be
added to provider records in databases to differentiate individuals.
Medical specialty
Including
medical specialty in the provider record increases its value exponentially. The
most accurate, fair, and illuminating evaluation is comparing peers. Comparing
neurosurgeons to dermatologists on some performance indicators makes little
sense. Pain specialists, for instance, usually receive complicated cases late
in the game and should be compared to other pain specialists, not those who
treat acute injuries. Medical specialties are vital to evaluating performance
accurately.
What to do
While it may not be Y2K, the impact of poor data might be greater for Workers' Comp organizations. Systems
should contribute to medical cost management intelligence. However, many cannot
because of data quality. Scrub and optimize existing data and establish protocols that prevent continuation of status
quo. Outsourcing to a third party specialist is easy and the return on
investment certain.
Karen Wolfe is the founder and president of
MedMetrics®, LLC, a Workers’ Compensation analytics company. MedMetrics specializes
in medical provider performance analysis, including provider file scrubbing and
optimization. MedMetrics also provides powerful online “apps” that link
analytics to operations, thereby making cost management intelligence
actionable. Visit MedMetrics to
learn more or contact karenwolfe@medmetrics.org
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