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
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