The first step is to clarify the characteristics of the best providers, especially in context with Workers’ Compensation. One resource is an article published by the American College of Occupational and Environmental Medicine in association with the IAIABC (International Association of Industrial Accident Boards & Commissions) entitled, “A Guide to High-Value Physician Services in Workers’ Compensation How to find the best available care for your injured workers” It’s a place to begin.
Although considerable effort from scores of industry experts contributed to this article, the approach they recommend is complex, time-consuming, and subjective. In other words, it is impractical. Few readers will have the expertise and resources to follow the guide. Moreover, one assertion made in the article is simply wrong.
The article states it would be nice to have the data, but the data is not available. “Participants in the workers’ compensation system who want to direct workers to high-quality medical care rarely have sufficient data to quantify and compare the level of performance of physicians in a given geographic area.”
Actually, the data is available from most payers whether they are insurers, self-insured, self-administered employers, or TPA’s. However, collecting the data is the challenge.
The primary reason data is difficult to collect is that it lives in discrete database silos. The industry has not seen fit to place value on integrating the data, but that is required for a broad view of claims from beginning and throughout their course.
At a minimum, claim data should be collected from medical billing or bill review, the claims system, and pharmacy (PBM). The data must be collected from all the sources, then integrated at the claim level to get a broad view of each claim. It takes effort, but it is doable. Yet, there remains another data challenge.
Payers have traditionally collected billing data from providers, through their bill review vendor. The payer’s task has been paying the bill and sending a 1099 statement to providers at the end of the year. All that is needed is a provider name, address, and tax ID so the payment reaches its destination. It makes no difference to payers that providers are entered into their systems in multiple ways causing inaccurate and duplicate provider records. One payment is a payment. The provider might receive multiple 1099’s, but that causes little concern.
What is of concern is that when the same provider is entered into the payers’ computer system in multiple ways, it can be difficult to ascertain how many payments were made to an individual provider. Moreover, when the address collected by the payer is a PO Box rather than the rendering physician’s location, matters become more complicated. This needs to change.
The new ask
Now payers are being asked to accurately and comprehensively document individual providers, groups, and facilities so the data can be analyzed to measure medical provider performance. They need to collect the physical location where the service was provided and it should be accurately entered into the system in the same way every time. (Note: this is easily done using a drop-down list function rather than manual data entry.)
Most importantly, a unique identifier is needed for individual providers, such as their NPI (National Provider Identification). Many payers are now stepping up to improve their data so accurate provider performance assessments can be made.
High-value, quality medical providers can be identified by using the data. However, quality data produces better results. Selecting the best medical providers is not a do-it-yourself project. Others will do it for you.