Medical management in Workers’ Comp has continued essentially unchanged for decades. The rationale for medical case management services continues to be valid, yet the processes guiding it have remained unchanged. As Ron Skrocki suggests, we need to get case management off auto pilot.[1]
Auto pilot challenge
The auto pilot primarily refers to doing things the same way they have always been done. Improvements that might be achieved are unknown because the processes have not been analyzed, challenged, and redesigned. How case management is mobilized, why, and when needs review. Moreover, upgrading the medical management process with current technology is imperative.
For instance, claims adjusters decide when and for what reason medical case management is needed. How structured are these referrals? Are they proactive, consistent, and timely? How do they reflect the organization’s business standards? Without business process standards, the old auto pilot remains in control. But what if the auto pilot were made smart? What if processes were made consistently and accurately actionable?
Making the auto pilot smart
The first step is to educate the medical management process using predictive analytics to assess the organization’s medical loss history. Every organization is unique in its mix of medical losses, how costly they are, and the internal processes used to mitigate them. Predictive analytics should be implemented to examine the organization’s historic data, uncover its medical loss cost drivers, and past processes.
Business process standards
Use the new knowledge to establish organizational process standards by carving out the medical loss diagnoses, comorbidities, and conditions that are of highest risk and for which the organization wants immediate action. Establish in the business process standards the persons or positions in the organization that will be notified for each kind of condition. Who will be notified and held accountable for addressing each issue?
Automate
Now that senior management knows what conditions in claims are of highest risk and in need of immediate attention, create a system that continually monitors the data, tagging those risk conditions as they occur. The condition might be obvious, especially at claim opening or it might slip into the data at any point. The subtle ones are easily missed when relying on auto pilot methods.
Alert stakeholders
Part of automation is automatically alerting the appropriate persons when a risk condition occurs in a claim. When establishing business process standards, pre-identify all stakeholders who should be alerted for each risk condition. Multiple stakeholders can be notified, even beyond the claims rep and the nurse case manager. No guessing. No relying on memory to engage case management. Moreover, claims reps can also be notified of the need to address reserving at the same time.
Alert for reserving
The predictive analytics-informed structured process has an even broader positive impact on the organization. When the identified medical loss risk conditions occur in claims and are tagged by the system, reserves probably need attention, as well. The claims rep is alerted and the system provides comprehensive knowledge assistance for claims professionals to know how to quickly and accurately adjust reserves.
Probable ultimate medical reserve amount
The system projects and displays the probable ultimate medical reserve amount for that claim based on the predictive analytics. Claim detail and projections portrayed eliminate the need to search for additional information. Claim documentation and projections displayed make it simple to complete the reserve adjustment. The organization’s business process impact of medical loss management is made broader in scope, thereby more powerful, accurate, and effective.
Coordinated power play
When the medical case manager is automatically notified of risk conditions along with the claims rep, coordinated initiatives can be mobilized. All appropriate resources are brought to bear early and intentionally resulting in improved outcomes. Moreover, the process delivers objective savings.
$ Calculate savings
The structured medical management process generates calculated objective savings at claim closure based on the projected ultimate medical reserve amount and real-time integrated, proactive medical management initiatives. Calculating savings is accurate and easy, yet concrete and defensible.
Turn off the auto pilot
The traditional auto pilot medical management process is undefined and inconsistently implemented. Measureable savings are elusive. The Workers’ Comp industry must turn off its medical management auto pilot and step up to this accurate and effective structured business process approach.
Karen Wolfe is the founder and President of MedMetrics®, LLC, a Workers’ Compensation, predictive analytics-informed medical management and technical services company. MedMetrics offers online apps and alerts that link analytics to operations, thereby making them actionable and measureable. We don’t do medical management. We make your medical management initiatives more powerful. karenwolfe@medmetrics.org
[1]
Skrocki, R. Getting Case Management Off Auto Pilot. WC Magazine. The CLM. 2015
