Seven Ways Your Data Can Hurt You

by Karen Wolfe

Your data could be your most valuable asset. Participants in the Workers’ Compensation industry have been collecting and storing data for decades. Big Data (meaning a lot of data) is available, as are vast numbers of smaller data sets, yet few analyze data to improve processes and outcomes or to take action in a timely way.

Analytics (data analysis) is crucial to all businesses today to gain meaningful insights into product and service quality, business profitability, and to measure value contributed. But data processes need to be examined regarding how data is collected, analyzed, and reported to determine and gain its current and potential value. Attention to data and its processes is crucial to insuring data is an asset, not a limitation. Begin by examining these seven ways data can hurt or help.

 1.   Data silos 
Data silos are common in Workers’ Compensation. Individual data sets are used within organizations and by their vendors to document claim activity. Without interoperability (the ability of a system to work with other systems without special effort on the part of the user) or data integration, the silos naturally fragment the data, making it difficult to gain full understanding of the claim and its multiple issues. A comprehensive view of a claim includes all its associated data.

     2.  Unstructured data

Unstructured documentation in the form of notes leave valuable information on the table. Notes sections of systems contain important information which cannot be readily tapped and integrated into the business intelligence. The cure is to incorporate data elements such as drop-down lists containing data elements to describe events, facts, and actions taken. Such data elements provide claim knowledge and can be monitored and measured.

     3.  Errors and omissions 
 Manual data entry is tedious work and often results in skipped data fields and erroneous content. When users are unsure of what should be entered into a data field, they might make up the input or simply skip the task. Management has a responsibility to hold data entry people accountable for what they add to the system. It matters.

Errors and omissions can also occur when data is extracted by an OCR methodology. Optical Character Recognition is the recognition of printed or written text characters by a computer. Interpretation should be reviewed regularly for accuracy and to be sure the entire scope of content is being retrieved and added to the data set. Changing business needs may result in new data requirements.

     4.  Human factors

Besides manual data entry, other human factors effect data quality. One is intimidation by IT (Information Technology). Usually this is not intended by IT, but they are often perceived that way. Remember people in IT are not claims adjusters or case managers. The things of interest and concern to them can be completely different and they use different language to describe them.

People in the business units often have difficulty describing to IT what they need or want. When IT says the request will be difficult or time-consuming, the best response is to persist. It’s their job and they will usually protect it by exclaiming its complexity.

     5. Timeliness

Timeliness regarding data, refers to timely reporting of critical information found in the data. This does not refer to analysis of historic data. Rather, it means appropriate reporting of critical information found in current data. The data can often reveal important facts that can be reported automatically and acted upon quickly to minimize damage. Systems should be used to continually monitor the data and report, thereby gaining workflow efficiencies. Time is of the essence.

     6.  Data fraud

Fraud seems to find its way into Workers’ Compensation in many ways, even into its data. The most common data fraud is found in billing—overbilling, misrepresenting diagnoses to justify procedures, and duplicate billing are a few of the methods. Bill review companies endeavor to uncover these hoaxes.

Another, less obvious means of fraud is when the provider seeks anonymity through confusion by using multiple tax ID’s or NPI’s (National Provider Number) for the same individual or group. The fraudulent provider is able to obfuscate the data, thereby disqualifying analysis. The system will consider the multiple identities as different and not capture the culprit.

The same result is achieved by the provider using different names and addresses on bills. Analysis of provider performance is made difficult or impossible when the provider cannot be accurately identified.

     7.  Data as a work-in-process tool

Data can be used as a work-in-process tool for decision support, workflow analysis, quality measurement, and cost assessment, among other initiatives. Timely, actionable information can be applied to work flow and to services to optimize quality performance and cost control.

Accurate and efficient claims data management is critical to quality, outcome, and cost management. When data accuracy and integrity is overlooked as an important management responsibility, it will hurt the organization.

Karen Wolfe is the founder and President of MedMetrics®, LLC, a Workers’ Compensation medical analytics and technology services company. MedMetrics analyzes the data and offers online apps that link analytics to operations, thereby making them actionable. MedMetrics analyzes data continuously and sends alerts as appropriate. MedMetrics also analyzes and scores medical provider performance. karenwolfe@medmetrics.org

Validation for Making Data a Work-in-Progress Claim Management Tool

by Karen Wolfe

According to a recently published White Paper by LexisNexis®, Data makes all the difference. The article, “More Data, Earlier: The Value of Incorporating Data and Analytics in Claims Handling”, states that carriers can reduce severity payments by up to 25 percent.[1]

The article further states that “PC carriers have implemented real-time data and analytics to enhance risk management, streamline processes and reduce costs. Yet historically within the claims function, data and analytics have mostly been isolated in the special investigative unit (SIU).  

LexisNexis believes that carriers should use data and analytics as an operational tool first, and an investigatory tool second. We conducted a study to investigate the effect of having more data earlier in the claims process and found that claims with more data are resolved faster, with lower overall costs.”

 

The study is about bodily injury claims, not about Workers’ Compensation, but the findings can logically be extrapolated and applied to Workers’ Compensation. Applying data early and throughout the claims process will result in lower costs, efficiency, and improved outcomes.

 

Early data
 

In Worker’ Compensation, having early and comprehensive data is a fait accompli. The First Report of Injury (FROI) from the employer and in many states, the treating physician, launch the data collection process. The claim is set up in the payer’s claim system and continually fed by additional data. Bills from medical providers and others are streamed through bill review systems, then to claims systems. Events such as litigation, court dates, and bills paid are documented in the claims system. Pharmacy is managed by the PBM (Pharmacy Benefit Management), thereby setting up an additional database for the claim. Most also collect utilization review and medical case management data. The question is not the data, but what is done with the data. How can it be applied?

Sitting data

 

Unfortunately, in Workers’ Compensation, voluminous data sets often remain in separate silos. The focus in Workers’ Compensation for the last twenty-five years has been on collecting the data. Now the question is, how to make data an operational tool and achieve the kind of positive results reported in the LexisNexis study. Doing so requires a different approach to data management.

Integrated data

 

Making data a useful work-in-progress tool is a matter of first integrating the data. This is not as difficult as is often portrayed by many IT departments. Nevertheless, the request and funding must come from the business units where data integration is also not usually a priority. Until business managers understand the value of converting data to actionable knowledge, little will be done.

Actualized data
 

To actualize the data for useful application, it must be analyzed and re-presented to the business units in ways that can be easily accessed, understood, and applied. The data is transformed to knowledge, knowledge about conditions in claims, approaching benchmarks, and performance of vendors.

Knowledge is actionable, not the data.

 

Actionable knowledge
 

Actionable knowledge is derived from analysis of the data. To achieve measureable cost savings, continuously monitor the integrated data, analyze it, and re-present it to the business units in the form of understandable knowledge, thereby making it actionable. Individuals can be prompted by the system to take specific actions based on the knowledge, thereby creating a structured and powerful approach to claims management with measurably positive results.

Karen Wolfe is the founder and President of MedMetrics®, LLC, a Workers’ Compensation medical analytics and technology services company. MedMetrics offers online apps that super-charge medical management by linking analytics to operations, thereby making them actionable. karenwolfe@medmetrics.org

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[1] A.Hassib and T.Fannin. LexisNexis. June, 2014 insurance.sales@lexisnexis.com

 

Why Poor Data Quality is Not an IT Problem

by Karen Wolfe

Everyone knows the old adage about data: “garbage in – garbage out”. Now, however, the meaning of the phrase is magnified because the volume, quality, and impact of data has reached unprecedented levels. With increasing importance and reliance on analytics and predictive initiatives, as well as the promise of metadata analysis, the importance of quality data is paramount.

This is not intended as a doomsday message. It’s more of a not-so-gentle nudge to change business practices regarding data management because doing otherwise will lead to significant financial disadvantages. Unfortunately, the people who have the power to change, frequently think the problem belongs elsewhere.

Not an IT problem!

The misconception is if it’s data, it must be an IT problem. However, only management has the power to change data quality, not IT. It is a management decision and responsibility to hold people and organizations accountable for data quality. The following is an excerpt from and email I received recently from our IT describing one client’s data. Unfortunately, the problem it describes is common.

“There is a field for NPI number in the data feeds but it is not often populated.  When it is populated we can definitely use that information to derive the specialty and possibly to determine the individual provider rather than the practice or facility.”

This example highlights a widespread problem in Workers’ Compensation data. Even though a field is available to capture a specific data element, in this case, NPI (National Provider Identification) number, it is not populated. This number is derived from medical bills and the reason for the omission should be thoroughly investigated.

The information trail

The first place to look is upstream in the information trail, to the submitting provider or entity. Standard billing forms such as the HCFA 1500 contain a field for NPI, but it may not be filled. Second along the information hand-off line is the bill review company. Is the NPI number being captured from the bill?

If the provider is submitting the NPI, is the bill review company capturing it? Then, if the bill review company is capturing the NPI, is it included in the data set transmitted to the payer? Once the source of the problem is discovered, management must require the necessary process changes.

Management intervention

If the submitting provider is not including the data needed, in this case the NPI number, the best management intervention is refusing to pay incomplete bills. Likewise, if the bill review company or system is not capturing the data or is not passing it on to the payer, management must demand the data needed.

Seemingly trivial data omissions can lead to multiple other problems. Another common data problem is the submitting provider or entity entering a facility, group, or practice name while excluding that of the individual treating physician. Management should insist upon using the individual treating physician name and NPI number rather than the entity name only. Systems should capture all three pieces of information.

Bad data comes in many forms beyond missing data in existing fields. Other kinds of bad data include erroneous data and duplicate records in the data. Regardless of the form and source of bad data, the challenges on the horizon are significant. The simple fact is, benefits from analytics to gain cost advantages are not accessible to those with poor data quality.  

Management owns data quality

Accurate and complete data is the only affordable and practical resource on the horizon to advance to the next levels of medical management and measureable cost control. Only management can insure data quality.

Karen Wolfe is the founder and President of MedMetrics, LLC, an Internet-based Workers’ Compensation analytics company. MedMetrics offers online apps that intensify medical management, including Provider Performance Analysis, Predictive Intelligence Profiles with Alerts, ICD-9 Predictive Scores, and Ask-the-Data Query Library. MedMetrics will import and analyze your data to identify omissions and opportunities for data quality improvement. karenwolfe@medmetrics.org

 

 

How to Tap the Secret Power of ICD-9's

by Karen Wolfe

The medical portion of Workers’ Compensation claims now meets or exceeds 60% of claim costs. That fact alone should easily convince payers to focus on the rich medical information in their data. Very powerful information residing in claims data is virtually untouched—diagnostic codes in the form of ICD-9’s. The problem is few in the industry really understand ICD-9’s or in what ways they could inform powerful medical management.

ICD defined

ICD-9 codes are not unique to Workers’ Compensation. ICD-9’s are the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). They are a standardized method of describing injuries, illnesses, and related issues worldwide.

ICD is the classification that codes and classifies mortality data worldwide. The ICD-CM is used to code and classify morbidity data from inpatient and outpatient records and doctor’s offices.

The purpose of the ICD and of WHO (World Health Organization) sponsorship is to promote international comparability in the collection, classification, processing, and presentation of mortality statistics. New revisions of the ICD are implemented periodically so that the classification also reflects advances in medical science.

ICD’s in standard billing forms

Those who bill for medical services in the U.S. are required to use one of two CMS (Center for Medicare and Medicaid) standard forms, the HCFA-1500 (Health Insurance Claim Form) for outpatient and UB-04 Unified Billing) for hospitals and other facilities. Both standardized forms require the medical provider to list ICD-9’s appropriate to the medical procedures for which they are billing. The verdant data derived from these forms should be analyzed and incorporated into managed care processes.

Unwieldy and ignored

Bill review organizations and payers capture data from the standardized billing forms in their systems. Nevertheless, while the ICD information is documented in systems, it’s use usually stops there. ICD-9’s are difficult to interpret.

ICD-9’s on bills are displayed in the form of codes, not descriptions of injuries and illnesses and they number in the thousands. Individuals cannot remember the codes, nor do they have the time to look up codes for interpretation. Instead, they simply ignore them.

Secret power of ICD

Incremental essential knowledge resides in ICD-9 codes that can be translated to powerful medical management. When they are monitored electronically and concurrently, they reveal and inform.

ICD-9’s reveal migrating claims

For instance, migrating claims accrue ICD’s. Migrating claims are those that are not going well, are becoming more complex and costly, often an insidious process that is missed by claims adjusters and medical case managers until considerable damage is done. What happens in migrating claims is the injured worker is not recovering for some reason and is referred to multiple specialists. Each specialist adds new ICD-9’s to the claim.

As a claims migrates, and the number of ICD-9’s associated with it mounts.

Computer monitoring

Using a computerized system especially designed to monitor ICD-9’s is a powerful knowledge solution. Alerts are sent to appropriate persons when the number of ICD-9’s in a claim increases beyond a designated point. Migrating claims cannot be missed and intervention is early, therefore far more effective.

ICD-9’s are predictors

Another way to tap the secret power of ICD-9’s is to score them individually for medical severity, the seriousness of the injury or illness. Each claim then contains a total ICD-9 score in the system for medical severity. As ICD-9’s are added during the course of the claim, the claim ICD score increases. As a claim migrates and accumulates ICD-9’s, an appropriate person is automatically notified by the system. Migrating claims cannot go unnoticed.

Claims with high ICD-9 scores are predictors of risk and cost. Claim ICD-9 scores can be monitored from the outset and throughout the course of the claim.

ICD-9’s scores level the playing field

The claim ICD-9 score reveals the seriousness and complexity of a claim. Medical doctors managing difficult claims can be differentiated from those handling less arduous claims, thereby creating fairness in measuring provider performance.

Many indicators are used for claim monitoring and provider performance including medical cost, frequency and duration of treatment, indemnity costs, return to work and multiple other factors. The claim ICD medical severity score automatically predicts trouble and alerts the appropriate medical managers.

Moving on—ICD-10

The ICD-9 contains thousands of codes. Moreover, the ICD-10 revision will more than double the number of codes, making its information value exponential. ICD-10 is slated to be activated in October of 2014.

Karen Wolfe is President and CEO of MedMetrics®, LLC, an online Workers’ Compensation analytics company. MedMetrics analyzes data and provides “apps” online to link analytics to operations, thereby making them actionable. MedMetrics also monitors concurrent integrated data to detect potentially high risk or high cost events in claims and automatically alert the appropriate persons.

 

Technology in Workers’ Comp—It’s Not Just for Documenting Anymore

by Karen Wolfe

Sweeping changes underway

Multiple articles have been published recently warning of sweeping changes impacting the Workers’ Comp industry. In an article entitled, Take Time for Technology, Steve Penman, COO at Sedgwick states, “Workers’ compensation is a data intensive system and it remains a challenge for virtually all employers. Increasing regulations, rising medical costs, and the uncertainty posed by healthcare reform continue to make this a formidable issue on all fronts. Technology is having a profound influence on the way organizations are managing their workers’ compensation programs.”[1] Yet, many organizations continue to do business as usual rather than embrace technology to understand and effectively manage through the quickly evolving business scene.

Beyond storage headaches

Payers in Workers’ Comp have long used computer technology to manage bill payments and document actions or events associated with claims. The result after many years of computerization is the vast quantity of data. However, little has been done in the industry to leverage that data to make it a viable decision support tool rather than just a storage headache. Little has been done to convert the data into a working tool that can impact claim process and outcomes.

Obama Care impact

In another recent article, Is your workers’ compensation technology platform readyfor healthcare reform? Mike Allen asks, “Is your workers’ compensation technology platform ready for healthcare reform?”[2] Allen offers a litany of initiatives taking place before our eyes in general healthcare.  He continues, “No doubt there are many opportunities to leverage the technologies implemented as part of new American medical model to improve treatment of injured workers.  What steps are you taking to make this happen?”

In yet another article entitled, Affordable Care Act of 2010 - Workers' Compensation Community, Take Heed![3] Todd Brown, EK Health's Director of Bill Review, states “The Affordable Care Act of 2010 in section 10109 gave authority to the Secretary of HEW to periodically review and determine whether or not Property and Casualty including workers’ compensation insurance should be brought up under the HIPAA umbrella. The act requires that the consideration for inclusion of Property and Causality under HIPAA be reviewed every three years.” In other words, Workers’ Comp payers may be quickly swept into the Obama Care technology surge at any time.

Heads-up!

The warnings are well-founded and clear. To manage change, the use of technology is increasingly important for the Workers’ Comp industry. Unfortunately, the industry is already significantly behind others. The Affordable Care Act (Obama Care) is driving the rush to technology in general healthcare and it will significantly impact Workers’ Comp whether or not it is formally included in the Act. Moreover, the greatest challenge to Workers’ Comp payers is not gathering more data. It is changing the way technology is applied to the data to make it a powerful tool.

New uses for technology

The use of technology must move beyond traditional computerized documentation and reporting. To their credit, some Workers’ Comp organizations have successfully applied predictive modeling techniques to the data to derive important knowledge about potential risk. But intelligence must be linked to operations through technology to make it actionable.

Integrated platforms

The major thrust in general healthcare technology in response to Obama Care is to significantly improve quality of medical care while controlling costs.  Platforms that integrate patients’ medical records from hospitals, laboratories, doctors’ offices, and ancillary providers are in place or well underway.

In Workers’ Comp, integrating the data from all sources associated with a claim is crucial. Bill review, claims, pharmacy, medical case management, and utilization review systems should be integrated at the claim level to gain the total picture of the claim at any point. In other words, documentation must continue, it must improve in accuracy, and the information must be integrated across the claim.

Decision support

Workers’ Comp data must also be re-presented to the business units for real time decision support. Claims and medical professionals should be able to access current comprehensive claim information to make decisions about best doctors and other factors pertinent to quality and cost management.

Data made a working tool

Additionally, the data in Workers’ Comp must be translated to make it a work-in-progress tool. The integrated data from all sources in Workers’ Comp should be monitored continually and concurrently using technology to identify conditions in claims that portend risk and cost. Monitoring historic and current claim data continuously and applying rules for alerts and interventions will improve quality of care and outcomes while automatically documenting the process. Such is the nature of the new technology.

Integrated claim data is monitored electronically to uncover conditions identified in predictive modeling, industry research, and gleaned from the wisdom of experienced professionals. When such conditions in a claim are identified, technology is used to automatically notify the appropriate person to intervene. Early, knowledgeable intervention avoids complexity and results in quality and improved outcomes while costs are controlled.

Better late…?

The technology imperative is urgent and clear for Workers’ Comp. “Better late than never” does not apply because the impact in underway. Never is not an option!

Ms. Wolfe is president and CEO of MedMetrics® that offers technology and analytics designed to strengthen medical and cost management methods in Workers’ Comp. MedMetrics' suite of technical services and online power apps offer payers, managed care service providers and provider networks a quick and affordable path to cutting edge technology that recharges managed care. For questions, contact karenwolfe@medmetrics.org

 

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[1] Penman, S. Take Time for Technology.  WorkCompWire  May 6, 2013 http://www.workcompwire.com/2013/05/steve-penman-take-time-for-technology/

[2] http://michaelgallen.wordpress.com/2013/05/07/is-your-workers-compensation-technology-platform-ready-for-healthcare-reform/

[3] http://www.ekhealth.com/v-2012/-june-2012/affordable-care-act-of-2010-workers-compensation-community-take-heed