Seek Counsel from the Data for WC Medical Management

by Karen Wolfe

“Given the avalanche of information that has become available to ­businesses over the past several years, data-driven decision-making (DDDM), the practice of basing business decisions on data analysis rather than intuition, has become a critical tool to help organizations reduce risk, avoid costly mistakes and take advantage of opportunities.”[1] In Workers’ Comp, there are scores of reasons to seek council from the data.

 

 

Predictive Analytics

Nevertheless, raw data must be analyzed to be useful. Predictive analytics looks for trends and patterns in historic data. Such analysis can predict probable ultimate medical costs in new claims when similar conditions occur. Predictive analytics uncovers cost drivers that might include organizational traits, timeliness of action, or specific serious injuries. Moreover, analysis of past performance by medical doctors offers decision support for selecting best providers going forward. These are only a few examples.

 

Data-driven decision-making in medical management is a powerful tool, providing knowledge and guidance for those who make direction-changing decisions in real time. Yet, all data-driven decision-making efforts are dependent on the quality and limitations of the data used.[2] Those relying on information provided by analytics must be confident the data is accurate and complete.

 

Data reliability

If data quality is inconsistent, incomplete, or has errors, conclusions derived from it cannot be trusted by those who would rely on it for decision-making. For instance, medical provider performance analysis relies heavily on provider data accuracy. Missing data items such as NPI (National Provider Identifier from CMS, Centers for Medicare and Medicaid Services) prevents accurate individual or entity identification. Individual providers cannot be accurately distinguished. Still other data quality issues are concerning.

 

Misspelling addresses creates duplicate entities in the data, thereby skewing analysis. Some of the supporting data is attributed to a provider name and address spelled one way and the rest of the data is attributed to another that is spelled differently, but is actually the same person. Separate files for the same provider prevent fair analysis of performance because the data for both is incomplete.

 

Similarly, data omissions lead to difficulties in interpreting the data. Missing key data elements such as medical provider specialty can make the data ineffectual for evaluating performance.

 

Errors are often caused by manual data entry. Years ago, typists competed for jobs based on how fast they could type a paragraph without errors. Today’s data entry personnel should be evaluated on accuracy, as well. Make accuracy a performance measurement.

 

Data quality

Often data is transmitted to an organization from outside entities. Hard copy forms are translated to digital formats using optical character recognition, OCR. The organization wanting to analyze the data for use in decision-making did not create the data, but it should not fall victim to it. The organization should select critical data elements and proceed to correct them in the data. The resources required are easily justified by the end game: applying analytics to create accurate decision support.

 

Fix the flaws

Data-driven decision-making in WC medical management is powerful. Frontline professionals and other stakeholders are made accurate and efficient. That means costly mistakes and re-dos are avoided. Moreover, interventions and actions are timely, all resulting in significant cost savings for the organization. If the data producing knowledge and decision support is not accurate and complete, fix it!

Karen Wolfe is the founder and President of MedMetrics®, LLC, a Workers’ Compensation, predictive analytics-informed medical loss management and technical services company. MedMetrics offers intelligent medical management systems that link analytics to operations, thereby making insights actionable and the results measureable. karenwolfe@medmetrics.org

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[1] Heires, K. Flaws in the Data. Risk Management. April 3, 2017.

[2] Ibid.

The Secret Power of the NPI

by Karen Wolfe

This is a David and Goliath story. It’s about how the seemingly insignificant NPI code can fight medical fraud and positively impact effective Workers’ Comp medical management. Many in the industry consider the NPI irrelevant. Yet it is a powerful factor in medical management and medical fraud detection.

The NPI
The NPI is the National Provider Identifier assigned by CMS (Centers for Medicare and Medicaid) to individual medical providers and organizations that deliver medical services. It is required on bills for Medicare and Medicaid. Individual medical providers and medical groups must include their NPI on all bills submitted. 

If the NPI is required for Medicare and Medicaid reimbursement, it follows probably all medical doctors have a NPI number from CMS that uniquely identifies them. The problem is that many Workers’ Compensation payers do not ask for the NPI, do not require it, and even when the NPI is available, do not record it or transfer it to the next level. 

State requirement
Some, but not all states require the NPI on Workers’ Comp bills. However, even if it is added to the bill, it often goes no further.

Why bother?
The value of the NPI is that it uniquely identifies individual medical doctors. It carves out individual treating physicians in groups, organizations and facilities. Without the NPI associated with individuals, all those in a group are lumped together under the organization’s NPI or, worse, the entity’s Tax ID. This matters. The assumption is all members of the group practice exactly the same. But they do not.

Distinguish individuals
The ability to parse individuals from groups in the data is essential to fair performance analysis. Individual differences evidenced in the data can be distinguished, even when associated with a group with individual NPI’s. This is essential to creating quality preferred provider networks and directories. It is also indispensable for leveraging the data to create a teaching platform for improving provider performance in Workers’ Compensation.

Behavior change
Physicians should be given the opportunity to see themselves portrayed in graphic reports comparing their performance to others like them. By nature, they are high achievers and they want to show well. The graphic presentations are targets or guides for improvement. 

Simply paying attention to a treating doctor in this objective manner will result in behavior change!  Using the comparative data is invaluable, however, success depends on accurately identifying individuals in the data using the individual NPI.

Specialties
Another valuable use of the NPI is to assign medical specialties to individuals. Professional specialties can be obtained electronically from CMS databases using the NPI. Specialty is yet another data element missing in much of the bill review and claim system data. If the NPI number is available, specialties can be derived. 

Specialties are important so that treating doctors are grouped with other doctors who are similarly prepared and licensed. The argument from doctors that they only treat the more difficult cases is nullified when they are compared only to others in their specialty. The best example is pain management specialists who really do treat the more difficult cases. Their performance should always be compared to other pain specialists.

Fraud by NPI
Unfortunately, there are those who twist the positive aspects of the NPI for fraudulent purposes. Close examination of the data reveals less reputable medical doctors and other providers obtain multiple NPI numbers, using them in different locations or situations to deliberately obfuscate the data.

When multiple NPI numbers are fraudulently used, the door is open to undetectable duplicate billing. Systems cannot recognize overall performance for the individual because their performance is fragmented across multiple NPI’s. In order to accurately analyze performance for an individual, all treatment incidences should be combined for one practitioner, thereby creating a critical mass of data for that individual.

Much ado
While some will think the focus on NPI is much ado about nothing, it is not. Individual NPI numbers on all medical bills is essential. Payers should insist on it. In fact, reimbursement should be withheld until the correct information is included on the bill as is done in Medicare. 

Impact on medical management
Treating doctors not only drive direct medical costs, but also indemnity costs, return to work, and disability ratings at the end of the claim. They can also influence legal involvement. Consequently, finding the best doctors and avoiding the bad ones is crucial. 

The way to determine who should be included in quality medical provider networks is to analyze past performance based on the data. The only way to accurately analyze performance is to identify individual treating doctors in the data and evaluate their performance across multiple claims based on the relevant performance factors. Correct NPI numbers included on medical bills are essential.

What to do
Workers’ Compensation payers must require correct individual NPI numbers on all medical bills. This is not an outrageous demand and does not add to costs. However, it does require attention to the matter. The benefits are too great to miss this simple, yet powerful opportunity.

The simple little NPI is a powerful element in Workers’ Compensation medical management. It is the David that can effectively and affordably fight the medical fraud Goliath.

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

 

How to Manage Medical Provider Networks in WC

by Karen Wolfe

David DePaolo posted a response to the CWCI’s[1] recent study of the use of networks in California and their related savings entitled “MPN Means Managed”.[2] The CWCI study compares three network formats in California since the year 2000: PPO’s 2000-2002, the transitions years from PPO’s to MPN’s, 2003-2008, and MPN”s 2009-2011.  “While the use of the networks to medically manage treatment of work-related injuries has fulfilled the legislative intent to encourage network use, over time the MPN’s have not lowered the cost of medical care.”[3]

DePaolo says medical cost savings is only part of the picture. MPN’s need to be managed because the medical impact on other aspects of claims such as disability, indemnity, return to work, and other factors is significant.


So true. But if networks mean managed—the question is how?


Networks can be managed only by evaluating and monitoring individual performance.


Network—a sum of its parts
A network is the sum of its parts, the parts being the physicians and other medical providers in the network. A network cannot be managed as a whole. Each individual medical provider acts independently and with differing results. Moreover, each provider, even within groups or facilities, acts independently. Consequently, they must be evaluated and managed individually.


Since networks began in Workers’ Comp back in the 1980’s, their rationale has been discounting services to create savings. Units of service are discounted and portrayed to payers as savings. The assumption is that all medical providers are equal and all offer equal, quality medical care. But no one checked.


Evaluating provider performance
No one checked because it was easier to claim savings through discounts than to evaluate the performance of individual medical providers in the network. Evaluating medical performance is especially tricky in Workers’ Compensation because in addition to cost and medical treatment factors there are elements unique to the industry that must be considered. Indicators of quality performance are many and varied and they can be found in the data.


Quality indicators 
Quality indicators include medical treatment indicators such as direct medical costs, prescriptions, surgery, hospitalization, and medical procedures analyzed by injury type. Non-medical performance indicators that are influenced by medical providers include return to work, indemnity costs, and legal involvement, along with ultimate outcome indicators such as claim closure and disability ratings at the close of the claim.


The way to manage networks is to Identify the best providers and monitor their performance.


Objective evaluation 
The data necessary to evaluate medical provider performance, particularly physician performance, can be found in bill review data, claims system data, pharmacy data, and the utilization review system. Unfortunately, the data resides in different silos, but by combining the data from these sources at the claim level, individual provider performance can be measured. 

Because the data reflects actual treatment and events, it is objective and quantifiable. Select quality indicators in the data, adjust for case mix, and keep them constant over time.

Swapping discounts for quality
Medical costs have increased to 60% of claim costs, calling into question the benefit of network discounts. The truth is medical providers long ago learned how to overcome the cost of discounts by increasing treatment frequency and claim duration, as well as prescribing expensive procedures, among other tactics. Discounts on more looks like more savings.


Going forward, the major hurdle in managing networks effectively is to de-emphasize discounts, while underscoring and rewarding quality performance. In order to make that financially feasible for the networks, a different approach to discounting should be entertained. For instance, those providers who rate highest in quality performance would be excused from discounts. Likewise, those performing the worst would be discounted the most.



Managing the network
To manage a network, the performance of individuals within it must be evaluated and monitored continually. No longer does it suffice to sign up providers for the network and walk away. When individual provider ratings slip, action should be taken. Moreover, let providers know they are being monitored. It has been proven that observed performance leads to behavior change.

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 super-charge medical management by linking analytics to operations, thereby making them actionable. MedMetrics also analyzes and scores medical provider performance. karenwolfe@medmetrics.org

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[1] California Workers’ Compensation Institute. http://www.cwci.org/research.html

[2] D. DePaolo. MPN Means Managed. DePaolo’s Work Comp World. June 10, 2015. https://www.workcompcentral.com/depaolo/index/post/1670487372170531417

[3] Ibid.

Data is Your Weapon of Choice

by Karen Wolfe

Managing the medical portion of Workers’ Compensation claims can be daunting. The variables are endless. Vendors of all types, extraneous and overlapping events, and even participant attitudes can impact the cost equation. Moreover, injured employee recovery lies in the balance, making the effort essential.

Longstanding methods

Current managed care initiatives have long been in play. They include bill review, utilization review, discounted medical provider networks, medical case management, fee schedules, guidelines, and peer review. That should do the job, but apparently not.

The medical portion of claims continues to rise while its portion of overall case cost is also increasing in most states. Medical costs are 60% of case costs, yet in some states, it is approaching 70%. 

The ‘tried and true” methodologies have been in place in Workers’ Compensation for about twenty-five years. Basically, the industry is continuing to follow the same pathways while hoping for different outcomes. Enough said.

Save the baby

This is not to say we should scuttle the strategies in place. Instead, the focus should be on updating and intensifying the existing processes to achieve their intended results.

Workers’ Compensation is an industry replete with transactions that are recorded digitally. First reports of injury, bill review, pharmacy benefit programs, and claims system paying bills and documenting events, all continually contributing to the data mass for each claim. Effectively analyzing that data on a concurrent basis and making the business knowledge available to claims adjusters and other decision makers is a powerful approach to strengthening current systems.

Data is your weapon

Analyzing data and converting it to useful information is the key to enhancing current medical management techniques. Writing reports and analyzing trends cannot impact outcomes. Such measures focus on the past that cannot be changed. Data must be utilized in new ways.

The first prerequisite is getting data-derived information to the front lines quickly. The business units should have access to analyzed information as concurrently as possible. Early information sets the scene for early intervention and resolving problematic situations in claims before they spin out of control.

Continuous data monitoring

Distributing information continuously requires that the data be electronically monitored and analyzed continually, not at the end of the month or quarter. When conditions that portend risk occur, the appropriate person is automatically notified. That might be the claims adjustor, medical case manager, medical director, supervisor, or manager. Importantly, the notified person will follow the organization’s approved procedures, thereby lending structure to the process.

Monitoring data and notifying the right people when indicators in claims point to risk mobilizes proactive medical management. Refer to the article, Early intervention drives better outcomes, but is not really pursued.

Other unique data initiatives can be even more compelling.

Select the best to improve networks

Research in the industry irrefutably shows poorly performing medical providers lead to high cost and poor results. Poorly performing doctors in the Workers’ Compensation context are those who have little understanding of the system or deliberately abuse the system through overutilization. Indicators of such poor performance are readily found in the data.

The data will reveal the poor performers, those who ignore basic Workers’ Compensation needs such as early return to work, as well as those who bleed the system with excessive treatment practices.

Treating doctors essentially cause, influence, or control the significant portion of medical costs. Once the injured worker is in the doctor’s care, opportunities to steer the course with medical management methods nearly disappear. Consequently choosing the right physician at the start is essential.

Directing care

Using data analysis to select the best practice doctors is the way to prevent problems and smoothly lead to the most optimal outcome. In many states this is possible and encouraged. In other states directing care is not allowed. Nevertheless, non-traditional applications of analytics can optimize results.

Behavior modification

When directing care to the best doctors is not possible, the next best option is to change the perpetrating doctors themselves. The fact is, people, and maybe especially doctors, do not like to look bad. Presenting them with analytic representations of their performance compared to others of the same specialty in the state is a powerful behavior change methodology. Those who are outliers will begin to move toward the mean.

Changing medical provider performance is not impossible! When they see themselves graphically compared to others based on the data, the information is indisputable. Of course, they will first attempt to push back. One way they argue is to say they treat only the more serious cases. That could be true.

Pièce de résistance

However, the pièce de résistance is to correct for medical severity in performance analytics, thereby leveling the playing field. Those who treat more serious injuries as evidenced in the data are compared only to others who treat similarly difficult cases.

Adjusting for case risk or severity by diagnosis is how to diminish resistance for poorly performing treating physicians. Graphic presentations of comparative performance cannot be disputed. The fairness is built in.

As the treating provider outliers move toward the performance mean, they may never achieve best-in-class, but their outcomes will gradually improve. They will also be aware of continued surveillance so the impact persists. Positioning data in this way is your weapon of choice for a powerful, yet bloodless medical management solution.

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 super-charge medical management by linking analytics to operations, thereby making them actionable. karenwolfe@medmetrics.org

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FAQ: How to Find the Primary Physician in Claims

by Karen Wolfe

A frequently asked question in Workers’ Compensation medical management is, “How can one determine which is the primary physician in a claim?” The reason for the question is usually an attempt to assign accountability for the outcome of claims. However, the question, if asked slightly differently, can provide much more valuable information.

The wrong question

Whether or not the correct question is asked, gathering information about treating doctors is essential. Knowing all the treating doctors in a claim is important and they can be easily found through analytics (data analysis). However, determining the primary doctor is misleading.

The notion of primary physician suggests assumptions that are inaccurate: that the primary physician has control of a claim. Rarely does one physician have full control. But one physician might have the most influence. Therefore, a more telling question is, “Who is the predominant physician in the claim?”

Predominant physician

The predominant physician in a claim is the one who has had the most influence on claim cost and outcome. That information can also be found in the data.  However, predominance cannot be measured in dollars billed or paid to physicians. Specialists, especially surgeons, will surface using dollars as the identifying metric. Those identified may or may not be the most influential in the course of treatment or outcome. Predominant physicians are the ones who encounter the injured worker most frequently.

Influence and Impact

An indicator of physician predominance in the data is how frequently they were face to face with the injured worker. Frequent encounters with the same physician will significantly influence the course of the claim, leading to positive or negative results. It is one measure of medical provider performance.

The treating physician who is seen more frequently by the injured worker will impact return to work, recovery, and often directly influence whether the claimant seeks litigation. Identify the best physicians using predominance in the claim data as one factor. Rather than directing injured workers to any physician in the network, select the doctors with better results, especially those who have greater influence in claims with positive outcomes.

New networks

Traditional discount networks do not evaluate provider performance regarding claim cost and outcome. Employers and their claims administrators are now undertaking that task and redesigning their networks by carving out the best performers. The only sure way to do that is to examine the data, especially provider performance data measured by multiple indicators. One of the indicators that should be evaluated is physician predominance in claims.

A groundswell is occurring in Workers’ Compensation, a dramatic shift from traditional medical provider discount networks to quality, outcome-based networks. Increasingly more organizations are evaluating their providers in networks and carving out the best-in-class doctors. Creating a “designer” network of the best doctors by analyzing the data guarantees improved claim outcomes.

Karen Wolfe is the founder and president of MedMetrics®, LLC, an Internet-based Workers’ Compensation analytics company. MedMetrics applies analytics and technology to evaluate medical provider performance, to significantly strengthen medical management in Workers’ Compensation, and to link the analytics to operations by means of user apps, thereby making the analytics actionable.