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The MedMetrics blog provides comments and insights regarding the world of Workers’ Compensation, principally, issues that are medically-related. The blog offers viewpoints regarding issues affecting the industry written by persons who have long experience in the industry. Our intent is to offer additional fabric, perspective, and hopefully, inspiration to our readers.

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Tuesday, July 26, 2011

Want to know how serious an injury is?

Wouldn’t it be great to know how medically serious an injury is without calling the doctor? Automatically receiving an injury severity score is an invaluable decision support tool for many reasons, but especially for setting reserves and applying resources such as medical case management. Until now, such knowledge has been elusive because it necessarily involves talking directly with the doctor. Injury severity is a medical matter, but medical data analysis is more readily accessible.

Injury severity drives cost
The severity of physical injury is central to claim cost and complexity. The medical seriousness of the injury drives not only the cost of a claim, but indemnity costs, claim duration, and often legal involvement. Measuring and predicting these costs is difficult, but a necessary business requirement. The process relies on solid information.

Obviously, the more serious the injury, the more medical services will be required. Medical services are costly. Regardless of other factors, injury severity is the core component of claim cost. Key decisions rest on how serious the injury is, but measuring severity has been elusive until now.

Predicting costs
Predictive modeling is a valuable tool in addressing the end question of claim cost. It provides insight into future costs based on historic data regarding similar cases. Analyzing historical data can suggest the future when similar circumstances occur in a claim. Nevertheless, another, easier and less expensive way to gain future cost insight is through injury severity scoring.

Scoring Injury Severity
MedMetrics assigns an injury severity score to diagnoses found in medical bills. Bills, usually via bill review data, are monitored electronically throughout the claim, beginning at the onset. When the score reaches a predetermined level, MedMetrics informs its client. The score represents the seriousness of an injury taking into consideration all the claimant’s diagnoses plus an age factor.

Medical diagnoses are the way doctors describe medical conditions. The treating doctor uses ICD-9 codes, a standardized system to describe claimants’ injuries and other conditions. While many factors can contribute to claim complexity, risk, and cost, a highly significant indicator of claim risk is the severity of the injury.

Injury Severity Predictive Score is MedMetrics proprietary methodology for assigning scores to diagnoses portrayed in billing or bill review data. The data are continually updated and electronically monitored to track additions and changes in the diagnostic picture. Total diagnostic scores for a claim are calculated for the accumulated diagnoses and MedMetrics client organization is notified electronically when the score exceeds a specified level.

Elements of injury severity
Research has demonstrated what many professionals have long known. Comorbidity adds to claim complexity and cost. Comorbidity means the claimant has other medical conditions in addition to the workplace injury defined in a claim. For instance, the claimant might also be diabetic or have a cardiac condition. These additional medical conditions can have an exponentially negative effect on recovery. When described by a diagnosis in the data, comorbidity is also considered in MedMetrics severity analysis.

Research has also shown that age impacts claim complexity and cost. MedMetrics also weighs the claimant’s age in its injury severity score algorithm.

MedMetrics analysis of hundreds of thousands of claims reveals another important and probably well-known fact: diagnoses in claims tend to accrue and migrate over the course of a claim. Consequently, it is important to score injury severity at claim outset and also continuously throughout the course of a claim. Claims that begin as Medical Only often insidiously creep into much more menacing levels without notice. MedMetrics addresses this by continuously monitoring the data, scoring and reporting findings to its clients.

Timely knowledge saves money
The medical portion of Workers’ Compensation claims now accounts for 60% of claim costs, therefore, medical analytics is now an even more critical component of claim management. MedMetrics develops medical analytic tools designed to recharge existing managed care initiatives which have fallen short in controlling medical costs.

MedMetrics clients benefit from its Injury Severity Predictive Score by setting reserves more accurately at the outset of a claim, and also by adjusting reserves in a timely manner over the course of the claim. Moreover, proactive medical management initiatives are launched earlier to step ahead of further financial and claimant damage, thereby improving outcomes and saving dollars.

Calling the doctor to determine injury severity is an unreliable and frustrating approach. MedMetrics Injury Severity Predictive Score provides immediate, consistent intelligence based on medical analytics.
Knowledge is the best cost management tool!
Read More MedMetrics Injury Severity Predictive Score

1 ICD is the abbreviation widely used for the International Statistical Classification of Diseases and Related Health Problems. ICD-9 refers to the ICD version currently in use. The ICD-10 version will be in required use in October, 2013