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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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Wednesday, April 24, 2013

EVEN MORE Tips for Building a WC Medical Provider A Team

by Karen Wolfe

Significant dollars can be saved by getting injured workers to the best doctor. Evidence supporting this fact is the mounting Workers’ Comp industry research clearly stating treatment by well-informed and well-intentioned medical doctors results in lower costs and better outcomes.

Belaboring a point
As repeatedly stated in this series, many doctors in networks are not well-informed or well-intentioned regarding management of Workers’ Comp claimants. As a consequence of their involvement, claim results are lacking, costs are high, and outcomes are precarious. This series of articles, “Tips for Building a WC Medical Provider A Team”, is intended to describe how to identify doctors who know the ropes in Workers’ Comp using indicators in the data.[1]

Beyond the indicators discussed in the previous articles in this series, additional salient data elements are available in the data to broaden the scope of medical management evaluation. What makes this approach so feasible is that solid knowledge of who demonstrates best practices is revealed in the data. However, to find that knowledge, some operational processes and the data itself need refinement. Access to the data and its quality must be addressed.

Getting to the knowledge in the data
Regrettably, access to the data by the right persons is often a problem. Those who know best what to look for, the business and clinical professionals, cannot use current data in a practical, work-in-progress manner. The reasons are many.

First, relevant data resides in separate databases that must be integrated to understand all activity in a claim. Moreover, in most organizations, provider records are simply inaccurate and incomplete. Until now, the need for them was for reimbursement purposes only, not performance evaluation. Yet another problem is that provider records are frequently duplicated in the data, making it difficult to accurately evaluate individual medical providers’ treatment process and results.

Data silos
Critical data for analyzing medical provider performance is still fragmented in most payer organizations. While people have long complained about data silos in Workers’ Comp, little has been done to correct the problem. If anything, data sources have increased. Pharmacy databases have been added, for instance. Yet the databases are not integrated on the claim level, thereby portraying the claim as a whole. Data silos too often lead those who are attempting to evaluate provider performance to rely on a single data source.

Single source analysis
Relying on one source of provider performance data is foolhardy. Nevertheless, bill review data is often used, but by itself is inadequate to tell the whole story. Claims level data is also critical to weigh return to work data, indemnity payments, and legal involvement associated with claims and ultimately, to individual doctors. None of these data items are found in bill review data, yet these are essential to complete analysis of provider performance. Because in Workers’ Comp, doctors drive the non-medical claim costs as well as the direct medical costs, these data items are essential to evaluating the quality of their performance.

Data quality
The problem of data quality can be even stickier. Traditionally, medical provider records are kept in the claims database, along with records of other vendors for payment purposes. All that is needed for bill payment is a name, address, and tax ID. Unfortunately, the same provider is frequently added to the database when a new bill is received. This outdated database management practice leads to slightly different records added for the same provider.

Data optimization
To evaluate medical provider performance, more information about individual providers is needed such as accurate physical addresses. PO Boxes will suffice for mailing checks, but injured workers cannot be sent there for treatment.

Merge duplicate records
Tax ID’s are still important for reimbursement and 1099 purposes, but often multiple doctors are represented by one Tax ID. To evaluate provider performance, individuals must be differentiated in the data. State medical license numbers and NPI (National Provider Identification) numbers are needed. Frankly, some doctors deliberately obfuscate the data by operating under multiple Tax ID’s and multiple NPI numbers. Consequently, provider records must be merged, scrubbed, and optimized before any analysis can begin.

What to do
For most organizations, choosing best practice providers by analyzing the data is challenged by the shortage of accurate and complete data. Therefore, those wanting to control costs by choosing the best providers should obtain provider performance analysis and scoring from a specialty third party, one that is expert in data integration from multiple sources, as well as provider data scrubbing and optimization.

When behaviors of doctors are analyzed using clean, integrated data, the well-informed and well-intentioned in Workers’ Comp will rise to the surface.

Karen  Wolfe is the founder and president of MedMetrics®, LLC. MedMetrics specializes in medical provider data integration, optimization, and analysis of performance for Workers' Comp. Additionally, MedMetrics leverages analytics and technology to provide powerful “apps” online that strengthen medical management for effective medical cost control. Visit MedMetrics to learn more or contact karenwolfe@medmetrics.org

Monday, April 8, 2013

More Tips for Building a WC Medical Provider ”A Team”

by Karen Wolfe

Our recent article, Tips for Building a WC Medical Provider ”A Team” described how to identify and avoid medical doctors in Workers’ Comp who over-prescribe Opioid drugs. The same article addresses those medical doctors who dispense medications directly from their offices. Both situations have proven costly for payer organizations and dangerous for injured workers These providers should be identified and avoided. But there is more to the story.

Find the right doctors
Industry research and plain common sense lead one to conclude that finding the right doctors to treat and medically manage injured workers is essential. Doctors directly impact both cost and outcome of claims. Consequently, it is imperative that organizations take action to find the right doctors and direct care to them, while avoiding the costly providers. This series of articles is designed to explain how to build a Workers’ Comp ”A Team” of medical doctors and other providers. Doing so will dramatically impact the cost and improve the outcomes of claims.

Obstacles to doing the right thing
Over the past two years there was a fair amount of chatter about developing outcome-based networks or quality networks. Of late, however, the talk has subsided. The reversal of enthusiasm may be driven by assumptions the process is extraordinarily difficult and costly. It need not be.

One obstacle to finding the right doctors is the way data is fragmented within the Workers’ Comp industry, often referred to as data silos. The first critical step is to collect and integrate the appropriate data. Many find that step a daunting. Yet, finding the right doctors, meaning those who provide excellent medical care while considering the ramifications for both the employees and employers, is quite doable and affordable for those willing to pursue it.

This series of “A Team” articles describes several indicators of provider performance that can be detected in the data and utilized to score medical provider performance in the context of Workers’ Comp. Decisions regarding providers, especially medical doctors, can and should be based on objective intelligence.

Frequency and duration
While Opioid prescribing behavior and selling drugs directly to patients are huge red flags, other factors should be drawn from the data and analyzed to evaluate provider performance. Not all poor providers will fall into these two categories. Building an ”A Team” should also include analysis of specific practice patterns. Next on the list of indicators are frequency and duration of medical services. These practice patterns are fairly easy to identify in the data.

Frequency of medical services and duration of medical treatment are easy calculations that can be found in billing or bill review data. Every time a claimant is treated, the provider sends a bill that includes the date of service, what service was delivered, the fees charged, and the standardized CPT codes (Current Procedural Terminology published and owned by the American Medical Association) that represent the service(s) provided.

The bill, also a standardized form, also includes diagnostic codes (ICD-9’s), is a veritable treasure trove of information. Nevertheless, the bill does not tell the whole story because outcome is critical to measuring provider performance. Still, the bill is a solid beginning.

Discounts versus volume
Unfortunately, the way medical networks in Workers’ Comp are traditionally and currently structured, doctors are encouraged to increase medical service frequency and duration. Their service fees are discounted by networks on a unit basis, meaning individual elements of a visit or service are discounted, rather than the visit or service as a whole. The discounts are reported as savings, but that is very misleading.

To offset the discounts and increase the billed amount, providers need only increase the units of service delivered within a visit or service. One way to identify those who are exploiting this tactic is to compare frequency and duration of medical services by injury type across all providers in the state. Comparisons should always be within a state or jurisdiction and are best made between physicians of the same specialty. When filtering for state, injury type, and specialty, providers are more fairly and accurately judged. Importantly, the outliers are objectively singled out, at least on those two counts.

More to the story
Many additional indicators of provider performance that can be found in the data should be analyzed when evaluating medical doctor and other provider performance. Watch for those in future articles in this series about how to build a WC medical provider “A Team”.

MedMetrics specializes in medical provider performance analytics and offers easy search tools to find them quickly online. We analyze your data for you to score medical providers performance based on multiple indicators. Visit MedMetrics to learn about MedMetrics’ Provider Performance Suite of information services, including detailed Provider Performance Analysis and Master Provider Index, a quick search for best practice providers by specialty and geo-zip. For questions, contact karenwolfe@medmetrics.org.