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.