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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, March 25, 2014

Make Your Data a Work-in-Process Knowledge Tool

by Karen Wolfe

Heard recently, “Our organization has lots of analytics, but we really don’t know what to do with them.” This is a common dilemma. Analytics (data analysis) are abundant, they are presented in annual reports, and published in colorful graphics. But too often the effort ends there. Nice information, but what can be done with it? How does it change operations and outcomes?

Obviously, the basic ingredient for analytics is data. After that comes skill, ingenuity, and creativity. Nevertheless, without data, there is no business knowledge, business intelligence, or much in the way of analytics.  Fortunately, the last thirty years have been primarily devoted to data gathering.

Data evolution
Over that time, all industries have evolved through several phases in data collection and management. Main frame and mini-computers produced data and with the inception of the PC in the 80’s, data gathering was the business of everyone. DOS systems were clumsy in the early PC years and there were significant restrictions to screen real estate and data volume. Recall the Y2K debacle caused by limiting year data to two characters.

Happily for the data gathering effort, progress in technology has been rapid. Advancement was enhanced first by local and wide area networks, then by the Internet along with ever more powerful hardware. Amazingly, wireless smart phones today are more powerful computers than were the PC’s of the 80’s and 90’s. Data gathering has been successful.

Big data
Now we have truckloads of data, often referred to as Big Data. People are trying to figure out how to handle it. In fact, a whole new industry is developing around managing the huge volumes of data. Once Big Data is corralled, analytic possibilities are endless.

The Workers’ Compensation industry has also collected enormous volumes of data. Yet, little has been done in the industry to actualize the analytics to reduce costs and improve outcomes.

Imbed analytic intelligence
The best way to apply analytics in Workers’ Compensation is to create ways to translate and deliver the intelligence to the operational front lines, to those who make critical decisions daily. Knowledge derived from analytics cannot change processes or outcomes unless it is imbedded into the work  of adjusters, medical case managers, and others who make claims decisions.

Consulting graphics for guidance is cumbersome, interpretation is uneven or unreliable, and the effects cannot be verified.  Therefore, the intelligence must be made easily accessible and specific to individual workers.

Front line decision-makers need online tools designed to easily access interpreted analytics that can direct decisions and actions. Such tools must be designed to target only the issues pertinent to individuals. Information should be specific.

Electronic monitoring
To effectively imbed analytic intelligence into operations, all claims data must be continuously electronically monitored. To link analytic findings to claims, all data must be monitored so the system can identify claims that contain conditions warned by analytics. Then that interpreted information is linked to operations.

Reverse strategy
When predictive modeling is employed as the analytic methodology, certain claims are identified as risky. Instead, all claims should be monitored continuously. By monitoring all claims for events and conditions pre-determined by analytics, no high risk claims can slip through the cracks.

Personnel can be alerted of all claims with risky conditions identified through analytics. At the same time, the analytic delivery system should automatically document itself.

The system that is developed to deliver analytics to operations should automatically self-document, that is, keep its own audit trail to continually document to whom the intelligence was sent, when, and why. Furthermore, the system can then be expanded to document what action is taken based on the information delivered.

Without self-documentation, the analytic delivery system has no authenticity. Moreover, those who receive the information cannot be held accountable for whether or how they acted on it. When the system automatically self-documents, those who have received the information can be held accountable or commended for their part. Self-documenting systems also create Additionality.

Additionality is the extent to which a new input adds to the existing inputs without replacing them and results in something greater. When the analytic delivery system automatically self-documents guidance and actions, a new layer of information is created. Analytic intelligence is linked to claims data and layered with directed action documentation.

A system that is self-documenting can also self-verify, meaning results of delivering analytics to operations can be measured. Claim conditions and costs can be measured with and without the impact of the analytic delivery system. Further analyses can be executed to measure what analytic intelligence is most effective, in what form, and importantly, what action responses generate best results.

The analytic delivery system monitors all claims data, identifies claims that match analytic intelligence, and imbeds the interpreted information in operations. The data has become a work-in-process knowledge tool while analytics are linked directly to outcomes.

Karen Wolfe is the founder and President of MedMetrics, LLC, a Workers’ Compensation analytics company. MedMetrics offers online apps that link analytics to operations, thereby making them self-documenting, verifiable, and actionable. karenwolfe@medmetrics.org





Thursday, March 6, 2014

The Secret Power of the NPI

by Karen Wolfe

This is a David and Goliath story. It’s about how the seemingly insignificant NPI can fight medical fraud and positively impact effective medical management. Most in Workers’ Compensation have either not heard of the NPI or consider it irrelevant. Yet the NPI is a powerful factor in medical management and medical fraud detection.

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. The NPI is required for billing Medicare and Medicaid. Individuals and groups must include their NPI on bills submitted. Without it, they are simply not reimbursed.

If the NPI is required for Medicare and Medicaid reimbursement, it follows that most, probably all, medical doctors have a NPI number from CMS. The problem is that most Workers’ Compensation payers do not ask for the NPI, do not require it, and when the NPI is available, do not record it.

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.

Distinguish individuals
The ability to parse individuals from groups in the data is essential to fair and adequate performance analysis. Individual differences evidenced in the data can be distinguished, even within a group. This is essential to creating quality preferred provider lists and networks. It is also indispensable for leveraging the data to create a teaching platform for improving provider performance in Workers’ Compesnation.

Physicians should be given the opportunity to see themselves portrayed in graphic reports comparing their performance to others. Like everyone else, they want to look good. They are high achievers. The graphic presentations are targets or guides for improvement when followed with progressive reports.

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

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

Specialties are important so that treating doctors are compared to 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 undetected duplicate billing. Moreover, systems cannot recognize overall performance for the individual. Their performance is fragmented across various 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, the reality is the opposite. 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.

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 critical.

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 based on the relevant performance factors. Correct NPI numbers included on medical bills are essential.

What to do
Workers’ Compensation payers must require a correct NPI number on all medical bills. This is not an outrageous demand and does not add to costs. However, it will take attention and initiative on the part of those involved. 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.

For more information on this related topic, view, “Why Poor Data Quality is Not an IT Problem”.

Karen Wolfe is the founder and President of MedMetrics, LLC, an Internet-based Workers’ Compensation analytics company. MedMetrics offers online apps that link analytics to operations, thereby making them actionable. karenwolfe@medmetrics.org