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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, September 22, 2015

Three Little Words That Spell Medical Management

by Karen Wolfe

Are your Workers’ Compensation medical doctors treating injured workers from a PO Box? That may sound ludicrous, but most Workers’ Compensation data suggests just that. The rendering physician’s address is a PO Box.

In the past, documenting only the provider’s mailing address was acceptable because provider demographic data was used exclusively to pay bills and file 1099’s, requiring only a mailing address and tax ID. But now provider data importance has risen to a much higher level.

Today medical provider demographic data is used for much more than paying bills. Its impact on monitoring, measuring, and managing provider performance is profound. Medical provider performance data is scrutinized and analyzed to determine medical performance as it relates to claim cost and outcome. As a result, the quality of the data is crucial.

Three little data elements 
Accurate analysis of provider performance relies on the data—complete data. Rendering physicians must be documented on the bill so that their performance is accurately tied to the correct injured worker and claim in the data. Including the 1) treating physician’s name, 2) physical location, and 3) NPI number of the rendering provider on each bill lets analytics tell us who are the best and why. When those three little data elements are missing, also missing is any useful information for medical management.

All doctors are not equal
When the data contains group or facility demographics without the rendering physician’s name, the actual treating physician cannot be linked to the claim. Performance cannot be logically averaged among all the providers in the group. Obviously, not every treating provider is equally gifted or competent.

The HCFA (Health Care Finance Administration) standardized form has a box to document the rendering provider’s name and NPI (National Provider Identification). Where is it?

Lost in space
One possible reason for missing treating provider name is the name of the provider is documented on the billing form but is not captured in the OCR (optical character recognition) process. OCR is the process whereby the data on the bill is translated to a digital form. Even when bills are submitted electronically, that data element, while present, may not be forwarded.

Follow the box
The handoff from the digital bill is usually to a bill review service that analyzes the appropriateness of the charges and passes its conclusions on to the payer. Rarely is all the information from the HCFA billing form passed on to the payer. The provider information that is handed off may be just the billing address and tax ID. Retrieving definitive provider demographics might be a simple matter of requesting it!

Old habits
Sometimes omitting the name and NPI of the rendering physician occurs simply because it has always been done that way. No one has changed the procedure. That behavior can be easily corrected by asking for it be completed on the form and passed on to the payer. Nevertheless, the reason accurate data is missing may be more sinister.

CMS requires the rendering physician name and NPI number on bills submitted to Medicaid and Medicare. CMS simply withholds payment on bills without that information. But those standards are not applied in Workers’ Compensation. The frequent result is bad or misleading data, but it can be even worse.

Business strategy
Unfortunately, omitting the name and NPI of the rendering physician is sometimes deliberate. This could be strategic or actual fraud. Some large multi-specialty medical groups and multi-location practices deliberately omit such information because they want the anonymity for their individual practitioners. They want to avoid measurement of their providers’ performance. They do not want individuals identified, not even by the location in which they practice. All the providers in the group treat from a PO Box and under the group NPI number.

Billing Fraud
Some providers deliberately obfuscate the data so they can stay under the radar to overbill. They submit different addresses and even different NPI numbers on their bills. The practice is clearly fraudulent because CMS (Centers for Medicare and Medicaid Services) expects that one physician or other medical provider is assigned one NPI. Providers who commit fraud also circumvent CMS.

The solution
Regardless of the reason for bad medical provider data, payers can correct the problem by demanding more. Often it is as simple as asking their bill review service for more complete data. Farther upstream, it might be as simple as requiring all providers in a network include the name and NPI of the actual treating physician on the HCFA billing form.

The three little words
One easy shortcut to powerful medical management is insisting on complete and accurate data so it can be analyzed for critical knowledge. All it requires is the 1) rendering physician’s name, 2) physical location, and 3) NPI number with every bill. With that information, the best and worst providers can be identified and the fraudulent ones exposed.

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 link analytics to operations, thereby making them actionable. MedMetrics scores medical provider performance and sends electronic alerts as appropriate. karenwolfe@medmetrics.org