If You Don't Know Where You're Going, You Might Land Somewhere Else

by Karen Wolfe

If you don’t know where you’re going, you might land somewhere else. It may at first seem like a senseless phrase, but research, planning, and goal-setting are important directional steps in both our personal lives and in business. The alternative is to react impulsively as events occur and conditions change following no particular plan or strategy. That sort of seat-of-the-pants approach insures landing off course.

Past is prologue
Even more importantly, without analysis of past performance, organizations will miss opportunities for designed excellence. If you don’t know where you’ve been, you could land somewhere else. Actions might be habit-based and detrimental in this fast-paced world.

Decisions and actions will be miscalculated when they are based on mere recollection of the past. Analyzing and understanding the past using technology tools is the way to gain insights that lead to knowledgeable actions going forward. That means analyzing the past to identify pivotal conditions and develop competitive or profitable responses.
 
Analytics of past performance will notify organizational leaders of conditions that should lead to strategic actions. Alerts are sent to the right persons at the right time regarding current situations with pre-planned initiatives.

However, simply studying the past is not enough. Too many organizations stop at the data analysis stage, missing the opportunity to maximize efficiency, accuracy, and profitability gained through applying analytics-informed insights. The insights gained through analysis should be conveyed to those making daily decisions for the organization. Still, there is a prerequisite to successfully leveraging analytics to inspire intelligent action. 

Spoiler alert
The spoiler for analyzing history to design the future is the organization’s data. Data must be accurate and complete to be reliable and worthy of logical planning based on it. For years the Workers’ Comp industry has focused on and relied upon billing and payment data. Most of it is accurate enough to pay bills, however, in this new age of analytics, gaps in data are obvious and sometimes crippling.
 
For instance, incomplete medical provider data in payer systems can be explained by the fact that in the past only an address and tax ID were necessary to pay a bill. But now analysts are asked to determine which providers are best, particularly for treating and appropriately managing injured workers. Such decisions cannot be made based on an address and tax identifier and making judgements based on inaccurate and incomplete data is perilous. In particular, medical provider data is often too lacking in quality and accuracy to be used in assessing medical quality.

Missing and misleading data
Provider name and address remain critical to performance analysis. However, the address on the bill should be the treatment rendering address rather than a PO Box. Granted, medical providers often list the PO Box because it is the location of accounts receivable, but it is no longer acceptable as the only address submitted with the bill. The rendering address is important to convenience for injured workers and employers, but it also is important in distinguishing individual providers and their practice patterns.

CMS (Centers for Medicare and Medicaid Services) requires the physician NPI (National Provider Identification) on all bills, as do all general health payers. The Workers’ Comp industry has not followed suit but now it must require NPI numbers. The NPI is essential for recognizing individual providers in all their rendering locations found in the data and distinguishing individual providers in group or facility settings.

The NPI is also crucial for assigning medical specialties when that significant data element is missing as it often is. Fortunately, the specialty can be ascertained from the CMS NPI. By insuring the organization’s data includes these few critical data elements, identifying the best medical providers and establishing outcome-based networks can be a straightforward and reliable process.

Take-away
Understanding the past is essential to intelligent development and consistent execution of organizational planning. Analytics relies on accurate and complete data to inform the best business strategies. Moreover, accurate and complete data is the tipping point because without it, the organization will land somewhere else.

Karen Wolfe is the founder and President of MedMetrics®, LLC, a Workers’ Compensation, predictive analytics-informed medical loss management and technical services company. MedMetrics offers intelligent medical management systems that link analytics to operations, thereby making insights actionable and the results measurable. karenwolfe@medmetrics.org

Seek Counsel from the Data for WC Medical Management

by Karen Wolfe

“Given the avalanche of information that has become available to ­businesses over the past several years, data-driven decision-making (DDDM), the practice of basing business decisions on data analysis rather than intuition, has become a critical tool to help organizations reduce risk, avoid costly mistakes and take advantage of opportunities.”[1] In Workers’ Comp, there are scores of reasons to seek council from the data.

 

 

Predictive Analytics

Nevertheless, raw data must be analyzed to be useful. Predictive analytics looks for trends and patterns in historic data. Such analysis can predict probable ultimate medical costs in new claims when similar conditions occur. Predictive analytics uncovers cost drivers that might include organizational traits, timeliness of action, or specific serious injuries. Moreover, analysis of past performance by medical doctors offers decision support for selecting best providers going forward. These are only a few examples.

 

Data-driven decision-making in medical management is a powerful tool, providing knowledge and guidance for those who make direction-changing decisions in real time. Yet, all data-driven decision-making efforts are dependent on the quality and limitations of the data used.[2] Those relying on information provided by analytics must be confident the data is accurate and complete.

 

Data reliability

If data quality is inconsistent, incomplete, or has errors, conclusions derived from it cannot be trusted by those who would rely on it for decision-making. For instance, medical provider performance analysis relies heavily on provider data accuracy. Missing data items such as NPI (National Provider Identifier from CMS, Centers for Medicare and Medicaid Services) prevents accurate individual or entity identification. Individual providers cannot be accurately distinguished. Still other data quality issues are concerning.

 

Misspelling addresses creates duplicate entities in the data, thereby skewing analysis. Some of the supporting data is attributed to a provider name and address spelled one way and the rest of the data is attributed to another that is spelled differently, but is actually the same person. Separate files for the same provider prevent fair analysis of performance because the data for both is incomplete.

 

Similarly, data omissions lead to difficulties in interpreting the data. Missing key data elements such as medical provider specialty can make the data ineffectual for evaluating performance.

 

Errors are often caused by manual data entry. Years ago, typists competed for jobs based on how fast they could type a paragraph without errors. Today’s data entry personnel should be evaluated on accuracy, as well. Make accuracy a performance measurement.

 

Data quality

Often data is transmitted to an organization from outside entities. Hard copy forms are translated to digital formats using optical character recognition, OCR. The organization wanting to analyze the data for use in decision-making did not create the data, but it should not fall victim to it. The organization should select critical data elements and proceed to correct them in the data. The resources required are easily justified by the end game: applying analytics to create accurate decision support.

 

Fix the flaws

Data-driven decision-making in WC medical management is powerful. Frontline professionals and other stakeholders are made accurate and efficient. That means costly mistakes and re-dos are avoided. Moreover, interventions and actions are timely, all resulting in significant cost savings for the organization. If the data producing knowledge and decision support is not accurate and complete, fix it!

Karen Wolfe is the founder and President of MedMetrics®, LLC, a Workers’ Compensation, predictive analytics-informed medical loss management and technical services company. MedMetrics offers intelligent medical management systems that link analytics to operations, thereby making insights actionable and the results measureable. karenwolfe@medmetrics.org

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[1] Heires, K. Flaws in the Data. Risk Management. April 3, 2017.

[2] Ibid.

The Secret Power of the NPI

by Karen Wolfe

This is a David and Goliath story. It’s about how the seemingly insignificant NPI code can fight medical fraud and positively impact effective Workers’ Comp medical management. Many in the industry consider the NPI irrelevant. Yet it is a powerful factor in medical management and medical fraud detection.

The NPI
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. It is required on bills for Medicare and Medicaid. Individual medical providers and medical groups must include their NPI on all bills submitted. 

If the NPI is required for Medicare and Medicaid reimbursement, it follows probably all medical doctors have a NPI number from CMS that uniquely identifies them. The problem is that many Workers’ Compensation payers do not ask for the NPI, do not require it, and even when the NPI is available, do not record it or transfer it to the next level. 

State requirement
Some, but not all states require the NPI on Workers’ Comp bills. However, even if it is added to the bill, it often goes no further.

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. The assumption is all members of the group practice exactly the same. But they do not.

Distinguish individuals
The ability to parse individuals from groups in the data is essential to fair performance analysis. Individual differences evidenced in the data can be distinguished, even when associated with a group with individual NPI’s. This is essential to creating quality preferred provider networks and directories. It is also indispensable for leveraging the data to create a teaching platform for improving provider performance in Workers’ Compensation.

Behavior change
Physicians should be given the opportunity to see themselves portrayed in graphic reports comparing their performance to others like them. By nature, they are high achievers and they want to show well. The graphic presentations are targets or guides for improvement. 

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

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

Specialties are important so that treating doctors are grouped with 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 undetectable duplicate billing. Systems cannot recognize overall performance for the individual because their performance is fragmented across multiple 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, it is not. Individual 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 as is done in Medicare. 

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 crucial. 

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

What to do
Workers’ Compensation payers must require correct individual NPI numbers on all medical bills. This is not an outrageous demand and does not add to costs. However, it does require attention to the matter. 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.

Karen Wolfe is the founder and President of MedMetrics®, LLC, a Workers’ Compensation, analytics-Informed medical management and technical services company. MedMetrics offers online apps that link analytics to operations, thereby making them actionable and measureable. karenwolfe@medmetrics.org

 

How to Find the Best Doctors for Workers' Comp

by Karen Wolfe

As is the case in any professional group, individual medical provider's performance runs the gamut of good, bad, and iffy. The trick is to find good medical providers for treating injured workers, avoid the bad ones, and scrutinize those who are questionable. To qualify as best for injured workers, medical providers need proficiency in case handling as well as medical treatment.

 

High-value physician services 
The first step is to clarify the characteristics of the best providers, especially in context with Workers’ Compensation. One resource is an article published by the American College of Occupational and Environmental Medicine in association with the IAIABC (International Association of Industrial Accident Boards & Commissions) entitled, “A Guide to High-Value Physician Services in Workers’ Compensation  How to find the best available care for your injured workers”[1] It’s a place to begin.

The article notes, “Studies show that there is significant variability in quality of care, clinical outcomes and costs among physicians.”[2]  That may be obvious, but it also verifies the rationale for taking steps to identify and select treating doctors rather than pulling from a long list of providers to gain the discount. The question is what process should be used to select providers?

Approach 
Although considerable effort from scores of industry experts contributed to this article, the approach they recommend is complex, time-consuming, and subjective. In other words, it is impractical. Few readers will have the expertise and resources to follow the guide. Moreover, one assertion made in the article is simply wrong. 

Misstatement 
The article states it would be nice to have the data, but the data is not available. “Participants in the workers’ compensation system who want to direct workers to high-quality medical care rarely have sufficient data to quantify and compare the level of performance of physicians in a given geographic area.”[3] 

Actually, the data is available from most payers whether they are insurers, self-insured, self-administered employers, or TPA’s. However, collecting the data is the challenge. 

Data silos 
The primary reason data is difficult to collect is that it lives in discrete database silos. The industry has not seen fit to place value on integrating the data, but that is required for a broad view of claims from beginning and throughout their course.

At a minimum, claim data should be collected from medical billing or bill review, the claims system, and pharmacy (PBM). The data must be collected from all the sources, then integrated at the claim level to get a broad view of each claim. It takes effort, but it is doable. Yet, there remains another data challenge. 

Data quality 
Payers have traditionally collected billing data from providers, through their bill review vendor. The payer’s task has been paying the bill and sending a 1099 statement to providers at the end of the year. All that is needed is a provider name, address, and tax ID so the payment reaches its destination. It makes no difference to payers that providers are entered into their systems in multiple ways causing inaccurate and duplicate provider records. One payment is a payment. The provider might receive multiple 1099’s, but that causes little concern.

What is of concern is that when the same provider is entered into the payers’ computer system in multiple ways, it can be difficult to ascertain how many payments were made to an individual provider. Moreover, when the address collected by the payer is a PO Box rather than the rendering physician’s location, matters become more complicated. This needs to change. 

The new ask 
Now payers are being asked to accurately and comprehensively document individual providers, groups, and facilities so the data can be analyzed to measure medical provider performance. They need to collect the physical location where the service was provided and it should be accurately entered into the system in the same way every time. (Note: this is easily done using a drop-down list function rather than manual data entry.)

Most importantly, a unique identifier is needed for individual providers, such as their NPI (National Provider Identification). Many payers are now stepping up to improve their data so accurate provider performance assessments can be made.

High-value, quality medical providers can be identified by using the data. However, quality data produces better results. Selecting the best medical providers is not a do-it-yourself project. Others will do it for you.

Karen Wolfe is the founder and President of MedMetrics®, LLC, a Workers’ Compensation medical analytics and technology services company. MedMetrics analyzes the data to score medical provider performance and offers online apps that super-charge medical management by linking analytics to operations, thereby making them actionable. karenwolfe@medmetrics.org

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[1] A Guide to High-Value Physician Services in Workers’ Compensation How to find the best available care for your injured workers

https://www.acoem.org/uploadedFiles/Public_Affairs/Policies_And_Position_Statements/Guidelines/Library_and_Reference_Material/A%20Guide%20to%20High%20Value%20Physician%20Services.pdf

[2] Ibid.

[3] Ibid.