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

 

Are You Listening?

a White Paper
by Karen Wolfe

We believe listening to your data is the way to successfully manage claims and medical costs in Workers’ Compensation. When you listen to your data you get timely and accurate information, information that tells you what’s happening and suggests what to do. When you listen to your data, outcomes improve. 

Listen 
For instance, listen to your data to direct injured workers to the best treating doctors. The data will tell you who they are. Listen to the data to understand how severe the injury is so you know the best type and amount resources to apply.Listen to your data to tell you when claims are not progressing. 

Listen to your data continually to know how your injured workers are progressing toward return to work and to remove obstacles in their path. Listen to your cumulative data to understand what is happening in and to your organization. 

Listening help
We also believe we can help you listen. We collect data from your various sources, integrate it, and analyze it for you. This is not something you can do in your head or on your own. Attempting to do so would be overwhelming and lead nowhere. 

We also update your data continually so when the information is returned to you, it is fresh and accurate, not outdated and unreliable. 

Return information 
When we finish collecting, integrating, updating, and analyzing your data, we give it back to you in forms you can easily understand and act upon. For example, we monitor claims continually and when we notice something that you should know, we send an electronic alert. The alert is sent to the right person at the right time and with the right amount of information for action. Intervening early always leads to better results and lower costs.

Besides alerts, we also give you back information in the form of easy look-ups, searches, and reports. We give you pre-defined queries that allow you to further analyze your data and to drill down for even more intelligence. 

Easy

The best thing about listening to your data is that it’s so easy because we do the listening for you and send you information via online apps. Our online apps are easy to access and operate. Let us help you listen to your data.

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

Quality Medical Treatment Drives Costs Down!

by Karen Wolfe

Workers’ Compensation is an industry where the high cost of medical care is a major issue, yet tracking accurate medical cost and outcome information for specific medical conditions is uncommon. It is all the more puzzling because evaluating outcomes and costs for medical care can be done rather easily using data readily available.

People have consistently dodged the issue of quality medical care, convinced that quality is more expensive. But more quality actually means less cost! Tracking claim outcomes and costs based on injured workers’ injury or condition leads to selecting the doctors that deliver better results and at lower cost. 

Understanding costs

Measuring and tracking results is a familiar principal in most industries, yet in Workers’ Comp medical costs are measured in broad terms such as overall medical spend. Medical costs are used to set reserves and calculate premiums. But rarely are costs measured in context with medical outcomes or how patients improve.

Michel Porter and Thomas Lee in their article, “The Strategy That Will Fix Health Care” published in the Harvard Business Review[1] list six methodologies necessary to change healthcare in the US. One of the six value strategies they list is to measure true outcomes and costs for every patient. 

“When outcomes are measured and reported publicly, providers are under pressure to improve and to adopt best practices, with resulting improvements in outcomes.” 

Defining quality medical care
Porter and Lee further state that we focus too much on what doctors do, rather than what is important to the patient (injured worker). What the injured worker wants is freedom from pain, return to pre-injury status, to health, and to work. We should be measuring what matters to the injured worker. 

What the patient wants is the true measure of 

quality medical care. 

Adverse effects 

It matters very much to injured workers that they avoid any adverse effects of the medical treatment they receive. Adverse effects include infection, re-admission to the hospital for the same problem, returns to the Emergency Department, complications such as embolism or thrombosis, and revision or re-do of a surgical procedure. Length of treatment is important, as is length of stay in the hospital. What injured workers want is quality care. 

Quality Medical Care
Traditional measures of quality focus on what providers do, the treatment they render. That can include laboratory tests and other diagnostic procedures, surgery, medications, referral to specialists, and, of course, cost. However, measuring the full set of outcomes that matter to patients with similar conditions is essential to understanding quality and meeting their needs and expectations.[2] It is the only real measure of quality care. 

Minimize disability
In Workers’ Compensation we can easily measure functionality or return to normal physical activity by return to work or modified work data. Duration of disability and disability rating at claim closure are other important indicators of the injured workers’ functionality. These are the things important to injured workers because they portray health. Moreover, shorter disability means lower costs.

Other measures of quality include length of medical treatment and length of hospital stays. Measuring the full set of outcomes that matter is critical to meeting injured workers’ needs and is a powerful vehicle for reducing medical costs.

When outcome measures improve, costs go down! 

Quality measures reduce costs
Absent complications and other adverse effects, costs are naturally lower. It’s simple logic. Analyzing the data reveals the elements of care that are positive and, as a result, keep costs down. 

Choose doctors with good results
Costs by themselves are not the driving force in medical management. The driving force is increasing the quality of care and the avoidance of adverse effects. The way to apply analysis of outcomes, including cost, is to identify the doctors who consistently get the best results for patients. Find the best providers associated with the best outcomes. Those with better outcomes will have lower costs.

Finding doctors who consistently get desired outcome measures is the first step. Then injured workers must be directed to them in states where that is appropriate. In other places, offering injured workers objective information regarding the doctors who get the best results in terms of outcomes can be very persuasive. 

Monitor the course
Provider performance can fluctuate over time. Consequently, the data must be monitored continually to insure the best doctors continue to generate the best outcomes.

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 other online apps that link analytics to operations, thereby making them actionable. karenwolfe@medmetrics.org

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[1] Porter, M. Lee, T. The Strategy That Will Fix Healthcare. Harvard Business Review.

https://hbr.org/2013/10/the-strategy-that-will-fix-health-care/ar/1

[2] Ibid.