Karen Wolfe, Author at Insurance Thought Leadership




Karen Wolfe

Karen Wolfe

Karen Wolfe is founder, president and CEO of MedMetrics. She has been working in software design, development, data management and analysis specifically for the workers’ compensation industry for nearly 25 years. Wolfe’s background in healthcare, combined with her business and technology acumen, has resulted in a unique and focused expertise. She has consistently worked from an entrepreneurial perspective, thereby maximizing her ability to create innovative technology products.

MedMetrics is an Internet-based workers’ compensation analytics company. MedMetrics offers a suite of technical services and online software apps to workers’ compensation payers, managed care service providers and networks. MedMetrics apps are designed to be quick and affordable pathways to powerfully recharge cost-control initiatives. They include provider performance analysis and ranking, predictive intelligence profiling, injury severity predictive score and “Ask-the-Data” query library. Wolfe, via MedMetrics, translates her medical, workers’ compensation industry and technology knowledge to clients through applied business tools that strengthen claim and medical management processes, resulting in measureable cost control.

Philosophically, Wolfe believes managed care in workers’ compensation has failed, evidenced by the steady increase in claim cost and complexity. She believes understanding and analyzing the data is necessary to revitalizing managed care and the industry. The data must be gathered, integrated and analyzed to gain critical business intelligence, but, even more importantly, it must be linked to operations in the form of easy-to-use, actionable software tools. Such tools offer decision-support, operational efficiency, cost control and optimized claim outcomes.

Wolfe has a bachelor of science degree in nursing from the University of Oregon, and a master of arts and a master of business administration from St. Mary’s College of California. She has published scores of articles and a book titled Information Technology Made Easy and Understandable, a Guide for Health Care Managers, OEM Press, 2002.

Recent Articles by Karen Wolfe

How Analytics Can Disrupt Work Comp

That the workers’ comp industry is uniquely slow in adopting analytics and applying the resulting intelligence to the operational process is generally known. The reasons vary, including natural resistance to new ways of working, fear of additional workload and cost-avoidance. Analytics may be misunderstood and is definitely undervalued. Notwithstanding amazing success with analytics by other […]

How to Avoid Being Disrupted

The abundance of data — and the technology used to capture it — is driving profound disruption in the relationship structure of the insurance industry. As the traditional gatherers and guards of massive amounts of data, insurers face threats from new, tech-savvy competitors that can adapt to changes more quickly. There are very powerful trends […]

How to Monetize Medical Management

Over the past 25 years, the workers’ comp industry has collected vast amounts of data, and organizations within the industry have easy access to this valuable asset. Their challenge now is to profit from it. Experts say medical costs now amount to 60% of claim costs in workers’ comp. If true, organizations should be charging […]

Intelligent WC Medical Management

Technology in workers’ comp is hardly new, but new ways to infuse technology and predictive analytics into the claims and medical management processes can significantly improve accuracy, efficiency, outcomes and, importantly, profitability. Well-designed technology that streamlines operational flow, provides key knowledge to the right stakeholders at the right time, promotes efficiency and generates measurable savings is […]

Proof of Value for Medical Management

Everyone knows the bulk of workers’ comp costs now are medical. Claims reps and nurse case managers handle injured workers and their medical costs with utmost care. Anecdotes show that their work saves time and money. The problem is that concrete evidence of their value has been elusive—until now. How can costs avoided and time […]

Will Watson Replace WC Professionals?

The Japanese firm Fukokui Mutual Life Insurance has replaced more than 30 office workers with artificial intelligence (AI), in this case the famed IBM Watson. Watson, or one of its doubles, is in fact affecting nearly all industries in multiple ways. Eliminating workers is a major goal. But could Watson replace workers in workers’ comp? […]

How to Power Down WC Medical Costs

It just makes sense. When an injured worker has an underlying medical condition, recovery is compromised in one way or another. The case will be more complex, and it is likely to have a longer duration, higher severity scores and cost more. A recent article published by Denise Johnson in Claims Journal describes how identifying […]

The Secret Power of the NPI

This is a David and Goliath story about how the seemingly insignificant NPI code can fight medical fraud and have a positive impact on 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 is the National Provider Identifier assigned […]

7 Reasons to Invest in Medical Analytics

In a recent post, Joe Paduda stated, “The workers’ comp, and, for that matter, the entire property and casualty insurance industry, is chronically systems-poor.  While other industries view IT as a strategic asset, continually investing billions in IT, WC/P&C considers IT an expense category to be mined for pennies to add to earnings per share.” […]

Confusion Reigns on Predictive Analytics

It seems everyone in workers’ compensation wants analytics. At the same time, a lot of confusion persists about what analytics is and what it can contribute. Expectations are sometimes unclear and often unrealistic. Part of the confusion is that analytics can exist in many forms. Analytics is a term that encompasses a broad range of […]

How to Make IT Efforts Strategic

Has your IT come out of the proverbial and actual basement to be an integral part of your business strategy? Too often, business leaders assign IT a task and expect an initiative to be delivered. End of story. The truth is, business owners must engage and own the outcomes of their IT investments, driving them […]

How Work Comp Can Outdo Group Health

We all know the current healthcare system in the U.S. delivers erratic quality at unsustainable, yet ever-increasing, costs. Workers’ compensation medical care is affected by those costs.  A major shift in the health industry, value-based healthcare, will benefit workers’ compensation. Embracing selected new medical management methodologies put forth in value-based healthcare has the potential to […]

How to Find Best Work Comp Doctors?

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 […]

The Rise of Big (Bad) Data

The workers’ compensation industry has created and stored huge amounts of data over the past 25 years. The copious amount of data has led to a new phenomenon in our industry, similar to most others-the concept of big data. The goal is to corral, manage and query the industry’s big data for greater insight. Big […]

Is Your Work Comp Doctor a P.O. Box?

Are your workers’ compensation medical doctors treating injured workers from a P.O. Box? That may sound ludicrous, but most workers’ compensation data suggests just that. The rendering physician’s address is a P.O. Box. In the past, documenting only the provider’s mailing address was acceptable because that and a tax ID were all that were needed […]

7 Ways Your Data Can Hurt You

Your data could be your most valuable asset, and participants in the workers’ compensation industry have loads available because they have been collecting and storing data for decades. Yet few analyze data to improve processes and outcomes or to take action in a timely way. Analytics (data analysis) is crucial to all businesses today to […]

Better Way to Rate Work Comp Doctors?

USA Today recently published a story about ProPublica, a nonprofit news organization that has developed a metric to score surgeons’ performance, comparing them with their peers. The study is intended as a tool for consumers, but it has generated concern among surgeons, who feel they are being treated unfairly. What the article neglects to mention […]

A How-To on Nurse Case Management

Nurse case management (NCM) has a powerful impact on workers’ compensation claim cost and outcome. Positive results of nurse involvement have long been anecdotally accepted, but widespread evidence of nurse impact has not emerged, and objective proof of value is still missing. Several factors account for this. Inconsistent Referrals For one thing, NCMs are usually considered […]

How to Manage MPNs in Workers’ Comp

A recent study of the use of medical provider networks ( MPNs) in California by the California Workers’ Compensation Institute (CWCI) found that, “While the use of the networks to medically manage treatment of work-related injuries has fulfilled the legislative intent to encourage network use, over time the MPNs have not lowered the cost of […]

Finding Actionable Provider Ratings

With the tongue-in-cheek title, “When Yelp reviews are better than hospital rating systems” Jason Beans of Rising Medical Solutions discloses the inconsistencies of standard hospital reviews. He cites a Health Affairs study that points out that traditional rating systems, those that have been relied upon in the healthcare industry for years, rarely come up with […]

A Secret for Comparing Workers’ Comp Costs

Workers’ compensation claims and medical managers are continually challenged by upper management to analyze their drivers of workers’ comp costs. Moreover, upper management wants comparisons of the organization’s results to that of peers. The request is appropriate. Costs of doing business directly affect the competitive performance of the organization. Understanding drivers of workers’ comp costs […]

How to Make Data a Robust Medical Tool

“Data makes all the difference.” This is according to a white paper published by LexisNexis, titled, “More Data, Earlier: The Value of Incorporating Data and Analytics in Claims Handling,” which states that carriers can reduce severity payments by as much as 25%. This is true for P&C carriers but especially true for workers’ compensation payers, […]

Do You Know Who Your Best Doctors Are?

In workers’ compensation, the medical provider network philosophy has been in place for years. Most networks were developed using the logic that all doctors are essentially the same. Rather than evaluate performance, the focus was on obtaining discounts on bills, thereby saving money. Physician selection by adjusters and others has frequently been based on subjective […]

Healthy Disrespect for the Impossible

When people are extraordinarily successful, examining their characteristics, values and attitudes can be instructive. The rest of us can learn from them and possibly adopt some of them to advance our own goals. Larry Page, co-founder of Google is an example of one who has achieved exceptional heights. Peering into his thought process can be […]

The Apple/Uber Effect, Coming to Work Comp

Industry disruptors change the entire industry — often forever — and they are coming to workers’ comp. Think of Steve Jobs’ invention and Apple’s implementation of the iPod. It turned the music industry on its side. The “smart” iPhone profoundly changed the way we use phones. Land lines have become almost obsolescent and old “Ma […]

Data Is Your Best Weapon in Work Comp

Managing the medical portion of workers’ compensation claims can be daunting. The variables are endless — vendors of all types, extraneous and overlapping events and even participants’ attitudes. Moreover, injured employees’ recoveries lie in the balance, making the effort essential. Tried-and-true methodologies have been in place for 25 years, including bill review, utilization review, discounted […]

A Better Way Than Predictive Modeling

Even though it’s obvious that early intervention drives better outcomes, few systems are in place to guarantee early intervention into problematic workers’ compensation claims. One widely acclaimed effort to identify troublesome claims early is predictive modeling, which conducts elaborate analysis of data using advanced mathematical methods. But finding those claims remains a guessing game. Not […]

ICD-10 Delay Creates Workers’ Comp Mess

Right now, we would be launching the long-anticipated shift from ICD-9 to ICD-10 — except that the Centers for Medicare and Medicaid Services (CMS) was ordered to make yet another change to the deadline. Instead of taking effect Oct. 1, 2014, the newest deadline for ICD-10 is Oct. 1, 2015. The inevitable is put off […]

Making Data Work Means Ending Silos

According to a recently published white paper by LexisNexis, data makes all the difference. The article, “More Data, Earlier: The Value of Incorporating Data and Analytics in Claims Handling,” states that carriers can reduce severity payments by as much as 25%. The article further states that “PC carriers have implemented real-time data and analytics to […]

Easy Way to Spot Workers’ Comp Fraud

While there is considerable talk about fraud in workers’ compensation, the discussion usually refers to fraud by claimants or employers. Unfortunately, fraud and abuse also occurs in medical management. Poorly performing medical doctors produce high costs and poor claim outcomes. When they are also corrupt, the damage can be exponential. We know poorly performing and […]

Cutting Healthcare Costs Doesn’t Lower Quality

Many believe medical quality is sacrificed when attempting to control costs. The logic assumes the way to achieve quality medical care is to deliver more of it. The other side of the same reasoning is that less medical care means less quality. However, the cost-quality balance is not a zero-sum game. These supposed opposites — […]

Research That Predicts Claim Risk

WCRI (Workers’ Compensation Research Institute) recently released a report identifying predictors of injured worker outcomes. While the report reflects only a few states, the information can logically be extrapolated to other areas. When seeking answers in medical management, the issues remain fundamentally constant regardless of location because they are medical, not jurisdictional. “Better information about the […]

Making Sure What You Did Stays Done

The workers’ compensation industry is often accused of resisting change. Simple observation bears this out, such as how long it has taken the industry to address analytics. Having now put its toe in the water, the industry is still light years behind other industries in implementing analytics. An opportunity can be rather simple, yet taking […]

A Better Way to Measure Claim Risk

The medical portion of workers’ compensation claims is now almost 60% of claim costs. That fact alone should easily convince payers to focus on the rich medical information in their data. Yet, very powerful information residing in claims data is virtually ignored — diagnostic codes in the form of ICD-9s. The problem is few in the […]

Make Your Data a Work-in-Process Tool

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?  The answer is: […]

How to Optimize Nurse Case Management in Workers' Comp

Traditionally, in workers’ comp, nurse case management (NCM) services have been widely espoused yet misunderstood and underutilized. The reasons for underutilization are many. Tension between NCM and claims adjusters is one. Even though overburdened, adjusters often overlook the opportunity to refer to NCM. Also to blame is the NCM process itself. In spite of professional certification […]

Don't Expect Analytics Alone to Change Outcomes

Research suggests 40% of major business decisions are based not on facts but on the manager’s gut.[1] In workers’ compensation, critical decisions are made not only by managers but by front-line workers. How accurate and timely are the decisions that claims adjusters make? What about the decisions made to ignore information and avoid taking action? How […]

Why Poor Data Quality Is Not an IT Problem

The adage about data, “garbage in, garbage out,” has taken on magnified importance because the volume, quality, and impact of data has reached unprecedented levels. The importance of quality data is paramount. Companies must change business practices regarding data management or suffer financial disadvantages. Unfortunately, the people who have the power to change frequently think the issue belongs elsewhere. Not […]

Portrait of a Smart Medical Provider Network in Workers' Comp

Smart is cool, especially in electronics. Smart phones answer their users' most obscure questions instantly. Computers are smart, as are iPads, some TVs and even children's toys. So why can't workers' compensation medical provider networks be smart? If they were, what would that look like? Portrait of a Smart Medical Network A smart medical network […]

Moneyball and the Art of Workers' Comp Medical Management

Recently, I watched “Moneyball,” the movie, for the third or fourth time. The story is compelling, as is the book by the same name that preceded it.1 “Moneyball” is based on the concept called Sabermetrics, defined as “the search for objective knowledge about baseball.” The central premise of “Moneyball” is that the collective wisdom of […]

How to Tap the Secret Power of ICD-9's

The medical portion of Workers’ Compensation claims now meets or exceeds 60% of claim costs. That fact alone should easily convince payers to focus on the rich medical information in their data. Very powerful information residing in claims data is virtually untouched—diagnostic codes in the form of ICD-9’s. The problem is few in the industry […]

Workers' Compensation—What the Numbers Say

Even though people talk a lot about the value of analytics for workers’ compensation, few have actually implemented them in ways that provide their full value. To improve, insurers should draw on lessons from, of all things, supermarkets. Supermarkets and grocery stores have long automatically documented transactions at the register. When those transactions are analyzed […]

California SB 863, a Guide to Building and Monitoring Networks with Intelligence, Part 3

This is Part 3 of a multi-part series on building and monitoring networks with intelligence. Part 1 can be found here and Part 2 can be found here. California has defined how medical networks in Workers’ Compensation should be structured and managed. Part 1 and Part 2 of this series described how California’s SB 863 […]

California SB 863, A Guide For Building And Monitoring Networks With Intelligence, Part 2

This is Part 2 of a multi-part series on building and monitoring networks with intelligence. Part 1 can be found here. Part 3 will be published soon. California has defined how medical networks in Workers' Compensation should be structured and managed. Part 1 of this series described how California's SB 863 LC 4616 (b) (2) […]

California SB 863, A Guide For Building And Monitoring Networks With Intelligence, Part 1

This is Part 1 of a multi-part series on building and monitoring networks with intelligence. Subsequent parts in the series will be published soon. Background Building a medical provider community for Workers’ Compensation can be challenging, regardless of the jurisdiction. Nevertheless, carving out a legislatively-compliant, outcome-based, quality network is doable, and the return on investment […]

Data Integrity – Y2K All Over Again?

Remember Y2K? “January 1, 2000, that is the day that was to change all of our lives. That was the day that the computers on which we all depended would fail us. That was the day that all of our luxuries of daily life would crumble, and we would be once again forced to live […]

Even More Tips For Building A Workers Compensation Medical Provider "A" Team

Fact Significant dollars can be saved by getting injured workers to the best doctor. Evidence supporting this fact is the mounting Workers' Comp industry research clearly stating treatment by well-informed and well-intentioned medical doctors results in lower costs and better outcomes. Belaboring A Point As repeatedly stated in this series, many doctors in networks are […]

Doctors Can Drive Claim Costs – A Case Study

In response to our recently published article, http://medmetrics.blogspot.com/2012_03_01_archive.html”>Survey: Employers Want WC Cost Control. Really? a reader commented: “The biggest problem I have is finding the right doctors. If all of my employees were in one location, this would be a piece of cake, but we are a trucking company with drivers who live and work […]

Unleash The Power Of Real-Time Data Monitoring For Managed Care

Data monitoring means applying technology and analytics to gain real-time intelligence and decision support in claims management. Moreover, data monitoring is the way to link analytics to operations, thereby making them actionable. Nearly everyone in Workers’ Comp is trying their hand at analytics now. The problem is that organizations that have implemented analytics do not […]

Where To Search For Best-In-Class Doctors

No doubt you have seen the ad for Angie’s List. A good-looking male doctor is pictured with the caption, “He has been nothing but focused, dedicated and concerned about my health and well-being.” If searching for a contractor or hair dresser, this might be a good start. But searching this way for doctors? Absurd! Finding […]

Predictive Analytics In Workers' Compensation Made Easy And Affordable

It's a safe bet that claims will not have a happy ending if the treating physician has a history of being associated with poor claim outcomes. In fact, physicians rated poorly in analytic studies based on past performance are 100% predictive of high costs and inferior outcomes in future claims where they are involved. The […]

Teach Your Data to Spot Creeping Catastrophic Claims

“One of the biggest cost drivers in Workers’ Compensation is seemingly ‘average’ claims that take a turn for the worst and result in several years of medical treatment and disability.”1 Too often seemingly innocuous claims lay under the radar, unnoticed until the damage is done. In this article, Mark Walls does an excellent job of […]

Medical Fraud By Identity Proliferation

Using Data To Define Quality Performance Based Networks People in Workers’ Compensation are beginning to power up their data to gain insight and objective decision support to structure their provider networks. To do that, physician and other provider performance is evaluated based on actual performance evidenced in the data. That seems simple enough on the […]

How to Evaluate Medical Providers

Workers' Comp Is Different While rating providers in group health is a long-practiced endeavor, its elements and parameters have not significantly migrated to Workers' Compensation. Efforts to translate group health provider quality measures to Workers' Compensation have fallen short of the mark because they omit several factors crucial to Workers Comp. Quality medical performance indicators […]

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