How to Monetize Medical Management

Workers' comp data can be made intelligent and monetized through predictive analytics combined with a timely information delivery system.

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 ahead to find ways to optimize medical loss management and monetize their data for profit. See also: Intelligent WC Medical Management   The first step toward monetizing medical data is to integrate it from disparate data silos. All bill review, claims system, pharmacy (PBM) and other relevant data should be integrated at the claim level to gain a full picture of individual claims. Once integrated, predictive analytics methodologies can be applied to convert the data to usable information. You need to analyze historic data using predictive analytics to discover conditions that are cost drivers or cost accelerators. What conditions or combinations initiate or perpetuate high-cost situations? Where are the gaps in timing in operational flow? What actions encourage positive or negative claim resolution? And the information must be made actionable. Predictive analytics has determined the comorbidity of diabetes adds complexity and cost to claims, so an alert can be generated, and key Information conveyed to appropriate persons. Based on predictive analytics, the probable ultimate medical costs for the claim are portrayed for the claims rep along with other key information regarding the claim in question. The claims rep adjusts medical reserves accordingly and moves on. Time is saved, and accuracy is optimized. At the same time, the predictive analytics-informed system automatically notifies the nurse case manager based on the organization’s referral protocol. The claims rep is informed of the referral but is not required to take action. Similar claim information is presented to the nurse case manager for quick review, thereby integrating and coordinating claims and nurse case management initiatives. Data is made intelligent and can be monetized through predictive analytics combined with a timely information delivery system. Searching for decision-support information takes time and is inefficient. Manually entering data is time-consuming, annoying and often inaccurate. On the other hand, intelligent information delivered appropriately is monetized as claim stakeholders make informed decisions quickly, effortlessly and accurately without need for data gathering and data entry. Projected probable ultimate claim cost with comprehensive supportive information displayed for claims reps does not require data search or data entry. Even less-experienced adjusters are accurate and efficient. Accuracy and efficiency is optimized, productivity is increased and profitability follows. Moreover, early intervention through timely alerts allows for action before further damage is incurred. Medical loss management is also monetized by the ability to objectively measure claim cost savings. Having projected the ultimate medical costs for a claim, quantifiable cost savings are available at claim closure due to coordinated medical management initiatives. Monetization is realized through client satisfaction, customer loyalty and client retention. Moreover, the story is proof of value serving the organization’s strategic competitive advantage. See also: Proof of Value for Medical Management   Organizations that monetize their data have greater returns, including return on investment. The intelligent medical management system is monetized internally and externally, thereby paying for itself. Such statements are familiar as sales platitudes, but with intelligent medical management, positive results are objectively measured. Savings are greater than the cost.

Karen Wolfe

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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 unique expertise.


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