December 15, 2016
How to Power Down WC Medical Costs
by Karen Wolfe
Monitoring the data continually to uncover new diagnoses of comorbidities is essential to avoid missing subtle issues in workers' comp claims.
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 comorbidities early can help control workers’ comp claim costs.
Johnson identifies common comorbidities to watch for, including obesity, diabetes, hypertension and depression. There are many more, too. For instance, a pregnant injured worker will require careful medical management. Pregnancy should be considered a comorbidity and followed closely. Other examples include HIV, hepatitis C, cardiac disease and chronic pulmonary disease. The important thing is to identify the comorbid conditions in claims so they are monitored carefully and referred to nurse case management early.
Comorbid diagnoses can be found in the data—usually. Treating doctors can include the comorbid diagnosis in the list of diagnoses on the bill, but sometimes they do not. They might consider a general health problem irrelevant to a workers’ comp claim, while it might be critical.
Reviewing diagnoses in a claim by the date they were added can be revealing. A diagnosis of diabetes or obesity can appear weeks after the injury date and well into the treatment process. Moreover, when in the course of treatment a diagnosis appears can be enlightening and deserves attention.
Some comorbid diagnoses appear late in the data because they are newly discovered or the treating doctor becomes aware of them later. An example is discovering a diagnosis for a mental disorder in the data long after the actual injury.
A mental disorder diagnosis might result from delayed or unsuccessful recovery as the patient acts out in frustration. Or the late diagnosis might imply previously unrecognized psycho-social factors. Nevertheless, the data should be monitored continually to tag any diagnosis that creeps into the claim picture at any point.
When comorbid or any apparently unrelated diagnoses appear later in a claim, it could be a pre-emptive signal of poor response to treatment or even impending litigation. Monitoring the data continually to uncover new diagnoses is essential to avoid missing subtle issues.
Data can be made smarter by the form and mechanism in which it is presented to those managing the claim. The manner in which diagnostic data is portrayed for claims reps and medical managers can be not only informative, but actionable. An example is portraying all diagnoses by the date they were added to the claim in bills. Such views can disclose subtleties about what is occurring in the treatment process and inform those managing a claim of ensuing problems.
Identifying comorbidities and other troublesome conditions in claims using predictive analytics and continuous data monitoring leads to early intervention and best results. For additional perspectives on this topic, please see, “Analytics-Informed Early Intervention Drives Best Outcomes.”