Tag Archives: medical management

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 to pay bills and file 1099s. Now, having more complete data has become profoundly important.

Data on providers is scrutinized to determine medical performance, claim cost and outcome. Accurate analysis relies on the data-complete data. Rendering physicians must be documented on the bill so that their performance is accurately tied to the correct injured worker and claim in the data. Including the 1) treating physician’s name, 2) physical location and 3) NPI number of the rendering provider on each bill lets analytics tell us who are the best and why. When those three little data elements are missing, so is any useful information for medical management.

When the data contains group or facility demographics without the rendering physician’s name, the actual treating physician cannot be linked to the claim. Performance cannot be logically averaged among all the providers in the group. Obviously, not every treating provider is equally gifted or competent.

The HCFA (Health Care Finance Administration) standardized form has a box to document the rendering provider’s name and NPI (National Provider Identification). That box must be used.

Sometimes, the name of the provider is documented on the billing form but is not captured in the OCR (optical character recognition) process, whereby the data on the bill is translated to a digital form.

Even when bills are submitted electronically, that data element, while present, may not be forwarded. The digital bill is usually handed off to a bill review service that analyzes the appropriateness of the charges and passes its conclusions on to the payer. Rarely is all the information from the HCFA billing form passed on to the payer. The provider information that is handed off may be just the billing address and tax ID.

Sometimes, the name and NPI of the rendering physician are omitted simply because it has always been done that way. No one has thought to change the procedure.

In other words: Retrieving definitive provider demographics might be a simple matter of requesting it!

Sometimes, though, the reason accurate data is missing may be more sinister. The Centers for Medicare and Medicaid Services (CMS) requires the rendering physician name and NPI number on bills submitted to Medicaid and Medicare. CMS simply withholds payment on bills without that information. But those standards are not applied in workers’ compensation. The frequent result is bad or misleading data, but it can be even worse.

Unfortunately, omitting the name and NPI of the rendering physician is sometimes deliberate. This could be strategic or actual fraud. Some large multi-specialty medical groups and multi-location practices deliberately omit such information because they want the anonymity for their individual practitioners. They want to avoid measurement of their providers’ performance. They do not want individuals identified, not even by the location in which they practice. All the providers in the group treat from a P.O. Box and under the group NPI number.

Some providers deliberately obfuscate the data so they can stay under the radar to overbill. They submit different addresses and even different NPI numbers on their bills. The practice is clearly fraudulent because CMS expects that one physician or other medical provider is assigned one NPI. Providers who commit fraud also circumvent CMS.

The solution

Regardless of the reason for bad medical provider data, payers can correct the problem by demanding more. Often, the solution is as simple as asking the bill review service for more complete data. Further upstream, it might be as simple as requiring all providers in a network to include the name and NPI of the actual treating physician on the HCFA billing form.

All you require is the 1) rendering physician’s name, 2) physical location and 3) NPI number with every bill. With that information, the best and worst providers can be identified, and the fraudulent ones exposed.

Claims Industry Has Lots to Answer for

The 2014 WC Benchmarking Study by Rising Medical Solutions depicts a claims industry with nowhere to hide and a lot to answer for. This very detailed and intelligent survey deserves some serious attention.

The survey is particularly revealing because it boldly juxtaposes four critical topics rather than focus on a single issue. The covered topics are:

  1. Core competencies
  2. Talent development and retention
  3. Impact of technology and data
  4. Medical performance and management

Surveying these four topics together prevents industry excuses. By contrast, any single-topic survey leaves the industry with room to equivocate and retort with presumptuous hope about the holistic system. For example, a survey on talent management might conclude that there is a woeful lack of investment in recruiting and training new adjusters, yet the editorial response might assert that efforts in work-flow technology can take up future slack. Further, a single-topic study showing a higher cost for WC medicine vs. non-occupational care might evoke an editorial response touting the latest strides in “managed care” that surely hold hope for future corrections to this problem.

Well, when a side-by-side evaluation of the four survey topics show consistent deficits in all areas among more than 400 responders I don’t think there is enough fresh coffee in any PR department to conjure up a reassuring response.

High-level findings include:

– Claim providers can easily cite the critical core competencies for adjusters: return to work, medical management and compensability investigations, etc. However, many do not measure performance based on these competencies, nor support active efforts to develop these talents. Only half of responders report using positive or negative reinforcement of core competencies.

– Regarding adjuster training, 48% of responders have no or “unknown” budgets. Only 36% have formal training for new hires, most of which is 40 hours or less.

– Fewer than 40% of responders use outcome-based claim measures.

– Fewer than 30% measure medical provider performance, indicating that the network discount is all important and that the care itself an afterthought.

– The IT/data areas indicate no clear focus or vision or investment in workflow, cross-system integration or predictive modeling. (Only 25% report using predictive analytics. Being a proud skeptic of this folly, that is fine with me, but hold that thought for a future article.)

There is creative cross-referencing one can do among this survey’s sections, which I believe shows responders’ disregard for outcome in favor of profit. For example, one section measures the use of cost-containment applications, while a separate section asks for ranking of cost-containment applications based on how critical they are. Nurse triage is listed as having the third most critical impact on outcome yet is in 7th place among tactics responders use. In contrast, bill review is number one in use, by 95% of responders, yet ranks as only 6th on scale of impact on outcome.

I conclude that, in spite of bill review’s low impact on outcomes, many claim-service providers deem the “percentage of savings” cash flow stream as most important. Let’s not forget there is a huge IT investment in bill scanning and processing centers. So, despite pressure on other aspects of IT, there apparently is an IT budget available when it supports cash flow.

Bottom line, claim providers do little to invest in long-term improvement, while focusing on short-term savings and cash-flow streams.

My suggestion for future studies by Rising Medical is to totally split for-profit insurers and TPAs from in-house, self-administered responders. The former chases profit; the latter chases outcomes. I predict a very telling dichotomy among this split.

Predictions for Work Comp in 2015

Once again, I’ll head out on a limb with saw firmly in hand…

1.  Aetna will NOT be able to sell the Coventry workers’ comp services (CWCS) division.  I’ll double down on last year’s prediction: Even if the giant health plan wants to dump workers’ comp, the network – which is where all the profit is – isn’t sellable. The rest of the operation isn’t worth much; the bill review business continues to deteriorate (and CWCS is looking for a replacement bill-review application), competitors are picking off key staff and customers continue to switch out services and network states.

2.  Workers’ comp premiums will grow nicely, driven by continued improvement in employment and gradually increasing wages coupled with increases in premium rates in key states (we’re talking about you, California).

3.  Additional research will be published showing just how costly, ill-advised and expensive physician dispensing of drugs to workers’ comp patients is. Following on the excellent work done by CWCI and Accident Fund/Johns Hopkins, we can expect to learn more about the damage done to patients, employers, insurers and taxpayers by docs looking to Hoover dollars out of employers’ pocketbooks.

4.  Expect more mergers and acquisitions; there will be several $250 million-plus transactions in the workers’ comp services space, with more deals won by private equity firms. Of late, most transactions have been “strategics,” where one company buys another; the financials of these have been such that private equity firms couldn’t match the prices paid. I’d expect that will change somewhat in 2015 as  “platform” companies come on the market.

5.  A bill renewing TRIA will be passed; the new GOP majorities want to show they can “govern,” and this has bipartisan support.

6.  Liberty Mutual will continue to de-emphasize workers’ comp. The company’s continued focus on personal lines and property and liability coverage stands in stark contrast to the changes in workers’ comp. The sale of Summit, management shifts and the financial structuring of legacy work comp claims portend more change to come. Recent financial results show the wisdom of this strategy.

7.  After a pretty busy 2014, regulators will be even more active on the medical management front. Workers’ comp regulators in several more states will adopt drug formularies or allow payers to more tightly restrict the use of Scheduled drugs via evidence-based medical guidelines and utilization review (UR). While the former is easy, the latter is better, as it enables payers to more precisely focus their clinical management on the individual patient. Expect more restrictions on physician dispensing and compounding, increased adoption of medical guidelines and UR, along with incremental changes in several key states (California, we hope) to “fix” past reform efforts.

8. There will be at least two new workers’ comp medical management companies with significant mindshare by the end of 2015. These firms, pretty much unknown today, are going to be broadly known among decision-makers within the year. While they will not generate much revenue this year, they will be attracting a lot of attention.

9. Outcomes-based networks will continue to produce much heat and little real activity. After predicting for years that small, expert-physician networks will gain significant share, I’m throwing in the virtual towel. There’s just too much money being made by managed care firms, insurers and third-party administrators (TPAs) on today’s percentage-of-savings, huge generalist network/bill review business model. Yes, there will be press releases and articles and speeches; no, there won’t be more than a very few real implementations.

10.  Medical marijuana will be a non-event. Amid all the discussion of medical marijuana among workers’ comp professionals, there are very few (as in no) documented instances of prescribing/dispensing of marijuana for comp claimants. Yes, there will likely be a few breathless reports about specific claims, but just a few. And, yes, there may also be a few instances of individuals under the influence of medical marijuana incurring workers’ comp claims, but these will be few indeed.

There you have it – here’s hoping I’m more prescient this year than I was last.

This article first appeared on Managed Care Matters on Jan. 5, 2014.

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 for NCM, the process is poorly defined for those outside the nursing profession. More importantly, NCM has difficulty measuring and reporting proof of value.

Underlying issues

Continuing to do business as usual is not acceptable. NCM needs to address several issues to qualify as legitimate contributors. First, NCM needs to articulate its value. To do that, NCM must computerize and standardize its process and measure and report outcomes, just like any other business in today’s world.

Too often, computerization for NCM is relegated to adding nurses’ notes to the claim system. However, such notes cannot be analyzed to measure outcomes based on specific nursing initiatives. 

In most situations, an individual NCM interprets an issue, decides on an action and delivers the response. The organization’s medical management is thereby a subjective interpretation rather than a definable, quantifiable product. 

Granted, the NCM is a trained professional. But when the product is unstructured, variables in delivery cannot be measured or appreciated. A process that is different every time can never be adequately defined.

It's crucial to establish organizational standards about what conditions in claims require referral to NCM—without exception. This will remove the myriad decisions made or not made by claims adjusters to involve the NCM. The referral can be automated through electronic claims monitoring and notification. NCM takes action on the issue according to organizational protocol, and the claims adjustor is notified.

Measure

When the conditions in claims that lead to intervention by NCM are computerized and standardized, the effects can be measured. Apples can legitimately be compared with apples, not to oranges and tennis balls. Similar conditions in claims are noted and approached the same way every time, so the results can be validly measured.

Results in claims such as indemnity costs, time from DOI to claim closure or overall claim cost can be compared before and after NCM standardization. Comparisons can be made across different date ranges for similar injuries going forward to measure continued effectiveness and hone the process.

Measuring outcomes is the most essential aspect of the process. Value is disregarded unless it is defined, measured and reported.

For non-NCMs, the dots in medical management must be connected to see the picture. Describe what was done, why it was done and how it was done the same way for similar situations and in context with the organization's standards. Then report the outcome value. Establish a continuing value communication process.

NCM constituencies should be informed in advance of the process and outcome measurements. Define in advance how problems and issues are identified and handled and how results will be measured. Then proceed consistently.

Recognized NCM value

Even as things now stand, NCM's value is being recognized. American Airlines recently reported it is adding NCM to their staff and will refer all lost time claims. The company cited a pilot project where nurse interventions were documented and measured, proving their value in getting injured workers back to work. 

Christopher Flatt, workers’ compensation Center of Excellence leader for Marsh Inc., wrote in WorkCompWire (http://www.workcompwire.com/), “One option that employers should consider as part of an integrated approach to controlling workers’ compensation costs is formalized nurse case management. Taking actions to drive down medical expenses is an essential component to controlling workers’ compensation costs.”1

Industry research and corporate or professional wisdom regarding risky situations can supply the standardized indicators for referral to NCM. American Airlines uses the standard that all lost time claims should be referred to NCM. But there are many, sometimes more subtle, indicators of risk and cost in claims that can be identified early through computerized monitoring and referred for NCM intervention.

Another example of developing standard indicators for referral is based on industry research that shows certain comorbidities, such as diabetes, can increase claim duration and cost. These claims should also be referred to NCM. Yet another example is steering away from inappropriate medical providers who can profoundly increase costs. 

As a long-ago nurse and a longer-time medical systems designer and developer, I believe the solution lies in appropriate computerized system design. The elements need to be simple to implement, easy to use and consistently applied. Only then can NCM offer proof of value.

1 Christopher Flatt: The Case for Formalized Nurse Case Management

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 baseball insiders, including players, managers, coaches, and scouts over the past century, is subjective and flawed. The book argues that the Oakland Athletics general manager, Billy Beane, took advantage of analytic, evidenced-based measures of player performance to field a team that could compete successfully against far-richer teams in Major League Baseball. During the 2002 season, the Oakland A's won enough games to make the playoffs in spite of a meager salary budget and “inferior” players.

Even though the two industries are diametrically dissimilar, distinct parallels can be drawn between baseball and workers’ compensation medical management.

Similar Resistance to Analytics

One similarity is the resistance to adopting analytics as a knowledge tool. Baseball insiders and managers opposed Beane’s analytics, sometimes vehemently. Long-held beliefs among baseball insiders promoted measures of performance such as stolen bases and batting averages. Beane’s metrics debunked the old methods, revealing unrecognized strengths in lesser-known, more affordable players.

Similarly, workers’ compensation leaders have relied on traditional medical provider networks and personal preferences to select medical doctors. If doctors are in a network and offer a discount on medical services, all is good. Yet, industry research has shown that not all doctors are equal. Doctors and other medical providers who understand and acknowledge the nuances of workers’ compensation drive better outcomes. It’s a matter of finding those doctors.

Finding Best Performers

The purpose of “Moneyball” Sabermetrics is the same as workers’ compensation medical metrics—to find the best performers for the job. The way to do that in baseball is to analyze the data defining actual performance in terms of outcome—games won. In workers’ comp, the data must be scrutinized to find doctors who drive positive claim outcomes. In both cases, a variety of metrics are used to support the most effective decisions.

Performance Indicators

As in baseball, the goal in medical management is to apply objective information to decision-making using evidenced-based measures of performance. For both industries, cost is a factor. However, in workers’ compensation, the cost of medical care must be tempered by other factors:  What is the duration of medical treatment? What is the return-to-work rate associated with individual doctors? What providers are associated with litigated claims?

As in baseball, the list of indicators for performance analysis is long. However, the sources of data differ significantly.

The Data Challenge

In baseball, all the data necessary for analysis is neatly packaged. Statistics are gathered while the game is in progress. In workers’ comp, the data that informs medical management resides in disparate systems and must be gathered and integrated in a logical manner.

Essential data lives in bill review systems, claims adjudication systems and pharmacy (PBM) systems and can also be found in utilization review systems, peer review systems, and medical case management systems. The data must be integrated at the claim level to portray the most comprehensive historic and current status of the claim. Data derived from only one or two sources omits critical factors and can distort the actual status or outcome of the claim.

Once the data has been integrated around individual claims, meaningful analysis can begin. Indicators of performance can be analyzed with new conclusions drawn about the course of treatment and medical provider performance. Moreover, concurrently monitoring the updated claim data leads to appropriate and timely decisions.

Data Positioned as a Work-in-Progress Tool

In baseball, the data is used as a work-in-progress information tool. Decisions about the best use of players are made daily, sometimes hourly. Workers’ compensation medical management can do the same. Systems designed to monitor claim details and progress can alert the appropriate persons when events or conditions portend complexity and cost.

Industry Status

Analytics in baseball is not exclusive to the “Moneyball” Oakland Athletics. All of Major League Baseball now relies heavily on its use. Unfortunately, there are still only a few visionary Billy Beanes in workers’ compensation medical management. Yet, applying analytics for cost and quality control is simple and affordable and can be adopted quickly by all.

1Lewis. M. Moneyball: The Art of Winning an Unfair Game 2003. The film “Moneyball”, starring, Brad Pitt was released in 2011.