Tag Archives: medical provider performance

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 without electricity, running water, heat. The great Y2K scare is what it was called. The scare was that all of our computer systems around the world would cease to function on December 31, 1999.”1 They did not.

Drawing A Parallel In Workers’ Compensation
The hype and fear of Y2K were paralyzing for some and organizations spent large sums of money to reprogram computers in preparation. Indeed, there is far less anxiety about the veracity of medical provider data in Workers’ Comp claims and bill review systems. Yet, medical provider records in Workers’ Comp are just as lacking as the year date in systems prior to 2000 and the ramifications could actually be consequential.

Opportunity Cost
The Y2K issue prior to the late 1990’s was caused by limited disk space that was conserved by using only two digits for the year. The number of bytes that would fit on a screen and in the memory of the machine was limited. On the other hand, the cause of limited medical provider data is simply a matter of traditionally paying the bill efficiently. Only name, address, and Tax ID is needed. However, inadequate and inaccurate medical provider data is opportunity cost for the industry.

New Applications
No longer is the industry interested in using medical provider information for bill payment only. Provider records in systems are key to evaluating provider performance beyond direct fees for service. Medical providers impact return to work, indemnity costs, claim duration, and other factors. The indicators can be found in the data.

Who Knew?
Medical provider records have recently risen to the level of essential information for quality and cost control. In order to evaluate individual medical providers, medical groups, and facilities, the data in provider records must be non-duplicative, accurate, and complete. Yet, most databases contain multiple records for the same, and presumably the same provider. Moreover, the records are incomplete, especially regarding unique identifiers such as state license numbers or NPI (National Provider Identifier) numbers that distinguish individuals.

Duplicate Provider Records
One of the major problems found in most Workers’ Comp data is duplicate medical provider records. Duplicates are a problem because the records for an individual are dispersed over multiple records and can only be evaluated separately rather than collectively. The cumulative data for a provider cannot be assessed until duplicate provider records are merged.

Duplicate provider records occur for many reasons. Some organizations simply add a new provider record to their database when a new bill is received, without checking to see if the provider already exists in the data. This is simple to correct administratively, by requiring data entry persons to check the data for the existing provider. A more reliable solution is to create systems with search and select utilities that limit “add” authority. However, duplicate records occur for other reasons as well.

Duplicate medical provider records can also occur when the same provider is added to the database, but the name is spelled differently, a different suffix is used, and when initials or abbreviations are entered differently. Computer systems read these as different and allow adding the new one. Similar address inconsistency has the same result. Using Ste, Ste., and Suite might result in three separate records for the same person or entity. The solution is using basic record search and select from a drop down list. Moreover, correcting the existing data by scrubbing the database is worth the time and cost.

Optimize Medical Provider Records
Tax ID, so important to paying a bill is nearly useless when evaluating medical provider performance because multiple persons often use the same Tax ID. Establishing a critical mass of data associated with one provider is difficult, and duplicate records simply dilute the information further. Certainty about individual identity is critical and the only way to achieve that is with state license numbers.

License Numbers
Unfortunately, NPI numbers, established by the CMS (Centers for Medicare and Medicaid Services) are abused by some. Notorious medical providers apply for and receive multiple NPI numbers. State license numbers are the most reliable and should be added to provider records in databases to differentiate individuals.

Medical Specialty
Including medical specialty in the provider record increases its value exponentially. The most accurate, fair, and illuminating evaluation is comparing peers. Comparing neurosurgeons to dermatologists on some performance indicators makes little sense. Pain specialists, for instance, usually receive complicated cases late in the game and should be compared to other pain specialists, not those who treat acute injuries. Medical specialties are vital to evaluating performance accurately.

What To Do
While it may not be Y2K, the impact of poor data might be greater for Workers’ Comp organizations. Systems should contribute to medical cost management intelligence. However, many cannot because of data quality. Scrub and optimize existing data and establish protocols that prevent continuation of status quo. Outsourcing to a third party specialist is easy and the return on investment certain.

1The Y2K Scare

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

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 not well-informed or well-intentioned regarding management of Workers' Comp claimants. As a consequence of their involvement, claim results are lacking, costs are high, and outcomes are precarious. This series of articles, “Tips for Building a WC Medical Provider A Team,” is intended to describe how to identify doctors who know the ropes in Workers' Comp using indicators in the data.1

Beyond the indicators discussed in the previous articles in this series, additional salient data elements are available in the data to broaden the scope of medical management evaluation. What makes this approach so feasible is that solid knowledge of who demonstrates best practices is revealed in the data. However, to find that knowledge, some operational processes and the data itself need refinement. Access to the data and its quality must be addressed.

Getting To The Knowledge In The Data
Regrettably, access to the data by the right persons is often a problem. Those who know best what to look for, the business and clinical professionals, cannot use current data in a practical, work-in-progress manner. The reasons are many.

First, relevant data resides in separate databases that must be integrated to understand all activity in a claim. Moreover, in most organizations, provider records are simply inaccurate and incomplete. Until now, the need for them was for reimbursement purposes only, not performance evaluation. Yet another problem is that provider records are frequently duplicated in the data, making it difficult to accurately evaluate individual medical providers' treatment process and results.

Data Silos
Critical data for analyzing medical provider performance is still fragmented in most payer organizations. While people have long complained about data silos in Workers' Comp, little has been done to correct the problem. If anything, data sources have increased. Pharmacy databases have been added, for instance. Yet the databases are not integrated on the claim level, thereby portraying the claim as a whole. Data silos too often lead those who are attempting to evaluate provider performance to rely on a single data source.

Single Source Analysis
Relying on one source of provider performance data is foolhardy. Nevertheless, bill review data is often used, but by itself is inadequate to tell the whole story. Claims level data is also critical to weigh return to work data, indemnity payments, and legal involvement associated with claims and ultimately, to individual doctors. None of these data items are found in bill review data, yet these are essential to complete analysis of provider performance. Because in Workers' Comp, doctors drive the non-medical claim costs as well as the direct medical costs, these data items are essential to evaluating the quality of their performance.

Data Quality
The problem of data quality can be even stickier. Traditionally, medical provider records are kept in the claims database, along with records of other vendors for payment purposes. All that is needed for bill payment is a name, address, and tax ID. Unfortunately, the same provider is frequently added to the database when a new bill is received. This outdated database management practice leads to slightly different records added for the same provider.

Data Optimization
To evaluate medical provider performance, more information about individual providers is needed such as accurate physical addresses. PO Boxes will suffice for mailing checks, but injured workers cannot be sent there for treatment.

Merge Duplicate Records
Tax ID's are still important for reimbursement and 1099 purposes, but often multiple doctors are represented by one Tax ID. To evaluate provider performance, individuals must be differentiated in the data. State medical license numbers and NPI (National Provider Identification) numbers are needed. Frankly, some doctors deliberately obfuscate the data by operating under multiple Tax ID's and multiple NPI numbers. Consequently, provider records must be merged, scrubbed, and optimized before any analysis can begin.

What To Do
For most organizations, choosing best practice providers by analyzing the data is challenged by the shortage of accurate and complete data. Therefore, those wanting to control costs by choosing the best providers should obtain provider performance analysis and scoring from a specialty third party, one that is expert in data integration from multiple sources, as well as provider data scrubbing and optimization.

When behaviors of doctors are analyzed using clean, integrated data, the well-informed and well-intentioned in Workers' Comp will rise to the surface.

1 Tips for Building a Medical Provider “A” Team and More Tips for Building a WC Medical Provider “A Team”