Tag Archives: national provider identification

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 as well as medical treatment.

High-value physician services

The first step is to clarify the characteristics of the best providers, especially in context with workers’ compensation. One resource is an article published by the American College of Occupational and Environmental Medicine in association with the IAIABC (International Association of Industrial Accident Boards & Commissions) titled, “A Guide to High-Value Physician Services in Workers’ Compensation How to find the best available care for your injured workers” It’s a place to begin.

The article notes, “Studies show that there is significant variability in quality of care, clinical outcomes and costs among physicians.” That may be obvious, but it also verifies the rationale for taking steps to identify and select treating doctors rather than pulling from a long list of providers to gain the discount. The question is, what process should be used to select providers?

Approach

Although considerable effort from scores of industry experts contributed to this article, the approach they recommend is complex, time-consuming and subjective. In other words, it is impractical. Few readers will have the expertise and resources to follow the guide. Moreover, one assertion made in the article is simply wrong.

Misstatement

The article states that it would be nice to have the data, but that the data is not available. “Participants in the workers’ compensation system who want to direct workers to high-quality medical care rarely have sufficient data to quantify and compare the level of performance of physicians in a given geographic area.”

Actually, the data is available from most payers whether they are insurers, self-insured, self-administered employers or third-party administrators (TPAs). However, collecting the data is the challenge.

Data silos

The primary reason data is difficult to collect is that it lives in discrete database silos. The industry has not seen fit to place value on integrating the data, but that is required for a broad view of claims from beginning and throughout their course.

At a minimum, claim data should be collected from medical billing or bill review, the claims system and pharmacy (PBM). The data must be collected from all the sources, then integrated at the claim level to get a broad view of each claim. It takes effort, but it is doable. Yet, there remains another data challenge.

Data quality

Payers have traditionally collected billing data from providers, through their bill review vendor. The payer’s task has been paying the bill and sending a 1099 statement to providers at the end of the year. All that is needed is a provider name, address and tax ID so the payment reaches its destination. It makes no difference to payers that providers are entered into their systems in multiple ways causing inaccurate and duplicate provider records. One payment is a payment. The provider might receive multiple 1099s, but that causes little concern.

What is of concern is that when the same provider is entered into the payers’ computer system in multiple ways, it can be difficult to ascertain how many payments were made to an individual provider. Moreover, when the address collected by the payer is a P.O. box rather than the rendering physician’s location, matters become more complicated. This needs to change.

The new request

Now payers are being asked to accurately and comprehensively document individual providers, groups and facilities so the data can be analyzed to measure medical provider performance. They need to collect the physical location where the service was provided and it should be accurately entered into the system in the same way every time. (Note: This is easily done using a drop-down list function rather than manual data entry.)

Most importantly, a unique identifier is needed for individual providers, such as their NPI (national provider identification). Many payers are now stepping up to improve their data so accurate provider performance assessments can be made.

High-value, quality medical providers can be identified by using the data. However, quality data produces better results. Selecting the best medical providers is not a do-it-yourself project. Others will do it for you.

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.

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 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”

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 surface, but it is fraught with challenges. A few are described here, along with a case description of fraud by data proliferation.

Primary Provider
Evaluating the data to determine provider performance quality is tricky. For instance, who among those treating a claimant should be held most responsible for claim outcome? Which provider is the so-called primary provider? Is it the first provider to see the claimant, the provider who has charged the most money, or the one who saw the claimant most frequently? There is no specific indicator in the data denoting primary provider, nor do providers generally self-identify in that way unless they are involved in a formal gatekeeper arrangement. Consequently, for analytic purposes a decision must be made regarding provider influence in the claim, aka, primary provider.

Distinguishing Individual Providers
Another common problem is that individual providers are often not differentiated in the data. Many payers accept bills “as is,” meaning they do not require the billing entities to specify individuals. Typically, individual physicians and other providers are camouflaged under the organization’s Tax ID. In the past, that was adequate because the purpose of the bill was to pay and record the transaction. But that is no longer good enough because of the demand for analytics.

Bills are now a significant piece of the data required for provider performance analytics. Therefore, for individual treating providers, the National Provider Identification number (NPI) or state license number is needed to recognize single medical doctors or other professionals treating claimants. Unfortunately these identifiers are usually not included in the data. Withholding payment is the most powerful method of generating compliance and payers have that power.

Moreover, among data issues, deliberate identity proliferation is even more damaging to accurate provider performance analytics.

Identity Proliferation
Medical fraud surfaces in many forms. Duplicate billing, up-charging, and optimizing charge codes and diagnostic codes (up-coding) are among the most common, but now newly creative methods are being employed by a few. Perpetrators are obfuscating the data to conceal their poor performance by proliferating their identities in the data.

By altering names or addresses slightly, thereby adding to their number, providers are able to cause the system to recognize each variation as a separate entity. That way, multiple provider records are created in the data, even though they are really all the same individual. Proliferating provider records in a data set effectively skews the results of performance analytics.

A Case Of Data Proliferation
Provider identify proliferation was discovered recently when a monthly billing report for an organization was analyzed. Fifty (50!) different name and address iterations for the same medical provider Tax ID were discovered. This had been attempted previously, but this time, the effort was extreme.

Is this provider representing themselves carelessly? Probably not. The provider knows computer systems consider data literally, so each submission would generate a new record, the hoped-for result. Without investigation, the provider’s billing will not be questioned, yet when the provider’s performance is analyzed, the results will be distorted and inaccurate.

The provider vendor will be paid because all 50 iterations have an acceptable Tax ID. However, the problem surfaces when executing provider performance analytics. Different claims are attached to the 50 different records for the provider rather than consolidated in one record for the provider. Performance indicators are distributed across the faux entities rather than consolidated for the single provider, thereby distorting performance results, a new-age form of medical fraud.

Real Solutions
As with many forms of fraud, the solution is to discover and subvert the effort early. Evidence-based quality networks composed of quality individual providers cannot be created using such distorted data. Payers should monitor their data to discover and expose such behavior as it occurs.

Payer systems are culpable, as well. Systems should be designed or updated so that multiple record entry is thwarted, either through administrative procedures for data entry or simple technical methods. Including individual identifiers such as National Provider Identification and state license numbers will add to the solution, forcing accuracy in provider records.

For the case described here, an additional solution was implemented. The multiple provider identities were merged electronically by the analytics company, thereby integrating the occurrences for this perpetrating provider. As a result, the provider’s performance can be analyzed as a whole rather than in fragments.

Because claims actually associated with this provider are distributed across the multiple artificial provider records in the data, analysis of performance is inaccurate. Not surprisingly, when this provider’s data was merged and re-analyzed, the provider ranked in the lowest performance quartile. Gotcha.