Tag Archives: work comp

Appellate Court Rules on IMR Timeframes

The 2nd Appellate District has issued the first of what should prove to be several appellate decisions on the timeliness of independent medical review (IMR) decisions. The court was considering the assertion by a W.C.A.B. panel that IMR timelines are mandatory and that late IMR means the W.C.A.B. — and not doctors — will determine whether treatment is medically necessary.

In SCIF v W.C.A.B. (Margaris), the court annulled the W.C.A.B. decision and remanded with instructions to issue a new decision. The court’s reason for accepting this case was set out early in the decision:

“…We issued a writ of review because this case presents an important issue of first impression regarding the interpretation of section 4610.6, and because it relates to an issue upon which the appeals board has rendered conflicting decisions.”

In its analysis, the court provided an extensive discussion of the history of authorization for medical treatment, the implementation of utilization review (UR) for treatment requests and the enactment of the statutory scheme for IMR.  As noted by the court in SB 228 and 899, the legislature changed both the standards and process used by an employer to evaluate a request for medical treatment. The legislature adopted the medical treatment utilization schedule (MTUS). The legislature then removed the existing process for resolving medical disputes using dueling doctors and required the use of utilization review, which required review of treatment requests in light of the MTUS.

In 2012, the legislature enacted another set of reforms to address disputes over UR determinations. As noted by the court, a UR determination authorizing medical treatment was binding on the employer but became subject to further review through IMR — but only for the employee. The court further observed that even where an IMR determination is ultimately reversed by the W.C.A.B., the issue of medical appropriateness was to be returned to IMR for further review, not decided by the W.C.A.B.

See also: IMR Practices May Be Legal, Yet…  

Turning to the specific issue before it, the court determined the use of “shall” in Labor Code 4610.6 was directive, not mandatory:

“…The appeals board concluded that section 4610.6, subdivision (d), is clear and unambiguous.  According to the appeals board, “shall” is mandatory, and any IMR determination issued after the 30-day time frame is necessarily invalid. In support of this interpretation, the appeals board cited section 15, which provides “‘[s]hall’ is mandatory and ‘may’ is permissive” (§ 15.). Thus, the appeals board concluded that construing “shall” as mandatory, such that an untimely IMR determination is invalid, comports with both the ordinary meaning and the statutory definition of “shall.” As we explain, however, the issue is more nuanced than the appeals board recognized.

We note that section 15, upon which the appeals board relied in this case to support its interpretation of section 4610.6, subdivision (d), juxtaposes “mandatory” against “permissive,” which arguably suggests the legislature used “shall” in the obligatory permissive sense rather than in the mandatory-directory sense, as the appeals board concluded. (See McGee, supra, 19 Cal.3d at p. 960 [discussing section 15 and concluding that “on its face, the statutory language suggests that the legislature intended the present provision to be mandatory (i.e., obligatory), rather than permissive.”]) However, given the difference in meaning given to “shall” in the statutory context, we conclude section 4610.6, subdivision (d), is ambiguous. Accordingly, we move beyond the plain language of that section and consider its meaning with reference to the rest of the statutory scheme and the intent of the legislature.”

The court commented further on this issue:

“Generally, time limits applicable to government action are deemed to be directory, unless the legislature clearly expresses a contrary intent.  (Edwards, supra, 25 Cal.3d at p. 410.) “‘In ascertaining probable intent, California courts have expressed a variety of tests. In some cases, focus has been directed at the likely consequences of holding a particular time limitation mandatory, in an attempt to ascertain whether those consequences would defeat or promote the purpose of the enactment.  [Citations.] Other cases have suggested that a time limitation is deemed merely directory ‘unless a consequence or penalty is provided for failure to do the act within the time commanded.’”

The court also found the lack of a penalty or consequence for noncompliance to be significant. Citing similar language in actions by the state personnel board, which had been held to be directive rather than mandatory, the court suggested a failure to meet the statutory time frame did not result in a loss of jurisdiction. The court also indicates in its review of the mandatory vs. directory dichotomy that statutes that set time frames for government actions that do not include a self-executing consequence are almost universally construed as directory.

The court also noted that construing the 30-day time frame as directory furthers the legislative objective of SB 863.

“We conclude from these findings that the legislature intended to remove the authority to make decisions about medical necessity of proposed treatment for injured workers from the appeals board and place it in the hands of independent, unbiased medical professionals. Construing section 4610.6, subdivision (d), as directory best furthers the legislature’s intent in this regard. The appeals board’s conclusion in this case — that an untimely IMR determination terminates the IMR process and vests jurisdiction in the appeals board to determine medical necessity — is wholly inconsistent with the legislature’s stated goals and their evident intent.

Finally, and perhaps most tellingly, the legislature provided that, “[i]n no event shall a workers’ compensation administrative law judge, the appeals board, or any higher court make a determination of medical necessity contrary to the determination of the independent medical review organization” (Stats. 2012, ch. 363, § 45, codified at § 4610.6, subd. (i)). We find this portion of the statute — particularly the use of the phrase “in no event” — to be a frank expression of the legislature’s desire to remove the issue of medical necessity of proposed treatment from the jurisdiction of the appeals board in all cases subject to IMR. The legislature’s intent would be defeated by giving section 4610.6, subdivision (d), mandatory effect, as the appeals board did in the present case.”

See also: 20 Work Comp Issues to Watch in 2016

Additionally, the applicant attorney argued that the W.C.A.B.’s holding in the Dubon case (Dubon 2) supported the W.C.A.B’s usurpation of authority to decide medical treatment. The court noted the holding in Dubon 2 is supported by the AD’s regulations providing that IMR applies solely to timely and procedurally proper UR but that no similar regulation existed for IMR. The court declined to comment on the W.C.A.B.’s decision in Dubon 2 as the issue was not before it.

Comments and Conclusions:

There are currently two other cases pending in the appellate courts, both in the 3rd appellate district — on this same issue and, interestingly, this case was not the first grant on the issue. However, the court set a very aggressive briefing schedule and, even with multiple amicus briefs it heard, considered and decided this case in, what is by appellate standards, a very short time (less than six months). Clearly the court was very interested in this issue, which had multiple W.C.A.B. panel decisions with conflicting holdings.

The court, in its decision, also rejected arguments offered by both the applicant and the W.C.A.B. that untimely IMR resulted in unnecessary delays — a rationale offered by the majority panel in both Dubon and Margaris. The court, very astutely, noted this argument made no sense given the time frame for obtaining QME opinions or litigating medical treatment issues before the W.C.A.B.  The court pointed out that, even with the delays in completing IMR, the W.C.A.B. decision was more than 13 months after the initial decision in UR and more than 10 months after Maximus rendered its decision. The court was clearly, and properly, skeptical of the argument that letting the W.C.A.B. decide medical issues would result in a more prompt disposition.

The court did offer an option to applicants to challenge untimely UR through the ability to file a petition for writ of mandate to compel a decision. While a statutorily viable option, this is impractical, especially in light of the current timeliness of most IMR determinations. Further, the issue here has never really been the timeliness of IMR. The goal for the applicant attorney bar, and apparently some of the commissioners, has been to usurp the medical decision making process from being medically driven to being litigation-based.

The decision does not provide a lot of nourishment for those who are waiting for some sliver of light on the Dubon 2 issue. The court, in its footnote, declined to really comment on Dubon 2, but it did note there was some basis for the W.C.A.B.’s decision. However, the very strong language of the court emphasizing the public and legislative policy behind having medical decisions made by physicians, and the much greater speed and certainty of the UR/IMR process over the legislatively disfavored litigation process, may provide some hope that, given a chance, the appellate court would also reject the W.C.A.B.’s arguments in support of Dubon 2.

Where the Oklahoma Court Went Wrong

This essay takes issue with the Oklahoma Supreme Court’s recent decision in Torres v. Seaboard Foods to declare some workers’ compensation (WC) laws unconstitutional.

The problem with the opinions of Justices Edmonson, Combs and Colbert isn’t simply that they reached the wrong conclusion — but that they reached it for the wrong reasons.

To justify their decision, all three justices went out of their way to invoke the grand bargain, a historic compromise between employers and employees that guarantees medical and wage replacement benefits to injured workers. Before the grand bargain was struck in 1917, most U.S. employees injured on the job had to sue their employers for damages. The process was often prohibitively expensive, onerous and time-consuming for hardworking citizens who found themselves unable to earn a paycheck — when they needed funds to cover medical bills and other expenses during their convalescence.

The grand bargain is worth championing because it put an end to this intolerable state of affairs, thanks, in part, to luminaries such as Crystal Eastman, who thought an injured worker shouldn’t have to spend “nearly half of (his settlement) to pay the cost of fighting for it.”

See also: Taking a New Look at the ‘Grand Bargain’

Eastman’s emphasis on avoiding long, costly court battles was typical of the thinking that guided the U.S. into embracing the grand bargain.

It is therefore disappointing to see Justice Colbert argue that he is “forced to insure that claimants and employers in the (WC) system have their day in court.” Colbert’s rationale is contrary to grand bargain principles.

The only thing forcing Colbert to such a conclusion is his decision to put the interests of injury lawyers ahead of the interests of injured workers and of the employers who provide the benefits those workers deserve.

If the Oklahoma Supreme Court is as committed to preserving grand bargain principles as Justice Colbert claims, it doesn’t need to do anything revolutionary. It only needs to rule in the same way that it did in 1917, when it initially recognized the state legislature’s ability to pass special legislation concerning WC in the interest of the general public.

This article is the summary of a much longer essay on the topic, which draws on numerous primary and secondary sources and which you can find here.

Power of ‘Claims Advocacy’

“Claims advocacy” is fast getting the attention of workers’ comp claims leaders as a powerful approach to better claims outcomes. The on-demand economy has created cultural and multi-generational expectations around service, speed and simplicity, and some claims leaders have already figured out how to deliver.

The workers’ compensation industry is in the throes of internal debate about mission and purpose.  Employee-centric claims models have become a large part of this debate. Some claims leaders say that payer organizations should move away from a compliance-oriented and, at times, adversarial style to an “advocacy” style of claims management.

Research, too, indicates that claims advocacy is top of mind for industry executives. The responses of 700 participants in Rising Medical Solutions’ Workers’ Compensation Benchmarking Study confirm that many claims leaders know the building blocks of advocacy and recognize its potential value. 

We recently interviewed claims leaders to better understand the practical meaning of the concept, as it applies to all claims operations, from self-administered employers to insurers handling claims for thousands of policyholders.

What Is Claims Advocacy?

We asked Noreen Olson, workers’ compensation manager with Starbucks, for a definition of advocacy.  (Starbucks employs 180,000 “partners” worldwide and has close to 12,000 outlets in the U.S.) Olson proposed this:

“In workers’ comp, advocacy is a process grounded by the values of dignity, respect and transparency that coordinates activities to assist the injured worker effectively and promote expectancy and engagement in recovery, efficiently restores (and often improves upon) health and well-being, and resolves the experience in mutual satisfaction.”

Others we spoke with endorsed this or a similar definition. They all have in mind not a checklist, nor a charm offensive, but a culture.  A claims culture that makes access to benefits simple and builds trust – and one that must be supported by executive buy-in, organizational values, technology and operating systems to be successful.

Access to benefits from the worker’s perspective includes ease of filing a claim, ease in obtaining prescribed medications, access to medical specialists and help in navigating the healthcare maze. Along the course of injury recovery, there are many opportunities that affect access and trust as perceived by the worker. The highly respected Workers’ Compensation Research Institute reports in its Predictors of Worker Outcomes Series that “trust” is a key driver of claims outcomes.

See also: How Should Workers’ Compensation Evolve?

Why Now?

Tom Stark, technical director of workers’ compensation at Nationwide Insurance, told us that advocacy has been around for a long time. He’s practiced advocacy since the 1980s Several forces converge to promote advocacy in claims today. Claims leaders are emphasizing, or perhaps “reemphasizing,” the importance of interpersonal relations. As claims handling has shifted from onsite home visits to lower contact models, the importance of emotional intelligence, soft skills and customer service skills is greater than ever to dispel uncertainty and engender trust.

Perhaps the biggest driver of customer service and transactional speed is the American retail sector. Its massive engagement in these areas has shaped everyone’s expectations – of all generations. Millennials, born in the 1980s and 1990s, in particular have grown up with this customer-focused approach and therefore bring to the claims environment high expectations for both delivering and receiving quality service. Slow, bureaucratic responses can shock injured workers. Darrell Brown, chief claims officer at Sedgwick, says, “We are now an on-demand economy. That is the way it is.”

Why Is Claims Advocacy Attractive?

Brown says that engaging the injured worker is key. Fast and helpful response to injury pays off in worker satisfaction and lower claims costs. “People file claims, but they don’t know what is going to happen. If you lose injured workers at the beginning of the claim, to anxiety and fear, they go to litigation.” Brown also says that when claims professionals engage more constructively with injured workers, their own experience is better. This leads to better morale and talent retention.

For employers, claims advocacy provides a special opportunity to directly align work injury response with their corporate brand, core values, employee communications and benefit delivery.

Walking the Walk

Albertsons Safeway, with more than a quarter million “associates” in 34 states, has crafted its claims approach to reinforce engagement and confidence for the injured workers. Director of Managed Care and Disability Denise Algire, who is also the principal researcher for the Workers’ Compensation Benchmarking Study, says that staff talks with injured employees on the day of injury. “We focus on education and reducing uncertainty,” she says.  They avoid potentially intimidating or antagonistic terms like “adjusting,” “examining” and “investigating.” They also start with the positive expectation that every employee wants to return to work. “Workers’ compensation has become adversarial because we manage the system based on the deceptive few versus the deserving many,” she says. “Our claims approach is based on the majority, not the minority.”

Brown talked to us about tangible actions. “If you can make a compensability determination in two days, even though the law gives you 14 days, imagine how much uncertainty and anxiety is removed,” he says. “The same applies to indemnity payments. The industry is often guided by regulatory requirements. If you can take action and make payments sooner, why make it later? You’ve got to walk the walk.” Starbucks, for example, direct deposits indemnity checks into employees’ accounts to increase speed.

Advocacy does not hinder organizations from being compliance-minded. Rather, it becomes one aspect of a holistic, customer-driven framework that aims higher than the bar often set by regulatory standards.

See Also: How to Win at Work Comp Claims

Barriers to Overcome

Stark sees lagging technology as getting in the way of engaging the injured worker. To him, claims tasks grew exponentially while support staff in claims offices were cut. Claims technology has often not kept up. He says, “Look at the work-arounds – count the number of sticky-notes on the adjuster’s screen. If technology is not there to support effective claims management, even in its most transactional form, you are really stressing the model. How are you going to be an advocate?”

Olson brought up two challenges that Starbucks has solved but still confront most employers. She believes that it is important to make it as easy as possible for a partner to report an injury. At Starbucks, they not only have web, mobile and call center options, they also allow partners to self-report their injuries versus going through their manager or HR.

Olson additionally stresses the importance of easily moving the partner to other benefit programs if the injury is not compensable and to avoid language like “your claim is denied.” She says that placing the award of benefits in the “right benefit bucket” needs to be done seamlessly so that the partner does not feel on the hook. In addition to the state mandated language in these instances, Starbucks includes its own letter that communicates that, while the claim isn’t eligible for workers’ comp, the partner may be eligible for other benefits to help with their injury/illness.

One barrier that Algire notes – simply “rebranding” claims adjusters as advocates is not enough. “A true cultural shift will require organizations to move beyond performance metrics that are based primarily in cost containment to those based on clinical quality, functional outcomes and patient satisfaction,” she says. This shift is critical to “walking the walk” and reinforcing the advocacy approach with claims staff.

Conclusion

The on-demand economy has created cultural and multi-generational expectations around service, speed and simplicity – giving workers’ compensation a blueprint for claims advocacy. Embracing consumer-driven models around injury recovery is emerging as a competitive advantage, both from a claims outcomes and a talent recruitment/retention perspective.

The 2016 Workers’ Compensation Benchmarking Study will be surveying claims leaders on advocacy, among other pressing topics, to better understand its current application and perceived viability.  A copy of the 2016 Study report may be ordered here.

How to Win at Work Comp Claims

So many people want to blame the injured worker for the high cost of workers’ compensation; they say the worker doesn’t want to get better.

But consider these two patients, limping into two different medical clinics with the same complaint. Both have trouble walking and appear to require hip surgery. The first patient is examined within the hour, is X-rayed the same day and has a time booked for surgery the following week. The second sees the physician after waiting three weeks for an appointment, then waits eight weeks to see a specialist, then gets an X-ray, which isn’t reviewed for another week, and finally has surgery scheduled for six months later, pending the review of a utilization board, which will determine the employee’s remaining value to his employer. Why the different treatment for the two patients? The first is a Golden Retriever taken to a veterinarian. The second is an injured employee entering the workers’ compensation system.

Maybe we need to send our injured employees to a good vet!

The No. 1 cost driver of a workers’ compensation claim is that the injured worker is not getting better. But the sad reality is that the injured worker isn’t even given an honest opportunity. Everyone just wants to kick the can down the work comp road, believing the best way to save money is by limiting treatment opportunities.

Look at back pain, which is the most expensive industrial injury and the most common cause of disability in patients under 45 years of age. More than five million Americans are disabled by back pain, and more than half of those will develop a permanent condition. Studies show that direct healthcare expenditures exceed $20 billion annually, and indirect expenditures associated with back-related injuries are greater than $30 billion. Disorders of the musculoskeletal system are the most common causes of absence from work in both men and women between the ages of 30 and 65. Back pain is the dominating subgroup and is the second leading cause of workplace absenteeism.

See Also: How Should Workers’ Compensation Evolve?

There are plenty of statistics showing the direct costs associated with occupational back injuries average $37,000. Indirect costs range from $147,000 to $300,000.

It therefore follows that if an employer could redirect its resources and attention to the aggressive treatment of the acute back pain patient, with a view to preventing chronicity, the company would be able to reduce costs.

In fact, we have a proven system that has direct and indirect cost savings; however, it requires the employer to take control of its workers’ comp group and change the way business is being done.

Unfortunately, only a small minority of employers play at the tip of the spear and way too many employers who sit on the sideline and expect everyone else to take care of the issues.

So, we are challenging you, the employer, to get in the game, change your team line-up and win the game of managing your workers’ compensation division.

Here’s how:

Once the injured employee enters the world of workers’ compensation as either a medical, indemnity or future medical claim, the healthcare professional becomes one of the key decision makers in the employee’s recovery and return-to-work. Usually, the professional helps the injured worker recover through minimum symptomatic treatment protocols authorized by utilization review boards and return to her job in a modified duty capacity with appropriate restrictions.

The employee comes back to work, with restrictions, and in most cases the safety supervisor or human resources person assists in monitoring the employee to verify that the healthcare professional’s recommendations are being reasonably accommodated.

In a perfect world, this scenario may work. The employee recovers, the medical bills are paid and the work tasks are re-evaluated. However, in most cases, once the employee is injured, delayed treatment ensues, the injured worker develops co-morbidities associated with his injury, an applicant’s attorney gets involved and the reserves then begin escalating. At this point, any optimal solution becomes a distant thought. The only player who has the incentive to change the game is the one paying the bills… the employer!!

How can an employer change the workers’ compensation cycle to bring about solutions for all the players involved? It takes moral courage to change your team line-up and manage your claims better. Can it be done? Absolutely, and we’ve done it.

Employers have historically taken an adversarial approach to workers’ compensation claims even though the law is on the employee’s side. It makes sense to immediately engage the injured employee and set the expectations for recovery. This is part of the overall strategy to create a claims handling “team” that will align with the core competencies of the business environment. Setting the team line-up to implement an active approach to claims management will be a game changer.

As an employer, here’s an outline of what this would look like:

  1. Identify your team members; business unit manager, risk manager, safety professional, claims examiner manager, claims examiner, medical director, healthcare providers, nurse case manager, legal counsel and medical fitness consultant.
  2. Have a prominent seat at the workers’ compensation round table, whether you are fully insured or a self-insured employer.
  3. Know the workers’ compensation claim life cycle and your role in influencing outcomes.
  4. Be sure the claim examiners on your files know and understand the employer’s risk management goals and objectives.
  5. Have essential job functions (EJFs) for all positions readily accessible for the healthcare professionals and claims examiner.
  6. Perform quarterly claim review meetings on all open and recently closed claims. The meetings should include your entire workers’ comp team, so discussions can progress around treating the whole person and not just the affected body part. Remember, at some point a body part adds to the potentially new claim of cumulative trauma.
  7. As the employer, limit the claim examiner case load to 100 claims or less per examiner. This allows for more in-depth understanding of claim resolution solutions in addition to claims handling by regulatory deadlines.
  8. Make sure your insurance broker supports your desire to incorporate a medical aftercare program managed by a medical fitness organization that understands the workers’ compensation process and your strategic claims management system.

Savvy Health Solutions has worked strategically with employers as part of their claims management team and addresses the whole person by focusing on improving overall strength and flexibility, postural responsiveness to activities of daily living and a motivational element that embeds the components of the program into sustainable lifestyle changes. Savvy has found that, the sooner an employee begins the program, the quicker the employee is returned to full duties, and the claim is closed:

  1. The safety person, now having a more comprehensive understanding of musculoskeletal issues, can revisit the company’s job hazard analysis for accuracy and completeness. This technique breaks each job down into individual tasks to identify hazards and focuses on the worker, the task, the tools and the work environment. The analysis is also a key component for compliance with OSHA’s injury and illness prevention program requirements.
  2. The claims examiner is educated on the work environment. With fewer claims to handle, the examiner can spend extra time on the job to better understand the work environment from an employee’s perspective. Essential job functions and job hazard analysis have more meaning once seen in action. Claims examiners will begin to understand how people do the work, in addition to meeting the expectations of the Department of Workers’ Compensation in managing a claim.
  3. A team approach helps the claims examiner to think more like a business person. Outside consultants, like Savvy Health Solutions, help the employer see a new way of claims resolution and prevention of further injuries.
  4. The effectiveness of the workers’ compensation team can be measured with metrics created as part of your annual insurance renewal process/contract or as part of your third party administrator contract renewal.

Too many internal silos and “leaving it to the claims experts” can run against a culture of treating employees with respect and dignity when injured. The employer needs to be the key stakeholder in the process, having the same key performance indicators (KPIs) for workers’ compensation as it is done for safety metrics and profitability.

This methodology is counterintuitive to the typical workers’ compensation claims handling structure. Success starts with the employer and involves every single team member, business unit manager, risk manager, safety professional, claims examiner manager, claims examiner, medical director, healthcare providers, nurse case manager, legal counsel, insurance agents and brokers and medical fitness consultants.

Developing a winning line-up with your team will improve your ability to control costs and reach a desired outcome for the employee first, and then the organization. Because when the injured employee recovers from his injury, restores normal function and improves quality of life, then everyone wins.

Confusion Reigns on Predictive Analytics

It seems everyone in workers’ compensation wants analytics. At the same time, a lot of confusion persists about what analytics is and what it can contribute. Expectations are sometimes unclear and often unrealistic. Part of the confusion is that analytics can exist in many forms.

Analytics is a term that encompasses a broad range of data mining and analysis activities. The most common form of analytics is straightforward data analysis and reporting. Other predominant forms are predictive modeling and predictive analytics.

Most people are already doing at least some form of analytics and portraying their results for their unique audiences. Analytics represented by graphic presentations are popular and often informative, but they do not change behavior and outcomes by themselves.

See Also: Analytics and Survival in the Data Age

Predictive modeling uses advanced mathematical tools such as various configurations of regression analysis or even more esoteric mathematical instruments. Predictive modeling looks for statistically valid probabilities about what the future holds within a given framework. In workers’ compensation, predictive modeling is used to forecast which claims will be the most problematic and costly from the outset of the claim. It is also the most sophisticated and usually the most costly predictive methodology.

Predictive analytics lies somewhere between data analysis and predictive modeling. It can be distinguished from predictive modeling in that it uses historic data to learn from experience what to expect in the future. It is based on the assumption that future behavior of an individual or situation will be similar to what has occurred in the past.

One of the best-known applications of predictive analytics is credit scoring, used throughout the financial services industry. Analysis of a customer’s credit history, payment history, loan application and other conditions is used to rank-order individuals by their likelihood of making future credit payments on time. Those with the highest scores are ranked highest and are the best risks. That is why a high credit risk score is important to purchasers and borrowers.

Similarly, workers’ compensation claim data can be collected, integrated and analyzed from bill review, claims system, utilization review, pharmacy (PBM) and claim outcome information to score and rank-order treating physicians’ performance. Those with the highest rank are the most likely to move the injured worker to recovery more quickly and at the lowest cost.

Both predictive modeling and predictive analytics deal in probabilities regarding future behavior. Predictive modeling uses statistical methods, and predictive analytics looks at what was, is and, therefore, probably will be. For predictive analytics, it is important to identify relevant variables that can be found in the data and take action when those conditions or events occur in claims.

One way to find critical variables is to review industry research. For instance, research has shown that, when there is a gap between the date of injury and reporting or the first medical treatment, something is not right. That gap is an outlier in the data that predicts claim complexity.

Another way to identify key variables is to search the data to find the most costly cases and then look for consistent variables among them. Each book of business may have unique characteristics that can be identified in that manner.

Importantly, predictive analytics can be used concurrently throughout the course of the claim. The data is monitored electronically to continually search for outlier variables. When predictive outliers occur in the data, alerts can be sent to the appropriate person so that interventions are timely and more effective.

For example, to evaluate medical provider future performance, select data elements that describe past behavior. Look at past return-to-work patterns and indemnity costs associated with providers. If a provider has not typically returned injured workers to work in the past, chances are pretty good that behavior will continue.

For organizations looking to implement analytics, those who have already made the plunge suggest starting by taking stock of your organization’s current state. “The first thing you need to know is what is happening in your population,” says Rishi Sikka, M.D., senior vice president of clinical transformation for Advocate Health Care in Illinois. “Everyone wants to do all the sexy models and advanced analytics, but just understanding that current state, what is happening, is the first and the most important challenge.”

The accuracy and usability of results will depend greatly on the quality of the data analyzed. To get the best and most satisfying results from predictive analytics, cleanse the data by removing duplicate entries, data omissions and inaccuracies.

For powerful medical management informed by analytics, identify the variables that are most problematic for the organization and continually scan the data to find claims that contain them. Then send an alert. Structuring the outliers, monitoring the data to uncover claims containing them, alerting the right person and taking the right action is a powerful medical management strategy.