Controlling Medical Severity through Modeling Risk Identification

Presentation to Oregon Self-Insurers Association

Controlling Medical Severitythrough Modeling Risk

Identification

July 12, 2012

© 2011 GENEX Services, Inc.2

Presenters

Dawn Yang, RN, MSN, CCMGENEX Services, Inc.


Presentation Outline

Overview of Predictive Modeling Targeting Risk throughout the Life of a

Claim Operational Impact Clinical Alerts Case Study Application Questions

© 2011 GENEX Services, Inc.

Overview of Predictive Modeling


Predictive Modeling: Definition


Predictive Modeling: Examples

RETAIL MARKETING

Past purchases predict future sales.

LAW ENFORCEMENT

Past crimes predict future patrols.

CREDIT SCORING Past payments predict future loans.

P&C INSURANCE Past behavior predicts future losses.


Predictive Modeling: Claims Predict which claims are

Costly/complexLikely to benefit from case management

Identify claims with demonstrated riskClinical alertsMedication safety


Targeting Risk Throughout the Life of a Workers’ Compensation

Claim


Targeting Risk Throughout the Life of a Claim

Early Intervention for Predicted Risk

Deferred Intervention for Demonstrated Risk

DATA Claim level Medical and pharmacy bills

TYPE OFINTERVENTION

Telephonic during 1st 30-60 days following injury

Telephonic or fieldbased on need

Operational Impact


Early Claim IdentificationClaim Data

Nature of injury

Gender

Claim type

Wage

Job class code

Cause of injury

Jurisdiction

Date of injury

Claimant age

Body part

Claim Scoring Engine

SCORE

Do notmanage

Nurse TriageDecision Manage

Clinical Alerts


Demonstrated Risk: Clinical Alerts

InterventionActionIdentification

Clinical profile

generated for nurse triage

Nurse review

Flagged in data

warehouse

Pend in bill review

Bill data and history compared

toclinical criteria

Based on Medical Bills


Mid-Claim Identification: Clinical Alerts Clinical profile triggers include:

Physical medicine utilization Surgical indicators

Bill review triggers include: Appropriateness of care (related/reasonable for

injury)

Customer-specific


Clinical Profile


Demonstrated Risk: Medication Safety

ImpactActionIdentification

Clinical Intervention

• Early intervention case management

• Provider Outreach• Pharmacy reviews• Patient Education• Complex Case

Management for future claims

Analysis of Claims and Rx

Bill Data

Narcotic Therapy

Management• Improve patient

health and safety• Increased

productivity• Eliminate fraud and

inappropriate utilization patterns

Based on Pharmacy Charges

Case Manager Triage

Confi

rmat

ion

of R

isk


Mid-Claim Identification: Medication Safety

Medication Safety AlertsUse of narcotics and other controlled

substances Multiple prescribing physicians or

pharmaciesHigh prescription fill quantities or

frequencyClaimant history of substance abuse

Case Study Application


Case Study Application

19

Pain• Mid-case claim

file, missed TCM intervention,

• Ability to validate an injured employee’s current treatment plan (including medications) when objective and subjective findings do not correlate,

• Injured employee says one thing, treating provider documents another.

Remedy• Excessive PT Clinical Alert fired identifying missed opportunity for TCM,

• Clinical Alert profile shows summarized detailed treatment plan (modalities) to facilitate TCM discussion with provider regarding excessive PT overall lack of progress,

• Concrete validation of treatment plan,

• Continuous Referral Expert evaluation for other missed TCM opportunities.


Benefits Complements case management/clinical

expertise Supports variable staffing levels across program Cost-effectively touch every claim Improve visibility into medical exposure Tool not rule System catches what people miss


Thank YouFor more information, please contact:

Dawn Yang, RN, MSN, CCMGENEX Services Inc.Director of Case Management Services, Western [email protected]

Documents

Controlling Medical Severity through Modeling Risk Identification