Medical Management Internship Paper

Running head: MEDICAL MANAGEMENT INTERNSHIP PAPER

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Medical Management Internship Paper

Richard Krasner

Florida Atlantic University

HSA 6855

Health Administration Internship

Dr. Palkon

August 6, 2011


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Introduction

Before deciding on where I wanted to do my internship in the summer of 2011, I knew

that I wanted to do something that had some relevance to my previous work experience in

workers’ compensation claims that could be related to health care. A large part of the process of

handling workers’ compensation claims has to do with managing the medical care and treatment

of the injured worker, and I wanted to learn more about what goes into managing the medical

side of workers’ compensation. I was able to secure an internship with a Third Party

Administrator company called Broadspire, a part of Crawford & Company, a Claims

Management company well-regarded in the Claims industry.

I secured my internship through a posting in several discussion groups on the social

networking site for professionals called LinkedIn. I was contacted by Nancy Murphy, the

National Compliance Manager for Medical Management at Broadspire’s office in Sunrise. I met

with Nancy and JJ Schmidt, one of the Vice Presidents there in March, and we discussed several

projects they wanted to assign me when I started.

The offer letter I received in May listed several projects they wanted me to work on.

They consisted of the following tasks:

Analyze cost impact of Preferred Provider Organization (PPO) physician

dispensed medications.

Reviews contracts, fee schedules and variances by state, network and provide type

to determine cost reduction strategies.


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Create business proposals for Medical Product and Drug Liability Services and

for Independent Review Organization (IRO) product expansion in non-

occupational markets.

Create internal marketing plans for Medical Management Services designed to

increase utilization of services and increase customer satisfaction levels.

Coordinate encryption for all external vendors and medical providers to ensure

compliance with medical data and privacy requirements.

Develop and maintain a policies and procedures database which includes links to

external resources.

Projects

When I started my internship, I was assigned to research the rules, regulations and

statutory requirements for the posting and creation of panel cards that are placed in an

employers’ place of business and inform the injured worker which medical providers they can go

to. I was given access to their Lotus Notes database called the Jurisdictional Guidelines database,

or JuD, as they call it, and reviewed the information that was already posted there by other

company employees. I then set about researching through the Internet into the various state

workers’ compensation or insurance department websites to see what the statutes, rules or

regulations said about the posting of panel cards.

One of the only states that actually has rules on how and what to post on the panel cards

is the state of Georgia. Rule 201. Panel of Physicians states “that an employer may satisfy the

requirements for furnishing medical care under O.C.G.A. § 34-9-200 in one of the following

manners: (1)(i) The employer may maintain a traditional posted panel of physicians that shall

consist of at least six non-associated physicians, but is not limited to a minimum of six…The

minimum panel shall include an orthopedic physician, and no more than two physicians shall be

from industrial clinics. Further, this panel shall include one minority physician. The minority


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physician so selected must practice within the State of Georgia or be reasonably accessible to the

employee's residence.” (Georgia Workers’ Compensation Rules and Regulations, 2011).

I contacted other states by telephone by focusing on those states that have the most

billing volume for Broadspire. Some states, such as California and Louisiana were not called

either because of legal issues or some other reason. The majority of the states do not have any

statutes, rules or regulations concerning the posting of panel cards, but they do have rules

regarding whether the employer or employee has the right to choose the treating physician. Most

of this information was already listed in their Jurisdictional Guidelines database, and I replaced

broken website links and added additional information.

The next large project I worked on concerned the automation of the process of creating a

report for one of the Account Executives who would manually take data from an Excel

spreadsheet and create the report in MS Word. The Health Check Report used data from each of

the various branch offices, aggregated by state, on a bi-monthly basis to analyze the penetration

of the company’s Field Case Management (FCM), Telephonic Case Management (TCM) and

Utilization Management (UM) services.

Field Case Management services include some of the following services: full medical

management services such as catastrophic case management, crisis intervention, full vocational

case management and specific limited or task assignments for services such as job analysis, job

club (in select markets), transferable skills analysis, labor market surveys, job development

and placement, earning power evaluations (state specific), ergonomic evaluations, and expert

testimony, (Broadspire Services, Inc. 2011; Coventry Health Care Workers Compensation, Inc.,

2011).


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Telephonic case management (TCM) services focuses on a proactive strategy that

stresses early intervention to successfully manage medical issues that may impede a prompt,

healthy return to work. This is accomplished by the following activities:

Assessment of the medical needs of injured workers

Review and evaluation of treatment options

Coordinate and facilitate of effective communication among employers,

employees, claims personnel and others to help expedite timely returns to work

Physician review services with contracted physicians in multiple specialty areas

Broadspire’s TCM services achieve a 97% rate of successful closures and healthy returns to

work, (Broadspire Services Inc., 2011).

Utilization Management (UM) services typically include the following:

An in-house medical department, with contracted physicians in multiple specialty

areas

Prospective/pre-admission/pre-certification/pre-authorization review to evaluate

and determine proposed treatment plan necessity and appropriateness

Concurrent review of continued services during inpatient hospitalization or

outpatient treatment

Retrospective review of all medical records following discharge from treatment

Pharmacy review to identify early over-utilization and inappropriate prescription

use

Utilization Management services, therefore are an important component of any claims

management process, (Broadspire Services Inc., 2011).

The Health Check Report consisted of arbitrary targets set by the Account Executive, for

each of the three types of services, TCM, FCM and UM that Broadspire provides its clients.

Instead of creating the report on a bimonthly basis, it was decided by both the Account Executive


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and my supervisor, Nancy Murphy, that we could do a full years report with a Year-to-Date total

at the end of the table. Every month, the four Excel spreadsheets that the Account Executive used

to create her Health Check Reports would now be save to four separate spreadsheets named

according to either the system that created the originals, or the type of report (TCM or UM,

followed by the year, e.g., TCM2011 or UM2011). These spreadsheets were then linked by me to

spreadsheets I created that would calculate the penetration percentages for the FCM, TCM and

UM services, for each state from the branches in that state or region, and then those spreadsheets

were linked to the final report in the same workbook, so that the process would not entail any

human data entry or calculations.

The last project, which I am currently working on, involves analyzing the total charge

amounts and total savings of prescription drugs from Preferred Provider Organizations (PPO’s)

versus non-PPO’s, for California, Florida and All Other States. The data was created off-site and

consisted of over 65,000 records that were not properly organized, so part of the project so far

has concerned breaking down the data into component parts such as by Network for California,

by Network for Florida (All Other States has not been done), then by Provider for California, and

then by Medication Prescribed for California, which I will attempt to work on this final week.

So far, in analyzing the Network data in California, I have found one network (PPO) that

has the highest total charge amount and highest total savings, based upon the total allowance

amount under the contract. The same hold true for Florida, but the networks are not the same. In

analyzing the data for providers, I have found so far, that there are several providers that are

charging in excess of $50,000 in prescription medication, many of them are physicians, and

some are pain management centers and pharmacies or pharmacy benefit managers.


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California was not included in a recent report issued by the Workers’ Compensation

Research Institute entitled, Prescription Benchmarks, 2nd Edition: Trends and Interstate

Comparisons, because the numbers contained a mix of pre-reform and post-reform experience. A

summary of the findings found that Florida was among the 17 states studied that had the highest

average prescription costs per claim. In California, statutory changes to their fee schedule in

March of 2007 to equalize prices for physician- and pharmacy-dispensed prescriptions, did not

prevent physicians from dispensing, although they did so with non-repackaged drugs, (Workers’

Comp Research Institute (WCRI), 2011, International Association of Industrial Accident Boards

and Commissions (IAIABC), 2011).

It would be interesting to see if Broadspire’s claims for Florida match the findings of the

WCRI report, and if the data for California is any indication, it most probably will reflect the

same findings of the WCRI. In looking at both sets of data, I am finding that the drugs mentioned

in the WCRI report are heavily prescribed in both California and Florida, which is logical since

most of the medications are either pain drugs or muscle relaxants, or similar drugs that are

prescribed for work-related injuries.

My preliminary analysis of the data does show where Broadspire can do an much more

detailed analysis and then make a determination as to which PPO’s and which providers they

will need to work with to bring down the total charges, which will increase their overall total

savings. These savings could conceivably be in the millions of dollars, and carried out in Florida

and the other states, will save Broadspire even more in prescription drug expenses.


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Conclusion

My internship at Broadspire has provided me with an opportunity to learn the medical

management side of workers compensation, and allowed me to get back into the “saddle” where

I began my career. It was a pleasant experience that gave me some insight to the workings of a

claims management and third party administration organization. My hope is that I can parlay this

experience into a full-time position with the right company. Unfortunately, time will not permit

me to complete my last project, which in its scope is very large, and could go on for a long

while. However, I did learn some valuable new skills, and have also regained my focus as to

what I would like to do after graduation. Overall, I am pleased that I had this experience.


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References

Broadspire Services, Inc., 2011. Field Case Management Services. Retrieved from

http://www.choosebroadspire.com/medmgmt/fieldcasemgmt/overview.aspx

Broadspire Services, Inc., 2011. Telephonic Case Management Services, Retrieved from

http://www.choosebroadspire.com/medmgmt/telephonecare.aspx

Broadspire Services, Inc., 2011. Utilization Management Services, Retrieved from

http://www.choosebroadspire.com/medmgmt/utilitymgmt.aspx

Coventry Workers’ Comp Services’ (“CWCS”), 2011. Field Case Management Services,

Retrieved from

http://www.coventrywcs.com/web/groups/public/@cvty_workerscomp_coventrywcs/doc

uments/webcontent/c000477.pdf

Georgia State Board of Workers’ Compensation, 2011. RULES AND REGULATIONS OF THE

STATE BOARD OF WORKERS’ COMPENSATION, Retrieved from

http://www.files.georgia.gov/SBWC/Files/Rules2011.pdf

International Association of Industrial Accident Boards and Commission, 2011. IAIABC

Pharmacy Slides 7-19-2011 Retrieved from http://www.iaiabc.org/

Workers’ Compensation Research Institute, 2011. Prescription Benchmarks, 2nd Edition”

Trends and Interstate Comparisons, Retrieved from

http://www.wcrinet.org/new_electronic_rpts/rx_bnchmks_2/wcri_rx_bnchmk_2_MS.pdf

http://www.choosebroadspire.com/medmgmt/fieldcasemgmt/overview.aspx

http://www.choosebroadspire.com/medmgmt/telephonecare.aspx

http://www.choosebroadspire.com/medmgmt/utilitymgmt.aspx

http://www.coventrywcs.com/web/groups/public/@cvty_workerscomp_coventrywcs/documents/webcontent/c000477.pdf

http://www.coventrywcs.com/web/groups/public/@cvty_workerscomp_coventrywcs/documents/webcontent/c000477.pdf

http://www.files.georgia.gov/SBWC/Files/Rules2011.pdf

http://www.iaiabc.org/

http://www.wcrinet.org/new_electronic_rpts/rx_bnchmks_2/wcri_rx_bnchmk_2_MS.pdf

Healthcare

Medical Management Internship Paper