Embed Size (px)
Citation preview
Running head: MEDICAL MANAGEMENT INTERNSHIP PAPER
1
Medical Management Internship Paper
Richard Krasner
Florida Atlantic University
HSA 6855
Health Administration Internship
Dr. Palkon
August 6, 2011
Running head: MEDICAL MANAGEMENT INTERNSHIP PAPER
2
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.
Running head: MEDICAL MANAGEMENT INTERNSHIP PAPER
3
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
Running head: MEDICAL MANAGEMENT INTERNSHIP PAPER
4
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).
Running head: MEDICAL MANAGEMENT INTERNSHIP PAPER
5
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
Running head: MEDICAL MANAGEMENT INTERNSHIP PAPER
6
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.
Running head: MEDICAL MANAGEMENT INTERNSHIP PAPER
7
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.
Running head: MEDICAL MANAGEMENT INTERNSHIP PAPER
8
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.
Running head: MEDICAL MANAGEMENT INTERNSHIP PAPER
9
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
