presentation to oregon self-insurers association controlling medical severity through modeling risk...
TRANSCRIPT
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.
© 2011 GENEX Services, Inc.3
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
© 2011 GENEX Services, Inc.5
Predictive Modeling: Definition
© 2011 GENEX Services, Inc.6
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.
© 2011 GENEX Services, Inc.
Predictive Modeling: Claims
Predict which claims are
Costly/complex
Likely to benefit from case management
Identify claims with demonstrated risk
Clinical alerts
Medication safety
© 2011 GENEX Services, Inc.
Targeting Risk Throughout the Life of a Workers’ Compensation
Claim
© 2011 GENEX Services, Inc.
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
© 2011 GENEX Services, Inc.11
Early Claim Identification
Claim 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
© 2011 GENEX Services, Inc.
Demonstrated Risk: Clinical Alerts
Intervention
ActionIdentificationClinical 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
© 2011 GENEX Services, Inc.
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
© 2011 GENEX Services, Inc.
Clinical Profile
© 2011 GENEX Services, Inc.
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
Con
firm
ati
on
of
Ris
k
© 2011 GENEX Services, Inc.
Mid-Claim Identification: Medication Safety
Medication Safety Alerts
Use of narcotics and other controlled substances
Multiple prescribing physicians or pharmacies
High prescription fill quantities or frequency
Claimant history of substance abuse
Case Study Application
© 2011 GENEX Services, Inc.
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.
© 2011 GENEX Services, Inc.
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
© 2011 GENEX Services, Inc.21
Thank You
For more information, please contact:
Dawn Yang, RN, MSN, CCMGENEX Services Inc.Director of Case Management Services, Western [email protected]