Sandy's Corner

Medata-ODG Study Shows that Focusing on Quality of Care Can Also Lead to Savings

“More with less, do more with less,” that is the mantra we routinely hear in business today. But what about changing this dynamic and beginning to do “more with more but with less effort?” Still, as technology allows companies to gather and aggregate more-and-more data it also allows companies to become buried under more-and-more data; however, it is this data that will propel companies to become more efficient, effective, and profitable. Yet when we look at the promises of the past it is understandable to see why many companies believe that this idea of using more technology and more data to increase efficiencies and cut costs appears more onerous than realistic.

Quality medical care at the appropriate time and cost is the balance we are constantly seeking in the workers’ compensation (WC) industry, but to achieve this balance requires large quantities of case-by-case, real-time data being sifted against millions of pieces of medical data. In order to more effectively and efficiently provide the most accurate and appropriate utilization of care, the industry began turning to evidence based medicine guidelines (guidelines). The Journal of the American Medical Association (JAMA) succinctly summarized the purpose and use of guidelines: It involves combining the best research evidence with the patient’s values to make decisions about medical care. Looking at all available medical studies and literature that pertain to an individual patient or a group of patients helps doctors to properly diagnose illnesses, to choose the best testing plan, and to select the best treatments and methods of disease prevention. … In addition to improving treatment, such guidelines can help individual physicians and institutions measure their performance and identify areas for further study and improvement.

There are a number of vendors providing guidelines within the WC industry, but the bulk of the industry is served by the Reed Group’s American College of Occupational and Environmental Medicine’s (ACOEM) Practice Guidelines and the Work Loss Data Institute’s Official Disability Guidelines (ODG). Independent studies have consistently shown that the integrated use of guidelines within the WC claims process can dramatically increase positive claim outcomes and reduce overall claim costs by allowing the payor and the medical provider to work together as partners to identify the most appropriate and necessary medical treatment for the injured worker over the entire course of the claim.

To prove how powerful the full and automated integration of guidelines can be for WC carriers/payors, Medata partnered with one of its multi-state customers to conduct a study which reran three months of extremely well-managed claims data against the ODG Treatment UR Advisor. The study found an additional 15 percent in cost savings from questioned medical procedures representing over seven figures in medical costs. If this is such a well-run carrier (and it is a very well-run carrier), how can there have been such a noteworthy potential finding of additional questioned care? The short answer is that no matter how good you are, it simply takes more to do more. It takes significantly more data run at deeper and deeper levels to yield more information for the adjuster to use in making her/his decision(s).

Because this level of full integration is essential but beyond most company’s allocated resources and capacities, Medata strategically joined its professional resources with ACOEM (through the Reed Group) and the Work Loss Data Institute (WLDI) to do design and implement a full, seamless integration of ACOEM’s, Reed’s, and WLDI’s guideline data and procedure crosswalks into Medata’s software, thereby allowing its customers to do more with more but with less effort. By having automated access to the ICD code(s), the CPT code(s), age, sex, and other key claimant data, Medata is able to automatically crosswalk key data elements to the guideline and advise payors on a claim-by-claim basis how this claim is developing as compared to: the frequency of use for each medical procedure; the expected disability durations for similar injured workers; and, average duration trends. This integration allows Medata to offer its customers the full power of guidelines without having to acquire, integrate, and maintain the entire set of databases and crosswalk tables within their system.

While each of the guideline providers has done an incredible job of distilling their evidence and data down to very user-friendly formats, the reality is their products are collections of millions of pieces of information representing billions of dollars in claims history which preclude even the very best adjuster from effectively hand comparing this quantity of data to each and every claim he/she has under her/his control. ODG, for example, in its entirety is a vast and far-reaching database of return-to-work guidelines, disability duration normative data, statistics on medical and indemnity costs in WC, incidence and prevalence figures, and treatment guidelines for work-related conditions broken into 16 core chapters with each chapter broken into three sections (Treatment Planning, Codes for Automated-Approval, and Procedure Summary). The complete ODG product line is delivered on the internet in a web version representing over 200 megabytes of content. No matter how good someone is at her/his job, it is simply not humanly possible to quickly, consistently, and fully sift through and digest this volume of information and then cross-connect it to other data in one case let alone over an entire caseload.

As the originator and industry leader of Automated Medical Bill Review, Medata prides itself on proactively maintaining its leadership within the WC and auto liability industries by continually pioneering powerful systems and tools. Since its founding in 1975, one of Medata’s top goals has always been to automate all aspects of medical billing review. It is for this reason that Medata has continued since its founding to expand its suite of cost containment features to address every stage of the bill review process within its software. From the origination of automating fee schedule and business rule to partnering with customers’ and their business partners to more effectively automate their processes, each of the products has been developed to complement a paperless workflow and make everyday tasks more productive, efficient and cost effective.

It is for this reason, that Medata is working with the WLDI and the Reed Group to fully integrate their nationally-accepted, evidence-based medicine guidelines and procedure crosswalks in its bill review engine to provide more powerful data analytic tools designed to assist quicker decisions based on the full availability of medical practice information available. When the WLDI was founded by President and CEO Phil Denniston, all of its data-rich tools were designed and developed from the start to ultimately be deeply integrated into partner and client systems in order to maximize the use of its millions of pieces of evidence and data. With the full integration like that of Medata, Mr. Denniston’s dream is coming to full fruition.

The ODG Treatment UR Advisor is a tabular mapping tool tied to recommendations from ODG Treatment and actual WC claims data. The complete file contains every possible combination of ICD diagnosis code and CPT procedure code seen in WC and in total is over 426,000 records based on over 2 million claims and 50 million medical invoices covering about 10 billion dollars in actual incurred medical costs. For each ICD-CPT combination, data is provided on the frequency, incidence, number of visits, cost, as well as an ODG Bill Review Payment Flag. The UR Advisor is designed to improve the efficiency and effectiveness of the UR and bill review process by automating approval for treatments consistent with the ODG guidelines which –as Medata’s study showed– is a significant enhancement for claims management in WC.

In the Medata study, data from over 15,000 prior-managed bills were loaded and rerun against the ODG Treatment UR Advisor for each ICD9-CPT combination on frequency, number of visits, recommendations from ODG Treatment, and the “Bill Review Payment (or ODG Approval) Flags” divided into Green, Yellow, Red, or Black indications:

  • Green, OK to auto-pay up to ODG Codes for Automated Approval (CAA) max number of visits;
  • Yellow, OK to auto-pay up to 25th percentile number of visits (or 50th percentile if a more liberal policy is desired by payor) defined by either (1) Frequency over 10%, or (2) Frequency over 2% & average total cost per claim under $200 for all use of this CPT code in the claim, or (3) Frequency over 1% & average total cost per claim under $50 for all use of this CPT code in the claim;
  • Red, need to review; and,
  • Black or not listed, need to review and considered unlikely as they are (a) Incidence Rate less than .10 (one paid occurrence per 1,000,000 workers employed for one year) & Frequency under 2%, meaning should be very rare, or (b) are not listed and thus should never happen in the claim.

The primary purpose of the ODG Treatment UR Advisor is to facilitate early access to the right treatment for injured workers. There are many treatments, diagnostic tests, and provider visits where the best thing the reviewer can do is get out of the way and let the doctors treat. The UR Advisor lets the provider treat while also freeing up the reviewer’s time to handle the more complex situations where their education and experience can be used to its best advantage. Additionally, within the list of procedure codes in the UR Advisor, there are medical codes that are lacking the support of quality medical studies but which are based on actual claims data showing these codes are very common for the diagnosis being reviewed, their outcomes are good, and the total costs are not excessive. These cases were deemed appropriate even though there was no specific entry in the Procedure Summary for them. However, there were other procedures that were flagged further review for appropriateness as they are extremely rare or non-existent procedures in WC. In the carrier study, the data was run against the UR Advisor data to identify any potential excessive PT/Chiropractic duration of care and visits, Yellow at 50th Percentile, Red, and Black procedures not previously identified. The results –as noted earlier– found an additional 15% in potential medical savings that were identified as follows:

While some cynics may say that this is all just about saving more money by denying care, this statement could not be farther from the truth. This further review is NOT just about saving more money but rather it is about providing the highest level of quality and appropriate care possible. As noted before, just because these procedures are identified does not mean they are inappropriate, rather it means they are procedures which require a second or deeper look as they may or may not be appropriate for that given claim. Keeping this fact in mind, if we were to set aside all the Yellow and PT/Chiropractic procedures as appropriate, over 78 percent of the questioned procedures still fell within the Red and Black categories. In the case of the Red procedures, they absolutely should be flagged for an appropriateness of treatment review on behalf of the injured worker and for the Black categories the question has to be routinely raised as to why that injured worker is being potentially subjected to care and procedures that are seen only once per one million workers employed for one full year in the WC industry –ONCE. In a small handful of cases the further review and consultation with the provider may deem the treatment to be appropriate, but certainly not as a matter of routine practice as medical evidence has shown that such treatment is rarely in the best interest of the injured worker. These are the actions of a quality of care payor not a quality of cost payor.

The fully-integrated guidelines and procedure crosswalks provide powerful data analytics tools designed to help the adjuster and the medical provider(s) in making the best quality of care decision(s). The key word here is that the toolsassist (not replace but assist) the human intervention. The software is not designed to replace or devalue the critical work of the claims and medical professionals, instead, it is designed to be an additional resource to help both parties more readily sort out and then focus on those claims where injured workers are most in need while at the same time allowing the medical community to treat their other patients in the most medically-appropriate and uninterrupted manner possible.

Medata’s study demonstrates that with the integration of guidelines customers ARE able to do more with more but with less effort by automatically applying real-time, case-by-case claim demographics against millions of pieces of evidence-based data in order to separate what should be left unquestioned from what should be closely reviewed for appropriateness. This timesaving tool not only provides a higher level of quality medical care, but it also eliminates wasted time, drives down costs, improves outcomes, adds consistency in practice, and increases claim outcome and customer satisfaction levels for the most important part of the formula –the injured worker and her/his family.