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Controlling Medical Severity through Modeling Risk Identification Presentation to Oregon Self-Insurers Association July 12, 2012 Presenters Dawn Yang, RN, MSN, CCM GENEX Services, Inc. © 2011 GENEX Services, Inc. 2 Presentation Outline Overview of Predictive Modeling Targeting Risk throughout the Life of a Claim Operational Clinical Case Impact Alerts Study Application Questions © 2011 GENEX Services, Inc. 3 Overview of Predictive Modeling © 2011 GENEX Services, Inc. Predictive Modeling: Definition © 2011 GENEX Services, Inc. 5 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. 6 Predictive Modeling: Claims Predict which claims are Costly/complex Likely Identify to benefit from case management 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 OF INTERVENTION Telephonic during 1st 30-60 days following injury Telephonic or field based on need © 2011 GENEX Services, Inc. Operational Impact Early Claim Identification Claim Data Cause of injury Nature of injury Claim Scoring Engine Jurisdiction Gender Date of injury Claim type Claimant age Wage Body part Job class code SCORE Do not manage © 2011 GENEX Services, Inc. Nurse Triage Decision Manage 11 Clinical Alerts Demonstrated Risk: Clinical Alerts Based on Medical Bills Identification Action Intervention Flagged in data warehouse Clinical profile generated for nurse triage Pend in bill review Nurse review Bill data and history compared to clinical criteria © 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 Identification Analysis of Claims and Rx Bill Data Case Manager Triage Confirmation of Risk Based on Pharmacy Charges Action Clinical Intervention • Early intervention case management • Provider Outreach • Pharmacy reviews • Patient Education • Complex Case Management for future claims © 2011 GENEX Services, Inc. Impact Narcotic Therapy Management • Improve patient health and safety • Increased productivity • Eliminate fraud and inappropriate utilization patterns Mid-Claim Identification: Medication Safety Medication Safety Alerts Use of narcotics and other controlled substances Multiple High prescribing physicians or pharmacies prescription fill quantities or frequency Claimant history of substance abuse © 2011 GENEX Services, Inc. Case Study Application Case Study Application 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, Outcome •Excessive PT identified early and stopped, •Treating provider recommended diagnostic testing to facilitate treatment, •Successful full duty RTW, •Provider outreach •Savings= $5K indemnity savings due to earlier RTW. •Continuous Referral Expert evaluation for other missed TCM opportunities. © 2011 GENEX Services, Inc. 19 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. Thank You For more information, please contact: Dawn Yang, RN, MSN, CCM GENEX Services Inc. Director of Case Management Services, Western Region 310.709.3318 [email protected] © 2011 GENEX Services, Inc. 21
