Transcript GENEX Services, Inc. presentation to

Controlling Medical Severity
through Modeling Risk
Identification
Presentation to
National Council of
Self-Insurers
May 16, 2011
Presenters
Ron Skrocki
GENEX Services, Inc.
© 2011 GENEX Services, Inc.
David Spring
OCI
2
Presentation Outline
Overview of Predictive Modeling
Identifying High Risk Claims
Targeting Risk throughout the Life of a Claim
Questions
© 2011 GENEX Services, Inc.
3
Overview of
Predictive Modeling
Predictive Modeling: Definition
Innovative and sophisticated use of statistical
and quantitative data to build models that
predict future events to improve human and
system decision performance
© 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 to Benefit from Case Management
Identify Claims with Demonstrated Risk
Clinical Alerts
Medication Safety
© 2011 GENEX Services, Inc.
Identifying High Risk Claims
© 2011 GENEX Services, Inc.
Why Identify High Risk Claims?
Identify high risk claimants for early contact
and targeted claims and/or intervention to:
Reduce lost work time
Reduce unnecessary medical expense
© 2011 GENEX Services, Inc.
9
Predictive Modeling Inputs
Historical Information from Previous Claims
Quantity (Repeater Status)
Duration
Injury Types, etc.
Information from Current Claim
Injury Type
Demographics
Claim Reporting Lag
Location, etc.
© 2011 GENEX Services, Inc.
10
Predictive Modeling Process
Each information input is given a weight,
depending on significance
Weights are combined to form the claimant’s
score
© 2011 GENEX Services, Inc.
11
Predictive Modeling Output (Scores)
Risk of extended claim duration and high cost:
1–2
3
4–5
Low risk
Moderate risk
High risk
© 2011 GENEX Services, Inc.
12
Which Claimants are Identified?
High Risk Claimant Characteristics
14% of the claimants account for 57% of the
total liability
Complex diagnoses
Use of multiple benefits
© 2011 GENEX Services, Inc.
13
Percent of High Risk Claims
The percent of high risk claims will vary by
company
8%
12%
80%
© 2011 GENEX Services, Inc.
14
Reducing the Cost of High Risk Claims
Management of high risk claims resulted in
per claim savings of 37%
© 2011 GENEX Services, Inc.
15
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
WHEN
Telephonic during 1st 30-60
days following injury
Telephonic or field based
on need
© 2011 GENEX Services, Inc.
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
18
Demonstrated Risk: Clinical Alerts
Based on Medical Bills
Rules
Created
with
Clinical
Thresholds
Bill Data
And History
Compared
to Rule
Criteria
Identification
Flagged
in Data
Warehouse
Clinical Profile
Generated
for Nurse
Triage
Pend in
Bill Review
Nurse
Review
Action
Intervention
© 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
ABC Company
Clinical Score Card
Jan 01, 2009 - Feb 03, 2009
Nurse CM Name:
Case Mgt Service:
Claimant Name:
Claim Number
Date Of Injury
JONES, MARIA I.
FCM
ABC,PATRICK
State: OH
Primary Diagnosis
Last Service Date
0000486688001
2/12/2008
Claim Office: COLUMBUS, OH
Adjuster Name: ABC,PATRICK
Total Medical Payments
Previous Case Management
SPRAIN SHOULDER/ARM NOS
1/8/2009
$53,121.86
Y
Provider Payments
Head
$0.00
Neck
$0.00
Shoulder
$52,750.43
Back
$105.07
Elbow/ForeArm
$0.00
Trunk
$0.00
Wrist/Hand
$0.00
Leg
$0.00
Knee
$0.00
General
$266.36
Ankle/Foot
$0.00
Utilization Metrics
Total Provider Count
Total Number of Visits
First Date of Service
Treatment Duration (days)
Physical Medicine Treatments
Case Mgmt Desc
Case Manager
Full Case Management
, MARIA I.
Dedicated/Onsite - Evaluation and Review SUZANNE P.
Deferred Case Management
VICKI F.
Date of Service
1/8/2009
1/8/2009
FT2HQ6WA
Provider Name
KATHLEEN
KATHLEEN
Procedure
Code
97140
97110
Confidential, Unpublished Property of Intracorp. Do Not Duplicate or Distribute. Use
and Distribution Limited Solely to Authorized Personnel.
 Copyright 2009 Intracorp
Open Date
Close Date
6/3/2008
2/25/2008
4/16/2008
2/26/2008
6/9/2008
Procedure Desc
MANUAL THERAPY
THERAPEUTIC EXERCISES
C-03-06-001-D
© 2011 GENEX Services, Inc.
18
105
2/21/2008
322
236
Total Number of Svs
Number of Clinical Alerts
Last Clinical Alert
In Network Charges
In Network Bills
302
16
12/23/2008
65.10%
95.19%
Medical
Savings
$0.00
$0.00
$0.00
Outcome
Inappropriate Referral
Transition to Intracorp medical management
Network
Y
Y
Charge
$60.00
$240.00
Clinical
Trigger
Allowance
$48.00
$192.00
Run Date: February 03, 2009
Y
Page 1 of 13
Demonstrated Risk: Drug Safety
Based on Pharmacy Charges
1
Case
Manager
Triage
3
Confirmation of Risk
Analysis of
Claims and
Rx Bill
Data
2
4
5
Clinical
Intervention
Narcotic
Therapy
Management
• Early intervention
case management
• Provider outreach
• Pharmacy reviews
• Patient education
• Complex Case
Management for
mature claims
Identification
Action
© 2011 GENEX Services, Inc.
• Improve patient
health and safety
• Increased
productivity
• Eliminate fraud
and inappropriate
utilization patterns
Impact
Mid-Claim Identification: Drug 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
© 2011 GENEX Services, Inc.
Life of Claim Monitoring: Benefit
Cost-efficient nurse staffing models and
workflow
Improved velocity and consistency
Easily adjusted based on ongoing results
Combined technology enables life of claim risk
monitoring
Increased ROI
© 2011 GENEX Services, Inc.
Thank You
For more information, please contact:
Ron Skrocki
GENEX Services Inc.
Vice President – Product Management & Development
610.964.5102
[email protected]
David Spring
OCI
Business Development Analyst
800.678.6613
[email protected]
© 2011 GENEX Services, Inc.
25