What passes for predictive modeling today is like Google maps, except the app tells you when to turn a half-hour after you’ve passed the intersection.
Adjuster finding out a claimant had spinal surgery 6 weeks ago…
By the time adjusters figure out a claim has gone off the tracks, it’s often too late to do anything but increase reserves. That’s because there’s no real-time monitoring, no way to clearly and definitively identify when – exactly – that happens.
A promising approach is in the works at Gallagher Bassett.
Building off research conducted by Johns Hopkins, GB has developed a tool that enables real-time monitoring of medical services delivered to its claimants. Using a proprietary platform, alerts are sent when patients’ quality of care is headed in the wrong direction.
The trigger is inappropriate medical treatments. GB matches medical bill data with evidence-based treatment guidelines, with each service, procedure, or medication individually assessed. As the number of inappropriate treatments increases, alarm bells ring.
Of course, that doesn’t mean all treatment that is non-compliant is inappropriate. However, much is, and there’s a clear – and quite strong – correlation between bad medical care and lousy claim outcomes.
Those are clinical words and hide the real import of GB’s approach. Getting claims back on track means patients get better faster, AND the risk of bad outcomes from inappropriate surgeries, injections, drugs, and tests decreases.
What does this mean for you?
There’s lots of data out there – and far too little smart use of data. This is promising indeed.
Joe, this is very encouraging. Consider the use of IME’s which can be scheduled effectively or ineffectively. One troubling pattern is the use of an IME to late to be able to address a claim effectively. Early intervention is a key and predictive modeling and the red flags triggered by these alarms could certainly make IME’s more purposeful and effective. I would like to see this technology employed on a greater scale. Information is powerful!
Not sure we need another app for that! What we need is better communication between, the MD, the injured worker, and the insurer. Traditionally on complex cases, a nurse case manager is usually assigned to assist with care coordination. Their role is to ensure all parties are up to date on the plan of care and ensure that evidence-based medicine is being followed. The adjuster and the case manager work closely…if everyone is doing their job, the example described above should not happen.
is kept updated by the case manager. Really in my experience in workers comp, nothing gets done until it is approved by the adjuster. Communication, communication, communication is key to improving the delivery of care for patients and controlling healthcare costs.
Hello Anne – good news is it’s all internal, so no phone app to bother with.
In Illinois we have no ability to direct medical care, so often it is the injured worker’s own attorney who is directing the worker to a treating physician or clinic that is known to over treat, over prescribe, or offer surgery when surgery isn’t warranted. The good news is many of the providers want an assurance from the adjuster they will be paid, so refusing to pay until the treatment, surgery or medication is reviewed either by UR or an IME can be effective.
Being on the Case Management side of the Insurance Industry, I concur with the aforementioned opinions.
We tend to see the “dysfunctional claim” surface during several scenarios. One, when too much time passes from acceptance of a claim, until a case manager is assigned, Two, when a claim is passed internally from adjuster to adjuster, etc and different action plans are involved and third, when claims are forwarded to a new Carrier or TPA. The transition time, review of Summary Reports and new claims handler involvement, etc add to the reasons for this reoccurring issue.