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.
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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.
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Overview of
Predictive Modeling
© 2011 GENEX Services, Inc.
Predictive Modeling: Definition
© 2011 GENEX Services, Inc.
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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.
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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
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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.
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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
Dawn.Yang@genexservices.com
© 2011 GENEX Services, Inc.
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