Controlling Medical Severity through Modeling Risk Identification

1. Controlling Medical Severitythrough Modeling RiskIdentification Presentation to Oregon Self-Insurers Association July 12, 2012

2. Presenters Dawn Yang, RN, MSN, CCM GENEX Services, Inc.

3. Presentation Outline Overview of Predictive Modeling Targeting Risk throughout the Life of a Claim Operational Impact Clinical Alerts Case Study Application Questions

4. Overview of Predictive Modeling

5. Predictive Modeling: Definition

6. Predictive Modeling: Examples 6

7. Predictive Modeling: Claims • Predict which claims are • Costly/complex • Likely to benefit from case management • Identify claims with demonstrated risk • Clinical alerts • Medication safety

8. Targeting Risk Throughout the Life of a Workers’ Compensation Claim

9. Targeting Risk Throughout the Life of a Claim

10. Operational Impact

11. Early Claim Identification SCORE 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 Do not manage Nurse Triage Decision Manage 11

12. Clinical Alerts

13. Demonstrated Risk: Clinical Alerts Based on Medical Bills Identification Intervention Action Bill data and history compared toclinical criteria Flagged in data warehouse Clinical profile generated for nurse triage Pend in bill review Nurse review

14. 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

15. Clinical Profile

16. Demonstrated Risk: Medication Safety Based on Pharmacy Charges Confirmation of Risk Identification Action Impact • Clinical Intervention • Early intervention case management • Provider Outreach • Pharmacy reviews • Patient Education • Complex Case Management for future claims • Narcotic Therapy Management • Improve patient health and safety • Increased productivity • Eliminate fraud and inappropriate utilization patterns Analysis of Claims and Rx Bill Data Case Manager Triage

17. Mid-Claim Identification: Medication 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

18. Case Study Application

19. Case Study Application

20. 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

21. 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 21