Presentation to Oregon Self-Insurers Association Controlling Medical Severity through Modeling Risk Identification July 12, 2012

© 2011 GENEX Services, Inc. 2 Presenters Dawn Yang, RN, MSN, CCM GENEX Services, Inc.

© 2011 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

© 2011 GENEX Services, Inc. Overview of Predictive Modeling

© 2011 GENEX Services, Inc. 5 Predictive Modeling: Definition

© 2011 GENEX Services, Inc. 6 Predictive Modeling: Examples

© 2011 GENEX Services, Inc. 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. 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 levelMedical and pharmacy bills TYPE OF INTERVENTION Telephonic during 1 st days following injury Telephonic or field based on need

Operational Impact

© 2011 GENEX Services, Inc. 11 Early Claim Identification Claim Data Nature of injury Gender Claim type Wage Job class code Cause of injury Jurisdiction Date of injury Claimant age Body part Claim Scoring Engine SCORE Do not manage Nurse Triage Decision Manage

Clinical Alerts

© 2011 GENEX Services, Inc. Demonstrated Risk: Clinical AlertsInterventionInterventionActionActionIdentificationIdentification Clinical profile generated for nurse triage Nurse review Flagged in data warehouse Pend in bill review Bill data and history compared to clinical criteria Based on Medical Bills

© 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 SafetyImpactImpactActionActionIdentificationIdentification Clinical Intervention Early intervention case management Early intervention case management Provider Outreach Provider Outreach Pharmacy reviews Pharmacy reviews Patient Education Patient Education Complex Case Management for future claims Complex Case Management for future claims Clinical Intervention Early intervention case management Early intervention case management Provider Outreach Provider Outreach Pharmacy reviews Pharmacy reviews Patient Education Patient Education Complex Case Management for future claims Complex Case Management for future claims Analysis of Claims and Rx Bill Data Narcotic Therapy Management Improve patient health and safety Improve patient health and safety Increased productivity Increased productivity Eliminate fraud and inappropriate utilization patterns Eliminate fraud and inappropriate utilization patterns Narcotic Therapy Management Improve patient health and safety Improve patient health and safety Increased productivity Increased productivity Eliminate fraud and inappropriate utilization patterns Eliminate fraud and inappropriate utilization patterns Based on Pharmacy Charges Case Manager Triage Confirmation of Risk

© 2011 GENEX Services, Inc. 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

Case Study Application

© 2011 GENEX Services, Inc. Case Study Application 19Pain 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, Continuous Referral Expert evaluation for other missed TCM opportunities. 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.

© 2011 GENEX Services, Inc. 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. 21 Thank You For more information, please contact: Dawn Yang, RN, MSN, CCM GENEX Services Inc. Director of Case Management Services, Western Region