How Technology and Data Can Enhance Medical Management
June 3, 2022
Medical management—utilization review specifically—has historically been handled manually, and tends to require a great deal of administrative oversight and dependencies on the adjuster. The limitations of manual processing often result in delayed utilization review decisions delivered to the injured worker at the other end of the claim. These manual processes can create task-oriented environments that are cumbersome, costly and time-consuming. In today’s age of innovation, data and automated technologies may be the key to managing and improving medical management in workers’ compensation claims. Enhancing the Entire Medical Management Process Technology can help improve medical management by enhancing the medical management process. For example, utilization review can require a lot of administrative oversight and consists of many repetitive tasks. Technology tools could be leveraged to help streamline and automate these often rote processes. This kind of automation can help improve time efficiencies for utilization review teams. Other Ways That Technology Could Help Improve Medical Management Include: Streamlining communications between stakeholders involved in a case Increasing compliance with mandated turn-around times and reducing the impact of human error Supporting integrations and linkages between systems Streamline Communications Between Stakeholders Through Highly Automated Business Rules Utilization review cases have the potential to be routed to multiple stakeholders either for review, to add case notes or to provide additional oversight tasks. To ensure that the right stakeholder receives a case in a timely manner, technology can create automated workflows and routing to speed up communications between all those involved in a case. For example, utilization review nurses are qualified to approve medical necessity requests but are not permitted to deny requests. This does not mean, however, that a nurse is needed to review every utilization review request in order to identify which requests should be routed automatically to a physician advisor for a second level review or peer review. Medical directors and utilization review teams can use data analytics to predict the types of requests that should be routed to a physician advisor, for example, hip, back, knee or other injuries that are typically more complex. Furthermore, technology could be used to build out custom rules within workflows that are client-specific and adhere to national or state-mandated jurisdictions. Increase Turnaround Time Compliance and Reduce Impact of Human Error Let’s take a look at an example that illustrates the need for automation in utilization review to ensure timely decisions that are compliant with state-mandated and jurisdictional rules and regulations get out the door in a timely manner. Often, utilization review turnaround times and due dates are highly monitored by either compliance regulations or best practice standards. The jurisdiction due date for utilization review cases is as critical as the due date for issuing indemnity payments to injured workers. And while not all states have an established turnaround time for utilization review decisions, it is critical to have a ‘due date’ built into the utilization review workflow in order to deliver timely medical decisions. In a state that may not mandate a specific turnaround time for completing cases, one could consider setting an ‘automated due date’ within their workflow to align with URAC criteria. In this example, the automated due date would help ensure compliance with URAC standards—an independent nonprofit organization nationally recognized in the utilization review community that provides standards and criteria to help ensure high-quality healthcare. Integrate and Link to Other Systems to Get a 360 View Into a Claim's Past and Help Predict Forward Trajectory As more solutions become integrated with one another, information, in-depth data analytics and insights can reveal where a case has been and where it has the potential to go. For example, claims data, medical bill review, utilization review, case management and pharmacy benefits management systems that are connected help piece together a complete holistic picture of a claim. All data points and information gathering across these areas help tell a story about the claim as a whole, which provides guidance in how to proceed and intervene with the necessary tools to mitigate potential pitfalls. With this intelligence coming from each of these complementary avenues, one can formulate an approach that will help yield better results for claims professionals and more importantly the injured worker. Mitchell is a partner to the medical management and workers’ compensation markets offering end-to-end cost containment solutions, which include technology-enabled clinical services. You can learn more about Mitchell’s medical management program and the ReviewStat medical management platform here. This article was featured first in WorkCompWire.
Six Questions to Ask When Evaluating a Medical Management Software Solution
June 3, 2022
The medical management software provider that you select as your partner can have a major impact on not only your organization's claims outcomes, but also the lives of the injured party. When looking for a utilization review partner, make sure to ask detailed questions before making a decision. One of the first things that you should do is evaluate the medical management software that the partner offers. The questions listed below can help you assess important features that you should be looking for in a software platform. 1. Does the software contain a repository for document and correspondence management? Having a tool that integrates medical records and treatment history at a glance allows clinicians to make informed decisions more efficiently. Additionally, if the software also serves as your communication hub for all relevant parties working a case, then email, fax and print notifications and conversations should remain within the tool for easy access and internal audit controls. These controls are lost when outside solutions are used to support these communications. 2. Is the software fully integrated with other case management, bill review and cost containment solutions? Disparate solutions can be costly. Lower the total cost of ownership and accelerate implementation time by asking your potential software provider if their utilization review medical management software can integrate with other systems. There are typically multiple users remotely working a utilization review and case management case; so those users should have efficient workflow processes and immediate shared access to medical documentation, case notes and evidence-based guidelines. Solutions that allow utilization review and case management parties to remain informed regarding progress and outcomes, as well as the ability to seamlessly integrate those outcomes to a bill review platform, are key capabilities. 3. What modes of communication are available to communicate with preferred suppliers? How are phone calls and faxes tracked? For example, does the software automatically re-send failed faxes? Can the user generate email correspondence with relevant parties from within the software? Can the responses to those emails auto-postback into the software and notify the sender that a response has been received? If a fax fails to generate to a provider or attorney, can the software automatically failover to print? These are all very important aspects that a comprehensive platform should provide. 4. Can users easily customize and run reports, including reports that use real-time data to help in managing workflows, tracking performance and detecting patterns in treatment requests and determinations? One important feature that you need to assess is whether the potential medical management software offers powerful reporting tools that help you efficiently notify parties of outcomes or progress and extract data as needed to support the analysis of your utilization review, case management programs and related workflows. 5. Are there rules, products and guideline tools embedded in the systems to support automated decision making? Is the software customizable to my company? Ideally, your medical management software will provide you with some structure and help to standardize processes. For example, a system could include letter templates and recommended guidelines which are helpful, but make sure the provider you choose also allows for some flexibility. Your company and business needs are unique and constantly evolving. Choose a medical management software system that can fit your needs through creating custom treatment review engine rules, letter templates and workflows to take customizing user workflows a step further. 6. Does the software help my organization stay compliant? The medical management software should allow users to create customized data fields to assist in meeting jurisdictional utilization review requirements, and tracking jurisdictional timelines. It should facilitate data capture to allow for fully compliant, automated notification letters, as well as support your utilization review quality program. Choosing a medical management software to support your utilization review and case management programs is a big decision that can impact an organization’s workflow, compliance, and outcomes. Time matters and medical decisions can impact an individual’s quality of life. It’s a good practice for utilization review companies to operate efficiently, always be in compliance and conduct all interactions with high quality. When looking for a software partner, be sure to ask detailed questions and get the right answers to help ensure that you’re finding a utilization review solution that delivers every time. Learn More
Prescriptions for Opioid Disorder Meds on Rise in Comp
May 23, 2022
Enlyte Names Steve Laudermilch EVP of Mitchell Casualty Solutions Group
May 17, 2022
P&C executive will head company’s auto casualty and workers’ comp technology division. SAN DIEGO—Enlyte, the parent brand of Mitchell, Genex and Coventry, has announced today that Steve Laudermilch has joined the company to serve as executive vice president and general manager of Mitchell’s casualty solutions group (CSG). With 25 years of senior leadership experience in workers’ compensation and auto casualty claims, Laudermilch will be charged with leading Mitchell’s CSG, bringing cutting-edge claims technology and workflow connectivity solutions to the auto casualty and workers’ comp markets, while helping restore the lives of injured drivers and employees. “We’re very excited and honored to have Steve Laudermilch join the Enlyte team,” said Alex Sun, Enlyte CEO. “Steve is a proven leader who comes to us with a successful track record of delivering results in workers’ compensation and auto casualty for global claims organizations. We look forward to him utilizing his extensive experience and knowledge to propel our products and services for years to come.” Prior to joining Enlyte, Laudermilch served as U.S. chief claims officer with Argo Group, a major underwriter of specialty insurance products in the property and casualty market. In this role, he led the technical claims teams for casualty, workers’ comp, financial lines, property and programs, and had oversight for claims operations and shared services. Prior to Argo, Laudermilch held key positions at Chubb, a leading property and casualty insurance company, and Deloitte Consulting. Laudermilch holds an MBA from Saint Joseph’s University, Philadelphia, and a BA in economics from Ursinus College, Collegeville, PA. *** About Enlyte Enlyte (www.enlyte.com) is the parent brand of Mitchell | Genex | Coventry, a leader in cost-containment technology, independent medical exams (IME), provider and specialty networks, case management services, pharmacy benefit and disability management. The three businesses have recently aligned their joint industry expertise and advanced technology solutions into a combined organization of nearly 6,000 associates committed to simplifying and optimizing property, casualty and disability claims processes and services. About Mitchell Mitchell International (www.mitchell.com) delivers smart technology solutions and services to the auto insurance, collision repair, disability and workers’ compensation markets. Through deep industry expertise, connections throughout the insurance ecosystem and advanced technology such as artificial intelligence and cloud-based solutions, Mitchell enables its customers and clients to succeed in today’s ever-changing environment. Each month, Mitchell processes tens of millions of transactions for more than 300 insurance providers, 20,000 collision repair facilities and 70,000 pharmacies. Its comprehensive solution and service portfolio empowers clients to restore lives after a challenging event.
Workers' Comp Sector Has Embraced Electronic Payments
April 19, 2022
A Personalized Approach to High-MED Opioid Management
April 19, 2022
Successful opioid management includes a tailored strategy that takes into account: Each injured worker’s current medication regimen The patient’s medical history and unique circumstances Evidence-based treatment guidelines The personalized approach to managing a high-MED population helped Mitchell Pharmacy Solutions clients collectively reduce average daily MED levels by more than 15% over the two years reviewed. This two-pronged program included setting customized MED levels per patient and adding greater controls for higher risk patients. 1. Prospective Utilization Review: Trigger of thorough clinical review if custom MED levels were surpassed 2. Retrospective Utilization Review: Comprehensive review of high risk patients and development of clinical plan, often including prescriber intervention Download the full case study to learn how to implement these strategies in your own pharmacy program. Download
The Long, Winding Road of Drug Pricing
April 11, 2022
One of the most persistent and complex challenges facing workers’ compensation claims administrators and insurers is managing prescription drug costs. The problems around prescription drugs are pervasive throughout the health care industry, have been around for over a century, and cover a wide range of issues including accessibility, efficacy and cost. For workers’ compensation payors, cost has been the most challenging issue. Annual price increases for half the drugs covered by Medicare outpaced inflation in 2019 and 2020. In 2021, ASH Clinical news reported that the median wholesale price for 645 brand name drugs increased 4.8%, just slightly above the reported average inflation rate for 2021. According to a Kaiser Health Network Morning Briefing, more than 450 drugs saw price increases of 5% or more at the beginning 2022. In 2020, the Kaiser Family Foundation reported that drug price increases outpaced inflation for half of the drugs covered by Medicare. JAMA, the Journal of the American Medical Association, published a study documenting brand name drug price increases over a ten-year period. The study noted, “Using 2007-2018 net pricing data on branded pharmaceutical products in the US, list prices increased by 159% and net prices increased by 60%”. Those increases amount to three and one-half times the annual inflation for the same period. Generic drugs are not immune to their own unique pricing challenges. While not impacted by inflation as heavily and broadly, market competition in the generic space that would tend to reduce costs over time has been inhibited by alleged anti-competitive behavior among generic manufacturers. Led by the Attorney General in Connecticut, 46 states, the District of Columbia and three U.S. territories, filed suit in June of 2020 against 26 generic manufacturers alleging a wide-spread and coordinated effort to interfere with competition and drive up the cost of generic drugs. As quoted in the referenced article, “Through phone calls, text messages, emails, corporate conventions, and cozy dinner parties, generic pharmaceutical executives were in constant communication, colluding to fix prices and restrain competition.” Further, Connecticut Attorney General William Tong said, “They took steps to evade accountability.” This is not a new problem in the prescription drug world. One of the first cases of drug price fixing was alleged in 1941. Twenty years after the discovery of insulin, three companies, Eli Lilly & Company, Sharpe & Dohme, and E. R. Squibb were indicted on charges of violating an anti-trust law by “unlawfully combin[ing] and conspir[ing] to bring about arbitrary, uniform and non-competitive prices for insulin and to prevent free and normal competition in its sale throughout the United States.” The researchers who developed the first insulin were more interested in helping humankind than profiteering. In 1923, three of the researchers who discovered insulin assigned their U.S. patents for the insulin formula to the University of Toronto for $1.00 each (equates to about $16 today). Yet, insulin prices remain problematic. Today, most state legislatures across the country have filed bills to reduce the out-of-pocket cost for health care consumers who use insulin. Prices have remained so persistently and inexplicably high that non-profit drug manufacturers are hoping to spur competition within the insulin market. CivicaRx, a newly formed, non-profit drug manufacturer based in Utah, publicly announced in early March of this year, that they have begun the process to begin manufacturing insulin that they hope to bring to market in 2024 with a list price up to 80% less than current insulin products currently being sold. Another area of concern, not limited to the workers’ compensation market but more persistent as a percentage of claims, is high-cost topical creams and topical compounds. Upon review of our internal Mitchell Pharmacy Solutions data, payors in the workers’ compensation system frequently see topical and compounded creams that are not FDA-approved but are billed at amounts that often exceed $2,000 for a 30-day supply. Based on recent reported action by the US Department of Justice, it appears they are working to eradicate and prosecute purveyors of these creams in the federal workers’ compensation and health care systems. On July 31, 2020, the US Department of Justice (USDOJ) Eastern District of Tennessee announced the sentencing of five individuals convicted of multiple counts of fraud in a compound cream scheme that cost the U.S. Tricare system, private insurers and self-insured employers more than 30 million dollars. In July of 2021, the USDOJ Western District of Arkansas, announced a Louisiana doctor pleaded guilty to workers’ compensation fraud for a topical patch and compounded pain cream scheme that netted over 1 million dollars. Additionally, the USDOJ Southern District of Texas released a statement on June 17, 2021, announcing the indictment of seven individuals in a compounding drug scheme. The indictment claims the defendants defrauded federal government programs of over 110 million dollars. States are starting to take action against these abusive practices. The Arkansas Board of Pharmacy revoked the license of a pharmacy involved in a topical pain cream fraud. Other states workers’ compensation programs have or are enacting strict fee schedules on topical creams and patches, including compounded creams. Colorado was the first to enact a specific fee schedule for topicals. South Carolina will become the latest with the adopting of its new fee schedule effective April 1, 2022. Over the last several years there has been a lot of legislative activity around drug price transparency and rebates. The efforts are primarily directed at Pharmacy Benefit Manager (PBM) services within the commercial and government health care markets, but in some states, workers’ compensation PBMs are also subject to the regulation. Unfortunately, most state laws only target the PBMs and wholesalers but fail to require accountability from manufacturers and dispensers. Price transparency could be a useful tool if the entire supply chain was subject to the same transparency rules, but most of the laws are only getting half the picture. Rebate reporting is generally a part of these transparency reports. Rebates are offered by manufacturers to health plans to encourage the plan to include a particular brand drug on their formulary. The rebate practice, in theory, should reduce costs when brand manufacturers with drugs that treat the same condition will offer discounts to get on a formulary. However, workers’ compensation programs mandate the use of generic medications and if there is a formulary, the formulary is chosen by the state and not by the payor. In non-formulary states, the workers’ compensation PBM develops a formulary based on treatment guidelines, medical necessity, and lower-cost generic medications as mandated. In the instances where a doctor prescribes a medically necessary brand name medication, a workers’ compensation PBM may receive a rebate, but the rebate is driven by the actions and decisions of a physician and not anything controlled by the workers’ compensation PBM. There is also some legitimate question as to whether or not rebates are increasing drug costs. A recent study by Matrix Global Advisors, as reported by the Coalition for Affordable Drugs, found the price increases from 2018 to 2021 for rebated drugs and non-rebated drugs were similar. The study concluded, “The market-based strategies most likely to constrain prices are robust competition among drug manufacturers and insurance-design mechanisms that incentivize cost-effective treatments.” This is an important point to consider. In a state where an injured worker has the choice of pharmacy provider, there are no market forces at play since the injured worker has no financial stake in the cost of the care and no incentive to shop around for the most affordable option. In fact, the inverse is true. The injured worker’s right to choose may ultimately increase costs. In the workers’ compensation pharmacy world, robust competition does exist among the various PBMs providing pharmacy benefit services for injured workers and decreasing costs for payors. That competition works best when states allow employers to direct the pharmacy care to contracted pharmacies. Most workers’ compensation pharmacy networks include 90% or more of the local pharmacies in a given state. Injured workers benefit from convenient access to care while the payors and the workers’ compensation system enjoy fiercely competitive pricing on drugs. Additionally, network pharmacies can help guide adherence to generic mandates, drug formularies and treatment guidelines at the point of dispensing. The pharmacy networks can also control areas of potential fraud and abuse around compounded creams and topicals. The PBM can screen medications for efficacy, medical necessity and can contract for reasonable, market-based pricing. While there has been some political reticence to embrace direction of pharmacy care for injured workers, the benefits of managed care and the resultant improvement in care and control of costs, fraud and abuse, may outweigh the potential inconvenience of an injured worker having 10% or less fewer pharmacies to choose from. It has been a long and winding road that got us to where we are today in pharmacy care for injured workers, but a systemic, managed and directed approach to providing pharmacy care to injured workers may increase market competition, increase adherence to state formularies and treatment guidelines, has the potential to reduce fraud and abuse and improve overall outcomes for injured workers by increasing the efficacy of the pharmacy care they receive.