services. Payors typically reserve it for
the small percentage of cases that require
mandatory utilization review or involve
Yet the remaining 80 percent of cases is
where nursing expertise can make a difference for payors. By spotting issues that
claims handlers might miss such as treatment plan deviations, co-morbidities and
unrelated conditions, nurses can uncover
early opportunities to revisit overall case
strategies and action plans. The application of clinical insights has the potential
to limit overall claims costs.
Growing acceptance for global delivery
models is also driving payors to reconsider how they put clinical insights to use.
Tapping offshore medical expertise from
qualified, experienced nurses — many
of whom hold U.S. licenses — is an option that allows them to address patient
needs and determine treatment methods
at lower rates.
Deploying nursing expertise more
4. Improve medical provider profiling.
broadly also requires ne w pricing models.
As nurse case managers engage in clinical
reviews rather than long-term coordina-
tion efforts, payors will likely switch to
transactional pricing for nursing utiliza-
tion from the popular model of billable
time and expenses.
Adopting evidence-based guidelines
and implementing more MNRs provides
payors with a world of new data to access,
including statistics on treating physicians. By mining data sets to rank providers in terms of performance, workers’
comp payors can determine which medical providers follow established treatment
guidelines and produce the best outcomes
for injured workers.
Profiling makes use of granular trans-
actional data such as insurers’ medical
billing and claims data, and external data
sets from ODG to score individual pro-
viders or provider groups relative to one
another based on quality of care. By run-
ning analytical models on the data sets,
payors can detect patterns of treatment
and duration of care, and compare pro-
viders’ performance against evidence-
based guidelines. They can develop
“outcome-based networks” comprising
health-care professionals who conform
The result is a one-two punch against
costs: Not only will insurers better understand providers’ costs, but they can
also potentially identify excessive charges.
More importantly, provider profiling shifts
stakeholders’ focus from discounts and
fees to better outcomes and treatment.
Despite the sliver of relief in NCCI’s
recent projection of a one percent decline in medical severity for 2015, it is
likely that medical severity will continue its march upwards. Informed claims
management provides workers’ comp
payors with a strategy to contain costs —
and stay profitable.
Chris Daniel is a director for Cognizant’s
( cognizant.com) global clinical services practice. Ajoy Kumar Palanivelu is an associate
director for Cognizant’s insurance practice.
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