By seeking the right data trends, organizations can increase operational efficiencies, maximize cost containment, and improve patient outcomes. To enhance your team’s decision-making during the utilization review (UR) and bill review (BR) processes, be sure to examine these four key data points:
1. Top Types of Injuries
Identify the most common injury types to help stakeholders recommend targeted loss prevention and cost-control strategies. Every industry has common workplace injuries, and there are common musculoskeletal injuries that can occur in any industry. Reviewing the most common diagnoses codes submitted through UR or bill review may reveal that, for example, falls make up a significant amount of the total injury burden in workers’ compensation. This information can then assist risk managers in developing safety programs that can help prevent these accidents.
2. Commonly Approved Treatment Requests
Save time and money by tracking which requests for services are frequently or always approved. In states that do not mandate utilization review, not all services should require utilization review. Using evidence-based guidelines to analyze common or high volume treatments can assist carriers in setting parameters for treatments that they can quickly authorize. This efficiency allows your team to focus their efforts on the more severe claims that require more attention.
3. Provider Trends
To strengthen provider performance and workers’ compensation networks, look for over-diagnosis, excess testing, and mistreatment of conditions. Identifying the right treatment at the right time is of the utmost importance, so data analysis becomes critical.
A number of fields will provide data for analyzing provider patterns. For example, you can take the date of injury, the diagnoses code(s), and the highest volume CPT codes, and determine whether the treatment falls within the evidence-based guidelines. Additionally, performing data reviews on a claim-by-claim basis allows you to identify over-treatment, duplication of tests or prescriptions by multiple providers, and other wasteful or harmful trends. Data analysis can also identify excessive referrals to orthopedic surgeons for uncomplicated lower back pain, which may indicate the need for a stricter authorization process that directs patients toward less aggressive care options.
By reviewing and analyzing UR outcomes, stakeholders can clearly identify which providers have a firm understanding of the guidelines and follow evidence-based medicine to ensure the best results. Providers who follow guidelines and provide the right care at the right time are great additions to a network.
4. In Bill Review
Use analytics to make clear a provider’s understanding of guidelines and conservative treatments or the need for specialists, based on request patterns. From a bill review perspective, data helps carriers identify which providers are appropriate to include in a network.
Data analytics aren’t the standalone answer in making the review process a win-win. Instead of taking data — such as consistently denied service requests — at face value, put the information to work by considering it within the full context of the healthcare culture.
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