Power of Data Sharing: Lessons for Utilization Review from WCI Conference

| | Technology & Integration, Utilization Review


At the 2015 WCI Workers’ Compensation Educational Conference, Lisa Hannusch moderated a panel discussion on the value of data in improving workers’ compensation claims outcomes. Panelists focused on the steps needed to share data effectively and how to ensure parties have the right security protocols in place to share data.

Many companies involved in workers’ compensation focus on claims adjusting and bill review as the key data-sharing opportunities. With the right information in play, however, utilization review can be tremendously effective in improving claims outcomes.

When a treatment request is denied prospectively in utilization review, decision data must feed into bill review processes to ensure the services do not get reimbursed. This should be standard for all companies. It is less common, however, that the right treatment and claim history also feed into the system to drive rules and optimize outcomes.

Utilization review software should have the ability to collect key information about claims to ensure the diagnoses, compensability and comorbidities are considered during utilization review. In addition, knowing the entire treatment history and capturing this specific data instead of collecting pages of medical records can add a powerful component to the process.

Serving on the expert panel were Aretimis Emslie from myMatrixx, Mary Ames, from The Zenith and Sherry Wilson from Jopari Solutions. Emslie, president of myMatrixx, shared her view that having information is critical but that sharing information is where real power comes from. She noted that as industry best-in-class participants, we can share data to help each other improve claim outcomes, and that will raise our value as system participants.

Lisa Hannusch is the CEO of UniMed Direct and the founder of UR Nation. At UniMed, Hannusch is leading the effort to continue refining ReviewStat® software for utilization review, case management and other medical management workflows. ReviewStat® will share data with bill review, claims operations, provider networks and scheduling providers, PBMs, and others. The powerful software will collect data that we can use to strengthen rules for greater efficiency and more complete decisions.

Collecting data and running reports is no longer sufficient. The real ROI comes when we share data and utilize it to optimize medical management and claims processes and significantly improve outcomes.