|By Business Wire||
|January 28, 2014 06:00 AM EST||
James Schlueter, President, Effective Health Systems (www.effectivehealthsystems.com), reported a study that evaluated the effectiveness of experienced workers compensation claims adjusters at determining whether a medical treatment request should be approved or escalated to a higher-level review. The study found the effectiveness of adjusters in making a correct decision was less than would be expected from flipping a coin.
The study involved a retrospective review of 6,250 medical requests submitted to workers compensation payers for approval. Seventy-percent (4,513) requests were from California, the remainder came from 36 other states. Each request had a defined diagnosis code (ICD9) and a medical code (CPT, HCPCS). In each of these instances, a claims adjuster followed their internal practices to either authorize the request or escalate it to a higher-level medical review.
The data was subsequently processed through EHS’ BaseLine technology. The Pre-Authorization Decision application within the BaseLine platform collects the diagnosis code, the medical code, and number of treatments/procedures being requested; it also compiles historic claim data to account for previous approvals. Then it bounces the request off national evidence-based guidelines, such as ODG, ACOEM or state specific guidelines. The application incorporates specific client customizations to the guidelines to control for unique items such as high cost procedures or surgical requests, where regardless of the evidence or number being requested, a higher-level review is just good practice.
The adjusters authorized 4,546 (73%) of the medical requests and sent 1,704 (27%) of the requests to a higher-level review. BaseLine found that only 2,696 (43%) should have been authorized at the adjuster desk, while 3,555 (57%) should have been escalated to a higher-level review.
Digging deeper into the data the retrospective review showed that of the 1,701 requests that the adjusters escalated to UR, the adjuster should have authorized 715 (42%) of the requests; while 986 (58%) met the evidence standards for the investment in UR.
On the other hand, of the 4,546 requests that the adjusters authorized, only 1,980 (44%) should have been authorized at the adjuster’s desk. Remarkably, 2,566 (56%) of the requests authorized by the adjuster had a diagnosis/treatment code combination that represented a significant likelihood that it would have been modified in some fashion by UR had it been escalated.
According to Schlueter, “The bottom-line is that adjusters are not medically trained professionals but they are being asked to make complex medical decisions in the name of operational efficiency. Without the support offered by BaseLine, the outcomes with this scenario are simply not effective. BaseLine bridges the gap between operational efficiency and organization effectiveness. BaseLine streamlines workflows and provides critical information and guidance adjusters need to do what they do best.”
For a discussion regarding the potential financial costs of this model on payers and TPA’s, EHS has prepared a complimentary white paper available by sending an email to [email protected]. Please put the words “Adjuster Effectiveness” in the subject line and include your contact information.
EHS released an abbreviated mobile-accessible version of the BaseLine pre-authorization decision tool. It is offered on a free-trial basis. The mobile application is a demonstration of how the API web-services can integrate BaseLine functionalities into the backend of any existing technology. To access a mobile app for free: https://pa.effectivehealthsystems.com/
About Effective Health Systems:
Effective Health Systems, (www.effectivehealthsystems.com) delivers technologies that help claims professionals do their jobs better. BaseLine is an inexpensive, quickly deployable and non-disruptive innovation to claims management. To learn more visit our website www.effectivehealthsystems.com.
The Internet of Things (IoT), in all its myriad manifestations, has great potential. Much of that potential comes from the evolving data management and analytic (DMA) technologies and processes that allow us to gain insight from all of the IoT data that can be generated and gathered. This potential may never be met as those data sets are tied to specific industry verticals and single markets, with no clear way to use IoT data and sensor analytics to fulfill the hype being given the IoT today.
Oct. 26, 2016 01:45 AM EDT Reads: 2,718
Ask someone to architect an Internet of Things (IoT) solution and you are guaranteed to see a reference to the cloud. This would lead you to believe that IoT requires the cloud to exist. However, there are many IoT use cases where the cloud is not feasible or desirable. In his session at @ThingsExpo, Dave McCarthy, Director of Products at Bsquare Corporation, will discuss the strategies that exist to extend intelligence directly to IoT devices and sensors, freeing them from the constraints of ...
Oct. 26, 2016 01:15 AM EDT Reads: 3,101
So you think you are a DevOps warrior, huh? Put your money (not really, it’s free) where your metrics are and prove it by taking The Ultimate DevOps Geek Quiz Challenge, sponsored by DevOps Summit. Battle through the set of tough questions created by industry thought leaders to earn your bragging rights and win some cool prizes.
Oct. 26, 2016 12:15 AM EDT Reads: 4,119
SYS-CON Events announced today that SoftNet Solutions will exhibit at the 19th International Cloud Expo, which will take place on November 1–3, 2016, at the Santa Clara Convention Center in Santa Clara, CA. SoftNet Solutions specializes in Enterprise Solutions for Hadoop and Big Data. It offers customers the most open, robust, and value-conscious portfolio of solutions, services, and tools for the shortest route to success with Big Data. The unique differentiator is the ability to architect and ...
Oct. 26, 2016 12:00 AM EDT Reads: 1,042
A completely new computing platform is on the horizon. They’re called Microservers by some, ARM Servers by others, and sometimes even ARM-based Servers. No matter what you call them, Microservers will have a huge impact on the data center and on server computing in general. Although few people are familiar with Microservers today, their impact will be felt very soon. This is a new category of computing platform that is available today and is predicted to have triple-digit growth rates for some ...
Oct. 26, 2016 12:00 AM EDT Reads: 34,220
The Internet of Things will challenge the status quo of how IT and development organizations operate. Or will it? Certainly the fog layer of IoT requires special insights about data ontology, security and transactional integrity. But the developmental challenges are the same: People, Process and Platform and how we integrate our thinking to solve complicated problems. In his session at 19th Cloud Expo, Craig Sproule, CEO of Metavine, will demonstrate how to move beyond today's coding paradigm ...
Oct. 26, 2016 12:00 AM EDT Reads: 3,859
Fifty billion connected devices and still no winning protocols standards. HTTP, WebSockets, MQTT, and CoAP seem to be leading in the IoT protocol race at the moment but many more protocols are getting introduced on a regular basis. Each protocol has its pros and cons depending on the nature of the communications. Does there really need to be only one protocol to rule them all? Of course not. In his session at @ThingsExpo, Chris Matthieu, co-founder and CTO of Octoblu, walk you through how Oct...
Oct. 26, 2016 12:00 AM EDT Reads: 3,190
Everyone knows that truly innovative companies learn as they go along, pushing boundaries in response to market changes and demands. What's more of a mystery is how to balance innovation on a fresh platform built from scratch with the legacy tech stack, product suite and customers that continue to serve as the business' foundation. In his General Session at 19th Cloud Expo, Michael Chambliss, Head of Engineering at ReadyTalk, will discuss why and how ReadyTalk diverted from healthy revenue an...
Oct. 25, 2016 11:45 PM EDT Reads: 2,991
In past @ThingsExpo presentations, Joseph di Paolantonio has explored how various Internet of Things (IoT) and data management and analytics (DMA) solution spaces will come together as sensor analytics ecosystems. This year, in his session at @ThingsExpo, Joseph di Paolantonio from DataArchon, will be adding the numerous Transportation areas, from autonomous vehicles to “Uber for containers.” While IoT data in any one area of Transportation will have a huge impact in that area, combining sensor...
Oct. 25, 2016 10:45 PM EDT Reads: 989
Without lifecycle traceability and visibility across the tool chain, stakeholders from Planning-to-Ops have limited insight and answers to who, what, when, why and how across the DevOps lifecycle. This impacts the ability to deliver high quality software at the needed velocity to drive positive business outcomes. In his general session at @DevOpsSummit at 19th Cloud Expo, Eric Robertson, General Manager at CollabNet, will discuss how customers are able to achieve a level of transparency that e...
Oct. 25, 2016 10:15 PM EDT Reads: 985
SYS-CON Events announced today that Cemware will exhibit at the 19th International Cloud Expo, which will take place on November 1–3, 2016, at the Santa Clara Convention Center in Santa Clara, CA. Use MATLAB functions by just visiting website mathfreeon.com. MATLAB compatible, freely usable, online platform services. As of October 2016, 80,000 users from 180 countries are enjoying our platform service.
Oct. 25, 2016 09:15 PM EDT Reads: 885
For basic one-to-one voice or video calling solutions, WebRTC has proven to be a very powerful technology. Although WebRTC’s core functionality is to provide secure, real-time p2p media streaming, leveraging native platform features and server-side components brings up new communication capabilities for web and native mobile applications, allowing for advanced multi-user use cases such as video broadcasting, conferencing, and media recording.
Oct. 25, 2016 08:45 PM EDT Reads: 3,245
Established in 1998, Calsoft is a leading software product engineering Services Company specializing in Storage, Networking, Virtualization and Cloud business verticals. Calsoft provides End-to-End Product Development, Quality Assurance Sustenance, Solution Engineering and Professional Services expertise to assist customers in achieving their product development and business goals. The company's deep domain knowledge of Storage, Virtualization, Networking and Cloud verticals helps in delivering ...
Oct. 25, 2016 08:30 PM EDT Reads: 1,106
SYS-CON Events announced today that Enzu will exhibit at the 19th International Cloud Expo, which will take place on November 1–3, 2016, at the Santa Clara Convention Center in Santa Clara, CA. Enzu’s mission is to be the leading provider of enterprise cloud solutions worldwide. Enzu enables online businesses to use its IT infrastructure to their competitive advantage. By offering a suite of proven hosting and management services, Enzu wants companies to focus on the core of their online busine...
Oct. 25, 2016 08:15 PM EDT Reads: 1,378
In the next five to ten years, millions, if not billions of things will become smarter. This smartness goes beyond connected things in our homes like the fridge, thermostat and fancy lighting, and into heavily regulated industries including aerospace, pharmaceutical/medical devices and energy. “Smartness” will embed itself within individual products that are part of our daily lives. We will engage with smart products - learning from them, informing them, and communicating with them. Smart produc...
Oct. 25, 2016 07:30 PM EDT Reads: 1,544