Workers’ compensation case severity can be tackled by recognizing and treating comorbidities early, according to industry experts.
Case severity scoring and other predictive analytic tools can assist adjusters in identifying potentially problematic claims.
Inside Workers’ Comp, a Genex multimedia series, recently delved into the issue of case severity scoring.
Mariellen Blue, RN, CCM, national director of case management services for Genex, explained how case severity scoring works.
“Whenever an individual sustains a work-related injury or illness, the length of treatment and the disability duration can vary significantly from person to person,” said Blue. “And our challenge, in the workers’ compensation environment, whether it’s from a claims management perspective or a case management perspective, is really to identify those claims that are most at risk for having a poor outcome and also those claims that are most likely to benefit from case management interventions to have a more successful case outcome.”
Blue explained that catastrophic claims tend to be easier for an adjuster to identify the necessity of further case management intervention. That’s not the case in non-catastrophic injury claims.
“In non-catastrophic claims, that determination really is not that cut and dry,” Blue said. “One of the preeminent tools that we use in workers’ compensation for predicting risk and to benchmark treatment is the Work Loss Data Institute’s Official Disability Guidelines (ODG).”
Genex created a link between data fields that are used in that comorbidity calculation.
“They’re pulled directly into, through our interface, into the ODG comorbidity calculator. The output from that will give us what we call our case severity rating, which is the comorbidity calculator risk assessment score,” Blue said. “This is a score that is given on a scale of 1 to 100 and it has five 20-point increment categories: low risk, moderate risk, cautionary risk, high risk and extreme risk.”
Blue said it is important to include all factors that could affect the injury and treatment outcome.
“Well, really with any type of injury or illness, but particularly in workers’ compensation, you’re really doing a disservice overall to the injured worker and to the claims administrator, if you are only looking at that compensable diagnosis because that really doesn’t tell the whole story,” Blue explained, using an example of a 30-year-old male with a diagnosis of a lumbar sprain/strain.
“If I was just trying to benchmark this particular case using only the compensable diagnosis, using our case severity rating scale, this would be rated as a 33 which would be a moderate risk which is relatively low on the scale. You might think, ‘OK, this isn’t that difficult of a case. The estimated return-to-work date would most likely be in the range of 14 to 19 days.’ And you might think this…is not a complex claim,” said Blue. “If you are an adjuster, you may or may not refer this due to that low score if you were using this tool.”
Using the same scenario but adding critical information that this individual is a smoker, obese (which is a BMI of 30 or higher), has psychosocial issues and has been prescribed opioids longer than 30 days, Blue said the comorbidity calculator reveals a case severity score of 75 which is high-risk.
“So here’s a claim that may have initially been perceived as maybe not needing very intense case management services. Bringing in those confounding factors, this suddenly becomes a case that is likely to not have that great of an outcome if left unmanaged,” said Blue.
Comorbidities, including obesity, hypertension, diabetes and depression can complicate claims by delaying recovery and increasing indemnity costs, according to risk manager HM Insurance Group.
According to the Centers for Disease Control and Prevention, obesity alone is linked to health risks such as “coronary heart disease, hypertension, stroke, type 2 diabetes, cancer, liver and gall bladder disease, gynecological problems and sleep apnea.”
An Advisen 2014 report sponsored by The Hartford, Mining Workers’ Compensation Data Nets Valuable Cost-Control, stated the costs associated with those conditions are a key driver in rising employer health plan and workers’ comp costs.
“There is mounting evidence that poor employee weight management can also impact workers’ compensation costs. One of the most recent studies linking obesity to longer disability duration is a 2013 NCCI study of more than 4.8 million workers’ comp claims in 40 states from 1998 through 2008. The duration of temporary total and permanent total indemnity benefit payments for obese claimants was five times longer than for claimants who were not obese, according to the study, Indemnity Benefit Duration and Obesity. When permanent partial benefits are included, the duration of benefits for obese claimants was six times greater than for non-obese claimants, the study found.”
The Hartford also uses predictive analytics to screen for comorbidities early in the claim.
“Our models look at a host of characteristics that can complicate an injured workers’ recovery, so we can assign appropriate resources when intervention is most effective,” said Glen Pitruzzello, vice president, workers’ compensation claim practices at The Hartford.
For example, the insurer’s models use text-mining to identify references to potential comorbidities, like obesity and high blood pressure.
“We may have a scenario in which an injured worker needs surgery, but his excess weight puts him at risk of surgical complications and needs to be addressed before the surgery can be performed,” said Pitruzzello.
The report noted that workers’ compensation claims data mining generates a plethora of information that employers can use to cut medical expenses.
According to John Santulli, executive vice president of workers’ comp risk management firm PMA Companies, who wrote an executive brief on the subject in 2015, early intervention is key.
“Early intervention in a claim is critical. This includes the prompt identification of comorbidities, expediting appropriate treatment and quick pharmacy intervention, among other strategies,” stated Santulli.