TPA Best Practices #2: Success with Evidence Based Medicine and Comorbidities

A major 2016 Workers’ Compensation benchmark study found that one of the largest differentiators of high-performers versus all other groups was the use of Evidence Based Medicine (EBM) guidelines. Users of EBM data were more than 4X more likely to be top performers than those who did not. The same study included a survey asking “What are the greatest obstacles to achieving desired claim outcomes?” Respondents ranked “Psychosocial/comorbidities” as the number one issue.

Using Origami Risk and ODG

Origami Risk is integrated with the Official Disability Guidelines (ODG) from the Work Loss Data Institute. Origami Risk’s ODG integration provides direct access to EBM data aggregated from over 10 million cases and decades of research. Risk scores and return to work estimates make it easy to identify the claims with the most risk. This allows for the early intervention that has driven down average disability duration by 30% for typical ODG users. With ODG guidelines and recommendations attached directly to the claim, Origami makes it easy to incorporate EBM best practices into any claim management process.

ODG and Comorbidities

Cited as the number one obstacle in the benchmark study, properly adjusting the risk scores and reserve estimates for claims based on changes in comorbidity factors can be challenging. Origami Risk includes comorbidity factors such as smoking, obesity, diabetes, and obtaining legal representation. As soon as any comorbidity factor is checked, ODG automatically updates risk scores, reserve recommendations and return to work estimates based on ODG’s comorbidity calculator that draws on the largest database of actual disability experience data available.

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Leveraging Report Triggers

Combining the vast best practice data from ODG with the powerful reporting features in Origami Risk makes it easy to identify and manage the most critical cases. Triggers can be set on claim risk scores, changes in reserves, return to work estimates, or any other ODG data. Any claim that meets these custom criteria can automatically create a task assignment for an adjuster to intervene, send alert notifications to supervisors, and email auto-generated reports complete with claim data to management. Escalating the claims that require immediate intervention turns the best practice goals of ODG into specific, concrete actions that ultimately reduce return to work timeframes and lower associated costs.

A TPA Differentiator

The benchmark study showed that while high performers were far more likely than other groups to use EBM tools such as ODG, it was still used by less than half of TPAs surveyed. This represents a large opportunity to provide a level of service that exceeds the competition. Origami Risk’s ODG integration makes it easy to monitor performance against best practice data, identify early which cases pose the biggest potential risk, and keep all levels of the organization focused on the most critical cases. Because the integration is real-time, ODG estimates change as soon as any factor is updated without having to re-run calculations in a separate application.

Moving to Best-in-Class

Incorporating EBM and comorbidity data into claims management is an important factor to reaching best-in-class performance. Origami Risk’s ODG integration provides both of these features. Direct access to the ODG evidence-based metrics and comorbidity impacts alongside all other claims data makes it easy to hone in on the claims for which early intervention has the greatest effect.

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