COMING UP SHORT
The article "Transparency of Evidence," appearing on Page 22 of the Oct. 1, 2009, issue makes a number of excellent points, but misses three key issues about the use of evidence-based medicine to identify workers' compensation fraud.
Start with durations. The article focuses on the use of treatment guidelines to identify fraud. A better place to start data mining for fraud is the use of return-to-work duration guidelines. Time away from the job is a much easier statistic to track than are type and number of procedures. Once you have identified a pattern of return-to-work durations that are suspiciously long, then you can drill down into the treatment data to see what is going on.
Data quality matters ... a lot. All evidence-based guidelines are not equal. Data quality can vary widely and make a huge difference in your ability to use it for detecting out-of-norm patterns. Choose guidelines carefully and subject them to a rigorous process of clinical and statistical quality checking. Guidelines should be physician-reviewed by experts in the appropriate medical fields.
Compare physiological durations with normative durations. It is no secret that normative (actual) workers' comp durations trend far longer than non-workers' comp disability durations for the same medical conditions. Choose duration guidelines that provide both physiological (i.e., the time it takes for the actual broken bone to heal, medically) and normative durations. When you compare the two sets of durations, you'll start to get a much clearer picture of fraud trends.
Evidence-based medicine guidelines can be powerful tools, both in combating fraud and in helping employees return to their normal healthy work lives. Choose guidelines wisely and use them well. You are certain to see positive results.
Dr. Jon Seymour, president, guidelines
Reed Group Ltd.
THE STATE OF THE FUNDS
I think there is an issue missed in the article, ("State WC Funds Growing, Represent Significant Share of Market," WORKERSCOMP ForumTM, Oct. 19, 2009), which is that state funds are not required to follow the same rating rules that apply to traditional insurers. State funds can increase or decrease rates, lower assessments, provide generous dividend plans ... which account for the higher loss ratios.
A good fund to study is California and the issues that led its failure, which certainly were not lower expenses or good loss ratios
I'm not sure that their expenses are that much lower than traditional carriers. I would like to see a study on that, and with respect to better safety and loss control, I would also like to see the research.
I have been in the business for several years and have seen customers go to the state fund and then leave the state fund for lack of services ... at least in my state of New York.
Jan Klodowski, vice president
Agri-Services Agency LLC
December 1, 2009
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