Method and system for enhanced medical triage

Description

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a divisional of U.S. patent application Ser. No. 10/084,326, filed Feb. 28, 2002, incorporated herein by reference in its entirety, which claims priority to U.S. Provisional Application No. 60/342,856, filed Dec. 28, 2001, incorporated herein by reference in its entirety.

BACKGROUND OF THE INVENTION

1. Field of the Invention

The present invention relates to the field of medical triage for health care plans, and more particularly, to a method and system for automated medical triage in a workers compensation plan.

2. Description of the Related Art

As is known in the art, medical triage is the act of categorizing or classifying patients (e.g., ill or injured persons) according to the severity of their health conditions and thereby determining who need services first. With rising health care and workers compensation costs, medical triage was designed to maximize and create the most efficient use of scarce managed care resources in medical personnel, medical facilities, and the like. While medical triage commonly occurs in emergency rooms, it can occur in other health care settings such as managed care organizations, workers compensation insurance, health care plans, and health care provider systems to steer patients away from more costly care and provide more appropriate services. For instance, medical triage can be used to steer a child with a cold away from an emergency room to preserve the latter for actual medical emergencies. Indeed, these health care organizations and systems have set up “triage centers” to serve as an extension of the utilization review process, as diversions from emergency room care, or as case management resources.

In the current medical triage environment for a managed care program, such as workers compensation (WC), a work injury claim is first called in from an employer of the injured worker (IW) to a telephone reporting center of a workers compensation insurance carrier or health care plan provider. The health and/or workers compensation insurance or care provider may have one or more telephone reporting centers handling the initial claim reportings. The telephone reporting center then performs logistic data collection and entry of information relating to the claim, such as the name of the injured person/worker, social security number of the worker, the employer's address and plant location of the accident and description of the accident. The collected claim information relating to the injured worker and the accident is then transferred out of the telephone reporting center to a local claim service center, (also known as an adjusting field office or AFO) via a claim management system (e.g., T-MATE of Travelers), wherein the AFO is a triage center of the health and/or workers compensation insurance or health plan provider. As with the telephone reporting center, there may be more than one local claim service center.

At the local claim service center, a case or claim handler is assigned to the claim. Part of the normal case set up of the case handler is to review the basic facts from the collected claim information and contact the injured worker to obtain additional facts and the injured worker's description of the accident. The case handler also contacts the employer to verify the information originally obtained by the telephone reporting center from the employer. Additionally, if a physician had provided medical care to the injured worker, the case handler also seeks out the physician to obtain the physician's diagnosis or prognosis of the injured worker and his/her injury. After completing the aforementioned inquiries, the case handler documents the additional facts along with the originally collected claim information, and sends via a system interface, to a medical case manager (MCM). The MCM's task is to review the set of facts and—based on his/her professional opinion as an MCM—determine whether the return-to-work (RTW) time for the injured worker can be impacted. For instance, if the injured worker is to be out for 30 days, can he/she return to work earlier (e.g., in 20 days) if additional medical attention is given; or if the RTW time is 19 days, can he/she come back in 14 days. There are certain instances where the RTW time cannot be impacted, such as when the injured worker was already back at work after the accident and when the worker suffered a fatal injury in the accident. If the MCM judges that the RTW time will not be impacted, the MCM will document a non-referral into the nurse's integrated case management system (ICMS). However, if the MCM judges that the RTW time can be impacted, the MCM will open a medical referral and assignment for the injured worker in ICMS. The assigned nurse will then co-manage the claim with the claims adjuster (i.e., MCM), and work with the appropriate physicians to provide the necessary medical attention and treatment plan to expedite the recuperation of the injured worker and shorten the RTW time. This is because for workers compensation, it is the workers compensation carrier, or self-insured employer, that pays for the medical treatment of the injured worker along with the indemnity payment (i.e., wage replacement) to the injured worker while he/she is not able to work. Thus, it is in the interest of the workers compensation carrier to accelerate and pay a little more on the medical treatment and impact the RTW time of the injured worker in order to cut down on the higher cost of indemnity payment.

BRIEF SUMMARY OF THE INVENTION

There are a number of problems associated with the current medical triage environment. Firstly, it requires the claims routing from T-MATE to ICMS to be “triaged” by the medical unit and its MCMs. The triage process required a review of the medical protocols and assignment by a MCM if lost time is expected to exceed a predetermined amount of time, e.g., 14 days. Because all medical referrals are triaged to determine if medical assignment is warranted in the current ICMS/medical assignment process, it has been found that, on average, a large percentage (48%) of the claims sent to the ICMS were assigned for medical management. It also has been found that there were wide disparities at the AFO level in the medical referrals and assignments sent to the ICMS. For instance, there was a wide variance of assignment percentage and inconsistent application of assignment procedures, wherein assignments by diagnosis and severity of injury vary by office, and a significant number of inappropriate referrals were sent to the ICMS. This is despite the fact that the MCMs are given criteria for medical referrals, such as those shown in Appendix A. Secondly, because an MCM's decision of nurse assignment is based partly on his/her individual experience on the job, turn-overs of MCMs further add to the disparities in the medical triage process. New MCMs with little or different knowledge will have different decisions on medical referrals from those of the more experienced MCMs. Thirdly, there is a huge operational cost in retaining MCMs, whose jobs are solely to determine whether a nurse can add value to workers compensation claims; thus, each office has costly medical resource allocated to the triage function.

Therefore, there exists a need for a method and system for enhanced medical triage in managed care plans, such as workers compensation, that streamlines the triage process and referral logic and sends only those claims to the ICMS that require medical intervention, e.g., by a nurse, thereby changing from an ICMS “triage roster” to an “assignment roster” (ICMS roster). Because each employer has unique claims that need to be properly managed when there is a major impact on medical management, there also exists a need for a method and system for enhanced medical triage that match claims to the right resources at the right time.

Accordingly, the preferred embodiments of the present invention provide a method and system for an enhanced medical triage that provides focused medical intervention, reduces the time needed to review lost time cases, lessens the number of unnecessary referrals or re-referrals, and further tailor the assignment process to medical personnel, such as nurses, based on specific market and/or employer dedication.

The preferred embodiments of the present invention also provide a method and system for an automated medical assignment process that eliminates the need to “triage” and assign claims based on anticipated disability timeframes, and only those claims meeting the medical assignment logic, or manually referred claims, can be routed to the ICMS “assignment roster” for medical assignment.

The preferred embodiments of the present invention also provide a method and system that implements sophisticated referral logic and professional skills for managing health care and/or workers compensation claims to the best outcome.

The preferred embodiments of the present invention further provide a method and system for an automated medical triage through system identification of claims requiring medical management.

The preferred embodiments of the present invention additionally provide a method and system for gathering the collective experience of triage personnel, establishing consistent assignment of selected injury types with high severity and/or potential for impact by a nurse, reducing or eliminating the staff resources required to triage claims, and developing improved claim data collection for future analysis.

Additional aspects and novel features of the invention will be set forth in part in the description that follows, and in part will become more apparent to those skilled in the art upon examination of the present disclosure.

BRIEF DESCRIPTION OF THE DRAWINGS

The preferred embodiments are illustrated by way of example and not limited in the following figures, in which:

FIG. 1 depicts the enhanced medical triage workflow logic in accordance with one embodiment of the present invention;

FIG. 2 depicts a sample screen used for collecting/mining the data elements necessary for the medical assignment logic in accordance with an embodiment of the present invention;

FIGS. 3A and 3B depict data mining results as viewed with the NCCI NOI/POB codes match; and

FIG. 4 depicts the existing system environment and the new system environment additions for implementing the enhanced medical triage in accordance to one embodiment of the present invention;

DETAILED DESCRIPTION OF THE INVENTION

Acronyms
AFO	Adjusting Field Office
APV	Average Paid Value
CAT	Catastrophic claim/severe injury
CB	Claim Benefit
CM	Claim Medical
CM-Plus	Claim Medical-Plus (medical involvement)
ICD-9	International Classification of Diseases, Ninth Revision
MIRA	Micro Insurance Reserve Analysis
NCCI	National Council on Compensation Insurance
NOA	Nature of Accident
NOI	Nature of Injury
NOL	Notice of Loss
POB	Part of Body
SAC	Special Account Communication
TT	Temporary Total disability
TP	Temporary Partial disability

Reference is now made in detail to an embodiment of the present invention, an illustrative example of which is illustrated in the accompanying illustrations, showing a method and system for enhanced medical triage that automates and streamlines the medical triage process. FIG. 1 shows the enhanced medical triage, i.e., medical referral/assignment, workflow logic in accordance with the preferred embodiments of the present invention. The enhanced medical triage includes both automated and manual medical referrals/assignments, as will be explained later. The goals and benefits to the streamlined medical assignment logic of the present invention include: 1) early medical intervention; 2) reduction in the amount of time required to review the ICMS roster; 3) reduction in the amount of unnecessary referrals to the ICMS roster; 4) improved consistency in the medical assignment of those claims that will benefit from medical intervention, such as assignment based on potential severity and ability to reduce lost time days; 5) ability of claim handlers to send manual referrals to medical assignment (i.e., manual medical referral/assignment); 6) system documentation of referral objectives for all medical assignments; 7) addition of medical assignment and closure measurements which allow future enhancements to the process; and 8) a re-write and clarification of SAC instructions impacting the medical assignment process, and need for pre-approval of certain services—thus allowing the host insurance carrier or health care plan provider to meet customer specific requests for medical assignment, such as the selection of an outside medical vendor. The current ICMS/medical referral and assignment process include the common triage/assignment decision points shown in Appendix A and the following settings:

• • All lost time/CB claims are automatically sent to the ICMS roster for triage when claim compensability is accepted;
  • A review of all CB claims by the medical team (i.e., the medical team “triaged” the claims) to determine if medical assignment will favorably impact the claim outcome by reviewing claim notes, injury type, and anticipated lost work time in excess of a predetermined period of time (e.g., RTW time >14 days);
  • Early intervention by the MCM; and
  • Re-referral of a claim by the claim handler, when there is a new disability period, when further medical services are warranted.

The present invention uses much of the above same initial logic that is in the current ICMS/medical referral and assignment process, and builds upon such logic for an enhanced medical triage workflow by preventing non-covered & controverted claims from referring to ICMS. Thus, FIG. 1 shows that steps 1-3 are similar to the current process. At step 1, a new claim notice is reported to a local claim service center (AFO) from a telephone reporting system via a claim management system, such as T-MATE. Although the name “T-MATE” is used throughout the disclosure, it should be understood that any claim management system with equivalent functionality to T-MATE can be used in its place. At step 2, the claim is reviewed and assigned to a claim handling unit, with one or more claim handlers, to investigate and/or manage the claim. At step 3, the claim handler assigned to the claim performs the normal case set up as discussed earlier and collects claim related information such as coverage, compensability, loss designator (e.g., as a CM or CB claim), and lost time information. This information is then used as input to the medical referral/assignment logic of the present invention, as shown in step 4. The formulation of this medical referral/assignment logic is described next.

According to preferred embodiments of the present invention, the T-MATE to ICMS referral & re-referral logic of the current ICMS/medical referral and assignment process is reviewed by soliciting feedback from all medical team leaders in the local claim service centers (AFOs) as to: a) current methods of claim evaluation to determine medical assignment; and b) SAC instructions that impact the medical assignment decisions. Additionally, a complete analysis is done on medical claims (e.g., workers compensation claims) currently being referred and assigned for medical management and claims non-intervened for medical assignment. This includes: a) finalizing a list of AFOs/service centers to pull data on assignments; b) finalizing a list of data elements that will be captured from the list of AFOs for data mining; c) setting up and completing code to capture the data elements; and d) completing a review of test files for data mining. The AFOs are chosen and finalized based on their claim volume and their current practice of adhering to the conventional manual medical triage process described earlier. Data elements are chosen and finalized based on current, reliable data fields captured in T-MATE that are considered to have an impact on determining medical assignment. Further detailed review included financials (APV, medical and indemnity incurreds), NCCI code combinations, ICD-9 data of assigned and non-assigned claims, anticipated surgery indicator, lost time days, and data mining to determine when certain data elements are populated. The list of data elements for mining includes but is not limited to those shown in Appendix B, with some of the data elements representing a grouping of data. FIG. 2 shows a sample screen used for collecting/mining the data elements. FIGS. 3A and 3B show an example of the data mining results of NOI. Appendix C shows an example of the data mining results, where the “average” column denotes the number of days to completion of the data field, the “count” column denotes the claim count, and the “percent” column denotes the percentage of claim files with data field populated.

Based on the data mining results, it is determined that injury codes alone do not drive the medical assignment/referral decision. It is often the injury plus any red flag factors such as those listed in Appendix A. Accordingly, a streamlined medical referral and assignment logic is developed based on factors that most significantly impact the claim assignment to medical care. These factors are in turn based on a combination of the data mining results and the actuarial/financial/manual analysis described above. All of these factors may be considered for initial referrals and re-referrals, and they include:

A) A combination of selected NCCI codes to include both NOI and POB, a list of which is shown in Appendix D. Refer/re-refer when the claim matches one of the selected NCCI NOI/POB codes. ICMS will then display a referral objective as shown in Table 2.

B) Refer/re-refer when the “anticipated surgery” indicator has a value of A (anticipated), P (performed), or B (both anticipated & performed). ICMS will then display a referral objective as shown in Table 2.

C) Refer/re-refer when there is a new date which disability began as entered by the claim handler. ICMS will then display a referral objective as shown in Table 2.

D) Refer/re-refer a claim when actual lost time exceeds a predetermined period of time, e.g., 14 days (i.e., initial lost days). ICMS will then display a referral objective as shown in Table 2. All claims are included, not just the selected NOI/POB codes shown in Appendix D. One time event—only refer/re-refer once. Here, the claim handler and/or the MCM completes the RTW date and qualifier as soon as the injured worker (IW) returns to work to avoid unnecessary referrals to ICMS.

E) Refer/re-refer when the sum of the TT incurred, TP incurred, and medical incurred values (i.e., total cost of all three) is greater than a predetermined amount of money, e.g., $20,000, and there is an open disability. TT denotes temporary total disability, wherein the IW is totally disabled from work temporarily; TP denotes temporary partial disability, wherein the IW is partially disabled from work temporarily, i.e., the IW cannot perform his/her job fully but can perform some faun of work. In other words, a referral/re-referral will occur each time that the claim incurreds are greater than $20,000. ICMS will then display a referral objective as shown in Table 2.

F) Refer/re-refer if a selected ICD-9 code or early strategic intervention (ESI) ICD-9 code is processed through the medical bill re-pricing system in which all medical bills are input for payment and possible re-adjustment of payment due to state fee schedule or negotiated network rates. In other words, referral/re-referral logic will look at all of ICD-9 codes stored (primary, plus most recent codes stored) and create a referral/re-referral if any of the stored codes match the selected or ESI codes. The ICD-9 logic includes two distinct groups of ICD-9 codes that may run through the ICMS referral/re-referral logic to create an automated referral. Thus, the referral/re-referral occurs when there is a change of ICD-9 code that matches the criteria of the ICD-9 codes in these two distinct groups, which are:

• • 1 ICD-9 codes that are associated with potential ESI claims (ESI ICD-9 codes), as shown in Table 1; and
  • 2. ICD-9 codes which identify claims with significant medical issues that require medical intervention (selected ICD-9 codes), a sample list of which is shown in Appendix E.

TABLE 1
	ESI Diagnosis	ICD-9 Code

	RSD	337.9
	Multiple Sclerosis	340
	Thoracic Outlet Syndrome	353.0
	Psychiatric Disorder	300.9
	Substance Abuse: ETOH	305
	Substance Abuse: Drugs	305.9
	Chronic Pain	729.5
	Post Traumatic Stress Disorder	309.89
	Organ Transplant - V Code	V43 (996.8 complication
		of transplanted organ)
	Toxic Exposure	980-987 depending
		upon type of substance
	Electrocution	994.8
	Post Concussion Syndrome	310.2/850.9
	Failed or multiple back surgeries	724.9
	Rape/Assault	959.9

For the first distinct group, i.e., the ESI ICD-9 codes, there may be an automated ICMS medical assignment/referral of the claim when the ICD-9 code of the claim matches the ESI ICD-9 codes used by the major case unit (MCU). The MCU is a dedicated unit of technical experts whose primary function is to handle catastrophic and large loss claims. Additionally, a referral objective may be displayed in ICMS as shown in Table 2. Consequently, a discussion may take place between the claim handler and the MCM to determine the ESI eligibility and referral to the MCU. For the second distinct group, i.e., the selected ICD-9 codes, an automated ICMS assignment will occur when the ICD-9 code of the claim matches one of the selected ICD-9. Again, a referral objective may then be displayed in ICMS as shown in Table 2.

If the claim factors match more than one automated assignment triggers or claim factors above, each trigger creating the automated assignment can be displayed. For example, if lost time exceeds a predetermined time frame, e.g., 14 days, and the anticipated surgery indicator is present, both referral objectives will be listed. As mentioned earlier, Table 2 shows the automated assignment/referral and re-referral objectives that can be displayed, individually or jointly, in the ICMS.

TABLE 2
Referral Logic	Referral Objective To Be Displayed
NOI/POB code	“Nature of Injury/Part
combination met	of Body description meets
	medical assignment criteria”
Anticipated/performed	“Surgery is anticipated or has
surgery (A/P/B)	been performed, please assign”
Lost time exceeds 14 days	“Patient has not RTW in over 14 days”
TT, TP and Medical Incurred	“The total TT, TP
total exceeds $20,000	& medical incurreds
	exceed $20,000”
a. Selected ICD-9 codes	a. “The current ICD-9 diagnosis
	meetsmedical assignment criteria”
b. ESI ICD-9 codes	b. “Claims falls within ESI criteria,
	pleaseevaluate for medical
	assignment and referralto MCU”
New date disability began	“Patient has begun a new disability period”

According to an embodiment of the present invention, the medical referral logic of step 4 in FIG. 1 includes claim factors that can prevent an automated assignment to ICMS, and they include: 1) claim is closed in T-MATE; 2) policy coverage=N (none) or U (unknown); 3) controverted indicated=Yes; 4) date of death is populated; 5) there is already an open ICMS referral; 6) the policy is an opted out account; 7) there is a prior carrier policy or excess carrier file; 8) the IW returned to work full duty, or the IW will never RTW; and 9) bypass some controlling offices, i.e., those customer-dedicated offices that have chosen to bypass and not use the medical program of the host insurance carrier or health care plan provider. When the aforementioned claim factors or data fields exist, a negative answer results from step 8, and an automated ICMS assignment will be blocked and the system referral is not sent in step 7. However, a manual medical referral may still be sent by the claim handler in step 6 in some circumstances as a result of the claim handler recognizing the need for medical assignment in step 5. For instance, a customer who may normally use the medical program of the host insurance carrier may request an assignment on a case-by-case basis (usually for serious injuries).

According to an embodiment of the present invention, an automated medical assignment/referral can be prevented—despite the fact that the claim data matches the medical assignment/referral logic in step 8 of FIG. 1, and a generated medical referral is sent to the ICMS roster—if there exists one of previous non-intervened milestones. All claims displayed on the ICMS roster at step 9 will take one of two paths: a) assignment to a MCM; or b) non-intervention. For MCM assignment, if all claim factors are updated in T-MATE as claim facts change, and the claim requires medical management, the MCM will complete the case assigned/case received and sent activity and assign the claim to a nurse in step 11. The “case assigned” activity: 1) is used to create a diary for the medical personnel, e.g., a nurse, to whom the claim is assigned; 2) is marked completed with the result code “case received” by the nurse to whom the claim is assigned, which creates the referral-opened-by-medical milestone; 3) is not used when a claim is non-intervened; and 4) is not used for the sole purpose of removing a claim from the ICMS roster. The “sent” activity happens when the nurse sends the claim activity to T-MATE to become part of the claim notes.

If the SAC instructions require pre-approval prior to managing the claims, the dedicated MCM to the account should seek pre-approval from the customer, prior to completing the case assigned/case received activity. To further streamline the assignment process, nurses can be designated to specific market, employer-dedicated claim units, and/or alpha-split claim units to allow them to remove their own claims from the ICMS roster. Alpha split claim units are those tasked with assigning claim notices to the claim handlers based on alphabetical split of the customer name; for example, one claim handler or adjuster may manage customers with first letter A to G in their names. According to the present invention, the ICMS will not automatically create assignments directly to individual nurses.

For non-intervention of a claim sent to the ICMS roster, there are three distinct reasons such claim may be non-intervened, i.e., three non-intervened milestones:

• • 1. The claim does not meet medical assignment criteria in step 12, when reviewed by the MCM in step 10. Here, a result code of “Non-intervene, does not meet criteria” will display in ICMS. The MCM can also add a note with the specific rationale as to why the claim does not require medical assignment. This will allow for future analysis and enhancements to the assignment logic. For instance, a claim may have met the referral logic because the claim data was not updated, where it appeared that there was an open disability, but the injured employee had returned to work; or the claim met the referral logic but the severity was very low, such as the surgery performed was to suture a cut hand and there was minimal time loss for work.
  • 2. SAC instructions indicate that the customer does not want medical management assigned. Here, a result code of “Non-intervene per customer request” will display in ICMS.
  • 3. Claim is a CAT and MCU has assigned an external resource. Here, a result code of “Non-intervene CAT” will display in ICMS.
    If one of the aforementioned non-intervened milestones exists, the claim is not assigned to a nurse to manage, as shown in step 13. T-MATE claim data is then updated as claim facts change, as shown in step 14, and the workflow is started at step 8 again.

As noted in the goals and benefits of the enhanced medical triage of the present invention, manual medical referrals are retained for the claim handlers, as shown in steps 5 and 6 of FIG. 1. In other words, claim handlers maintain the ability to manually refer a claim to ICMS that does not meet the automated assignment logic, and requires medical intervention. As with the automated medical referral/assignment, the claim is reviewed by the MCM at step 10 to determine whether the claim meets the assignment criteria, and the workflow of FIG. 1 continues as mentioned earlier with regard to steps 11-14. Claims sent manually by the claim handlers at steps 5 and 6 may include CM claims and CB claims. Appendix G shows a table detailing the key data elements to manually determine medical assignment.

The medical claim assignments found on the ICMS roster include CB claims, CM-Plus claims, and CM claims. The CB claims include claims that meet the automated assignment logic & claims that are manually sent by the claim handler through the T-MATE Medical referral screen process. The CM-Plus claims are those CM claims that are identified as potentially requiring medical management, due to the type injury and/or treatment, and include those claims that meet the CM-Plus referral logic and the customer has elected to use the CM-Plus product. The CM-Plus referral logic includes repetitive trauma, carpal tunnel, knee injuries, and back injuries with ongoing physical therapy or chiropractic treatment. CM-Plus claims may require review and an assignment decision because the assigned medical personnel, such as an assigned nurse, may need to review for the potential to positively impact the claim outcome due to the medical management charge to the claim file. The review often requires the nurse to contact the treating physician to determine the medical status of the IW. CM claims include only those claims that are manually sent by the claim handler through the T-MATE Medical referral screen process.

In order to maintain the early intervention and quick turnaround of medical assignments, one person per service center may be designated to review the ICMS roster periodically at a predetermined interval, e.g., daily, to be sure all claims, either assigned or non-intervened, are periodically removed. As mentioned earlier, all claims sent to ICMS through the automated assignment logic and through the manual medical referral screen process will list a referral objective and be displayed in ICMS in the “Claim. Rep Notes” on the Event screen. Appendix F shows the notes that will display in T-MATE when a medical referral is created. These notes will also display in ICMS in the “Claim Rep Notes” on the Event screen.

As part of the continual improvement process, the enhanced medical triage and assignment process is reviewed to assure consistency of assignments from office (AFO) to office by injury type, severity of injury, and potential medical impact. In addition, the goal is to continually decrease the number of unnecessary referrals sent to the medical unit for review, thus increasing efficiency of the medical assignment process. Part of the improvement process is the use of management information reports that are generated based on “milestones” which are created when certain system activities take place. Milestones include: referral (assignment) and closures (non-intervened). These milestones is used to report statistics on AFO acceptance of claims for medical management. Table 3 shows the Referral Type Milestones that are created in T-MATE when various types of referrals are made to ICMS.

TABLE 3
Referral Type Milestones

	Milestone	Description
	Auto referral to Medical	Standard Automated Referral
	14-day Auto referral	Automated Referral when no
	to Medical	return to work within 14 days
	New Disability Auto referral	Automated Referral when new
	to Medical	Date Disability Began is entered
	Manual Referral to Medical.	Manual Medical Referral
	Nurse Referral to Medical	Nurse opens claim in ICMS
		and T-MATE sends back a referral

Table 4 shows the referral-opened-by medical milestone, which is created in T-MATE when “case assigned”/“case received” is completed in ICMS.

TABLE 4
Referral-Opened-by-Medical Milestone

	Milestone	Description
	Referral opened by medical	Referral has been
	{Case Assigned/Case Received}	accepted for Medical
		Management.

Table 5 shows the non-intervened milestones that are created in T-MATE when specific result codes noted below are used with the activity “Cease Activity” in ICMS. Non-intervened result codes are not appropriate when closing a claim after medical management has been initiated. Closure codes such as “Adjuster Requests Closure” are more appropriate when the claim has been initially managed and then requires closure.

TABLE 5
Non-intervened Milestones

Milestone	Description
Non-intervened by Medical - Does not	Non-intervened by Medical as
meet criteria {cease activity/non-	claim would not benefit from
intervene - does not meet criteria}	medical intervention.
Non-intervened by Medical	Non-intervened by medical on
per Customer Request	this specific claim as
{cease activity/non-intervene -	requested by customer
per customer request}
non-intervened by medical - CAT	Non-intervened - catastrophic
{cease activity/non-intervene CAT}	claim which MCU will manage

Additionally, the referral objectives for both automated and manual referrals are reviewed to determine if the claim requires ongoing medical case management, or utilization review/pre-certification only. The manual referral displays the primary service requested which includes telephonic case management, UR only, or on-site medical or vocational. The referral will also indicate an UM or surgical referral if the referral includes a current treatment request. Ongoing medical management, rather than pre-cert/UR only is considered any time there is ongoing lost time and/or medical treatment. This includes manual and automated referrals.

FIG. 4 shows the existing system environment (top part of the figure) for the current medical referral/assignment process and the new system environment additions (bottom part of the figure) to implement the enhanced medical triage of the present invention. The PICM Auto Medical Assignment driver is a traffic router and a driver for the automated medical assignment system process. It is initiated first, filters through preliminary edits, and initiates other components that conduct more detailed and specialized functions. The components initiated by the PICM return control back to the PICM and provide a return message. The PICM then interrogates the message to determine the appropriate next step to conduct for the entire process. The Referral/Re-referral is one of the components initiated by the PICM. It performs all of the triage/assignment edits that have been stored in various data stores. Its basic functions is to determine if a claim needs to be sent to medical either for the first time or as a re-referral. This decision point is triggered when a triage/assignment edit exists. Once a decision is made, it returns control to the PICM driver component and passes a return message. The MedRef Process component is another component initiated by the PICM for two functions: 1) whenever a new referral or a re-ferral is required to by processed; and 2) whenever the system must determine if data has changed in the WC claim system that needs to be propagated into the medical system, so that both system can be in sync with its data. Once processing is complete it returns control to the PICM driver component and passes a return message. The Data Reformatter process component is also initiated by the PICM, and its function is to format a referral/re-referral message or a data update message to be sent to the medical system. It also reads the data stores, gathers the data, builds a message to conform to a specified layout, and places this message onto the ICMS queue component. The data from the ICMS queue is then forwarded via an existing hourly ICMS process to a medical vendor, such as Intracorp, for processing of the claims.

In summary, the enhanced medical triage of the present invention maintains early intervention by the system review of referrals, in addition to creating assignment logic to send only those claims to medical review that require medical intervention. The enhanced medical triage is based on a detailed study of claim data elements, actuarial study, and predictive modeling was reviewed and modeled after the medical supervisor review process. The benefits to this approach are to improve consistency and quality of medical assignments from office to office, and to reduce the unnecessary referrals to ICMS. In addition, the claim handler maintains the ability to manually assign a claim to the medical unit at any time. Furthermore, with turn-overs of claim personnel, inconsistent claim handling and referrals may arise with new claim personnel coming into the job with different opinions and/or different sets of experience. The enhanced medical triage of the present invention allows the new claim personnel to build the body of knowledge of previous personnel, instead of having to start over and provides more consistency between personnel, between offices, and between jurisdictions (because health care plans such as workers compensation plans are state-driven and statutory-driven). Employers will benefit from reduced claim costs, early intervention by claim handlers, and consistency of medical case assignment. This puts the employer in the position where selected lost time claims that have the potential for the greatest medical impact are assigned automatically once compensibility is established.

Although the invention has been described with reference to these preferred embodiments, other embodiments could be made by those in the art to achieve the same or similar results. Variations and modifications of the present invention will be apparent to one skilled in the art based on this disclosure, and the present invention encompasses all such modifications and equivalents.

APPENDIX A
Common Triage/Assignments Decision Points
Utilized in Today's ICMS Environment

1.	Date of Injury (DOI) → If DOI already exceeds a
	predetermined period of time, e.g., 14 days, immediate
	medical assignment should be made.
2.	Special Account Communication (SAC) instruction review →
	Follow customer request from SAC instructions for
	medical assignment (SAC instructions refer to
	customer-specific service requirements that the
	claim professional must meet in handling the claim).
	For accounts with SACs related to medical
	assignment pre-approval, up to 50% of
	the triage time is related to SAC compliance.
3.	Diagnosis/ICD-9 (if available) → The following diagnoses are
	medically assigned the majority of the time (can also be derived
	from NCCI injury and body part codes):
	Backs
	Necks/disc involvement
	Shoulder/rotator cuffs
	Knee injuries
	Repetitive injuries
	Hernia - 50% assignment;
	Wherein ICD-9 refers to the International Classification
	of Diseases, Ninth
	Revision; and NCCI refers to the National Council
	on Compensation Insurance.
4.	History of prior injury and pre-existing conditions.
5.	Work status → If out of work (OOW), then assign; if
	modified work duty, then 50% assignment.
6.	Type of ICMS referral → If manual by adjuster, then assign;
	If automated to ICMS, then perform triage.
7.	All claims where surgery is anticipated.
8.	When there is a request for medical services, for all
	therapy, diagnostics, DME, etc.
9.	Red flags present, e.g., no follow up doctor visit and OOW,
	multiple claim history, out of network provider,
	injured worker (IW) in need of physician referral.
10.	Description of IW's job (e.g., heavy, repetitive)
11.	If modified duty is available, and if RN can
	assist in identifying modified duty.
12.	Disability duration, as outlined in medical protocols (limited use).

APPENDIX B
Data Elements for Mining

CARR market code (or any market code)

ICMS referral date

ICMS manual (MedRef) indicator

ICMS assignment date

Job class code

Job hazard index code

Loss designator

Loss designator level indicator

Second injury indicator

Education level

Work level (i.e., heavy, light, sedentary)

Light work available (Y/N)

Occupational risk indicator (i.e., Char(1); L—light; M—medium;

H—heavy, blank)

Probability of permanent injury (i.e., Char(1); L—low; M—medium;

H—high; N—none; blank)

Controverted indicator

MIRA factors

Selected system data items:

1.	AFO code
2.	Claim number
3.	Adjusting state
4.	Date of NOL (Notice of Loss)
5.	SIC code (Standard Industry Classification)
6.	Employee Sex
7.	Initial treatment code
8.	Full/Part time indicator
9.	Date of birth
10.	Injured worker type
11.	Wok days per week
12.	Average weekly wage
13.	Overtime indicator
14.	Date of hire
15.	Length of employment - years
16.	Accident date
17.	Date reported to employer
18.	Lost time indicator
19.	Return to work indicator
20.	Return to work date
21.	Fatality indicator
22.	Date of death
23.	Last day worked
24.	Cause code
25.	Part of body (POB) code
26.	Nature of injury (POI) code
27.	Previous injury indicator
28.	First aid indicator
29.	Hospital indicator
30.	Physician indicator
31.	Ambulance indicator
32.	First Aid date
33.	Hospital first date of treatment
34.	Hospital length of stay
35.	Physician First date of treatment
36.	Physician's specialty.

APPENDIX C
Data Mining Results and Data Integrity

Variable	All Claims	Average	Count	Percent (%)

	Days_NOL	28.38	6570
1	T_NOL_Date	1.0	6570	100
2	T_Adj_State	1.0	6570	100
3	T_Cov_Ver_Ind	1.0	6570	100
4	T_First_Aid_Ind	1.0	814	12
5	T_Hosp_Ind	1.0	4537	69
6	T_Phys_Ind	1.0	1454	22
7	T_Work_Days_Week	1.01	6570	100
8	T_DOL	1.02	6570	100
9	T_Part_Body	1.03	6569	100
10	T_Gender	1.03	6569	100
11	T_Cause_Injury	1.03	6570	100
12	T_Reg_Work_Status	1.04	6192	94
13	T_Nature_Injury	1.05	6570	100
14	T_Initial_Treat_Code	1.10	5794	88
15	T_Rept_Employer_Date	1.10	6567	100
16	T_Claimant_Zip	1.17	6516	99
17	T_DOB	1.32	6349	97
18	T_Policy_Num	1.33	6463	98
19	T_CARR_Market	1.42	6393	97
20	T_Hire_Date	1.42	5632	86
21	T_Sailor_Acct_Num	1.43	5175	79
22	T_Lost_Time_Ind	1.47	5820	89
23	T_Prev_Injury_Ind	1.75	6310	96
24	T_Loss_Des	1.99	6570	100
25	T_Subro_Flag	3.46	6401	97
26	T_Ret_Work_Ind	3.47	5686	87
27	T_Cum_Trauma_Ind	3.61	6399	97
28	T_AWW	4.08	5783	88
29	T_Last_Day_Worked	4.25	3620	55
30	T_Level_Ind	4.89	5433	83
31	T_Cat_Code	4.91	573	9
32	T_Salary_Cont	5.14	5514	84
33	T_Cat_Ind	5.18	5463	83
34	T_Educ_Level	5.77	371	6
35	T_Contro_Ind	6.32	4936	75
36	T_ICMS_Ref_Date	6.63	3573	54
37	T_Light_Work_Avail_Ind	6.65	1984	30
38	T_Marital_Status	7.49	2409	37
39	T_Non_Inter_Med_Date	7.74	2142	33
40	T_Sec_Injury_Ind	8.39	1377	21
41	T_Litig_Antic_Ind	8.77	4989	76
42	T_Antic_Med_Mang	9.00	4207	64
43	T_Occ_Risk_Ind	9.02	4966	76
44	T_Ret_Work_Data	9.08	1659	25
45	T_Job_Class_Code	9.11	5111	78
46	T_Comp_Rate	9.14	5084	77
47	T_Surg_Antic_Ind	9.30	4899	75
48	T_ICMS_Assign_Date	10.04	1649	25
49	T_Ret_Work_Qual	10.44	1513	23
50	T_Prob_Perm_Inj	11.63	4656	71
51	T_DOD	11.94	380	6
52	T_ref_Clsd_Med_Date	17.91	443	7

APPENDIX D
NCCI NOI/POB Codes

NOI	Do Not Assign
1	no physical injury
3	angina pectoris
54	asphyxiation
30	freezing
31	hearing loss or impairment
32	heat prostration
36	infection
37	inflammation
53	syncope
55	vascular
58	vision loss
60	dust disease
61	asbestosis
62	black lung
63	byssinosis
64	silicosis
65	respiratory disorders
66	poisoning—chemicals
67	poisoning—metal
68	dermatitis
69	mental disorder
70	radiation
71	all other occupational disease
72	loss of hearing
73	contagious disease
76	VDT
NOI	Small 100% Assignment
7	concussion
13	crushing
22	enucleation
25	foreign body
42	poisoning
41	myocardial infarction
74	cancer
75	aids
77	mental stress
90	mult physical injuries
91	mult inj/phys & psych

	Large	Recom-
NOI	Numbers	mendation	POB
10	contusion	include	10	mult head inj
			11	skull
			12	brain
			20	mult neck inj
			21	vertebrae
			22	neck disc
			25	neck soft tissue
			30	multiple upper extremities
			38	shoulder
			42	lower back
			43	trunk disc
			53	knee
			63	lumbar & sacral vert
			91	body systems
40	laceration	include	11	skull
			13	ears
			20	mult neck inj
			26	trachea
			34	wrist
			38	shoulder
			90	mult body parts
			91	body systems
49	sprain	include	22	neck disc
			30	mult upper extemities
			31	upper arrn
			38	shoulder
			39	wrist & hand
			40	mult trunk
			42	lower back
			43	trunk disc
			47	trunk spinal cord
			51	hip
			52	upper leg
			53	knee
			90	mult body parts
			91	body systems
52	strain	include	11	skull
			21	vertebrae
			22	neck disc
			25	neck soft tissue
			30	mult upper extemities
			31	upper arm
			32	elbow
			33	lower arm
			34	wrist
			38	shoulder
			39	wrist & hand
			41	upper back
			42	lower back
			43	trunk disc
			52	upper leg
			53	knee
			63	lumbar & sacral vert
			90	mult body parts
59	all other spec.	include	10	mult head inj
	inj., NOC		12	brain
			22	neck disc
			23	neck spinal cord
			38	shoulder
			39	wrist & hand
			41	upper back
			42	lower back
			43	trunk disc
			50	mult lower extremities
			51	hip
			53	knee
			63	lumbar & sacral vert
			90	mult body parts
	Investigated
NOI	by POB	Rec'dation	POB
2	amputation	include all
4	burn	include	40	multiple trunk
			50	multiple lower extremities
			52	upper leg
			61	abdomen incl groin
			90	multiple body parts
16	dislocation	incl. all but	36	finger
			37	thumb
			56	foot
			57	toes
			58	great toe
19	electric shock	include	11	skull
			35	hand
			90	mult body parts
			91	body systems
28	fracture	incl. all but	16	teeth
			18	head soft tissue
			35	hand
			36	finger
			37	thumb
			44	chest
			45	sacrum & coccyx
			57	toes
			58	great toe
			62	buttocks
			64	artificial appliance
			34	hernia include
			20	multiple neck injury
			21	vertebrae 22 neck disc
			42	lower back
			43	trunk disc
			61	abodomen Incl. Groin
43	puncture	include	13	ears
			14	eyes
			48	internal organs
			91	body systems
46	rupture	incl. all but	36	finger
			37	thumb
			54	lower leg
47	severance	include all
78	carpal tunnel	include all
80	all other	include	20	mult neck inj
	cumulative		21	vertebrae
	injury		22	neck disc
			30	mult upper extremities
			31	upper arm
			32	elbow
			34	wrist
			38	shoulder
			39	wrist & hand
			40	multiple trunk
			41	upper back
			53	knee
			56	foot
			90	mult body parts

APPENDIX E
Sample List of Selected ICD-9 Codes

ICD-9 Code	ICD-9 Description

308.3	acute stress react nec
308.9	acute stress react nos
309.81	prolong posttraum stress
337	idiopath auto neuropathy
337.2	reflex sympat dystrophy
337.2	reflex symp dystroph nos
337.21	ref symp dyst upper limb
337.22	ref symp dyst lower limb
337.29	reflex symp dystroph nec
353.1	lumbosacral plex lesion
353.2	cervical root lesion nec
353.3	thoracic root lesion nec
353.4	lumbsacral root les nec
354	carpal tunnel syndrome
354	mononeuritis upper limb
354.1	median nerve lesion nec
354.2	ulnar nerve lesion
354.3	radial nerve lesion
354.4	causalgia of upper limb
354.5	mononeuritis multiplex
354.8	mononeuritis arm nec
354.9	mononeuritis arm nos
550	inguinal hernia
550	unilating hernia w gang
550.1	unilating hernia w obst
550.12	bilating hernia w obst
550.9	unilatinguinal hernia
550.9	inguinal hernia nos
550.92	bilatinguinal hernia
553	other abdominal hernia
553	femoral hernia
553	unilat femoral hernia
553.02	bilateral femoral hernia
553.1	umbilical hernia
553.2	ventral hernia nos
553.2	ventral hernia
553.21	incisional hernia
553.29	ventral hernia nec
553.3	diaphragmatic hernia
553.8	hernia nec
553.9	hernia nos
682.4	cellulitis of hand
6826	cellulitis of leg
682.7	cellulitis of foot
6829	cellulitis nos
715	general osteoarthrosis
715.15	loc prim osteoart-pelvis
715.16	loc prim osteoart-l/leg
715.91	osteoarthros nos-shlder
715.92	osteoarthros nos-up/arm
715.93	osteoarthros nos-forearm

APPENDIX F
Medical Referral Notes

Med Referral Information:

The employee's SSN is ____________

The employee is __ (Male/Female) Date of Birth: __/__/____

Occupation: _____________________________________________

Date of loss: __/__/____

This a surgical referral OR This is a non-surgical referral.

Primary service requested: _________________________________

Medical information: (followed by at least one of the following 5 lines)

Physical therapy is requested.

Chiropractic is requested.

Diagnostic tests are requested.

No medical requests.

Injury description: _________________________/______________

Cause: _________________________________________________

Nature: ________________________________________________

An IME has been performed. OR An IME has not been performed.

Current Treating physician: ________________________________

Phone: (___) ___-____ Address: ____________________________

Modified duty is available. OR It is unknown whether modified duty

is available. OR Modified duty is not available.

The employee is currently out of work since __/__ /____

OR They employee is currently working

SAC Text, if any.

Med Referral Objective:

Comments/Referral Objective:

_______________________________________________________

APPENDIX G
Manual ICMS Triage Process

	Source	Timing/
Data	of Data	Availability
Work Status - if OOW	T-MATE/Host	NOL
or on modified duty:		Updated after initial
A. Actual lost		claim contacts
time > 14 days
B. Anticipated lost
time > 14 days
C. Modified duty >
14 days
SAC	Claim Reference	SAC language and
	Library	SAC coding impacting
		ICMS referrals
		requires updating
Diagnosis	Claim notes only.	ICD-9 not displayed in
	Note: the nature of	T-MATE. Diagnosis is
	injury listed may be	found to frequently be
	viewed as the	missing (in notes) at
	diagnosis	initial stage. Dx
		confirmed at 1st
		medical bill.
ICMS Protocols -	ICMS	Once diagnosis is
to determine		known, protocols may
disability duration		be used to estimate
		disability period
IW's job category or	Job Class code - T-	Job Class - MIRA factor
description of	MATE	Title - NOL
physical demand	Job title - T-	Job category (i.e.,
category	MATE/ICMS	sedentary, light, etc.)
	DOT/Job category -	derived from DOT
	ICMS	code
Treating physician look	T-Mate - C&I	At NOL - often
for network status	screen, directory &	missing or inaccurate
or specialty of MD	notes	information available
	ICMS - Med Ref	at triage
Red Flags present:
A. Prior injury to	T-MATE	MIRA factor
same body part
B. Age > 55
C. Employee	T-MATE	MIRA
hospitalized
D. Pre-existing	Notes
condition
E. Lay-off status/
seasonal worker
F. Date of Hire	T-MATE	MIRA
	T-MATE
	T-MATE	MIRA
Compensability status	T-MATE	After ICU/RTW
		determination
Anticipated surgery	Notes/protocols	At MD contact
Expected or requested	Notes/derived from	At MD contact
treatment (need for	protocols
pre-cert/UR
or watch Tx)