Case management/bill review/UR/IME company Genex has been re-purchased by Stone Point Capital; Stone Point sold the business to Apax in 2014. Takeaways are:

• Stone Point really understands workers comp and the WC services business. The company is currently pursuing insurer AmTrust and own or have owned a number of companies involved in workers’ comp including:
  • Cunningham Lindsey
  • Oasis Outsourcing
  • StoneRiver
  • Sedgwick
• Apax’ divestiture is likely NOT a signal the firm is going to break up or sell off OneCall Care Management. OCCM is deep into a systems conversion intended to tie the disparate businesses it owns together and the company just moved most of it’s home office people into a single location. Perhaps most importantly, OCCM’s debt is still trading well below par, an indication the investment is under water.
• CEO Peter Madeja and the core of the senior management team will stay on. Peter is one of the finest people I know, universally liked and respected in the work comp community, and he and his team have performed well, keeping Genex growing in a declining market.
• My guess is Genex will likely keep acquiring related businesses. These could include firms in the IME and MSA space as well as the occasional case management company. Mature markets require participants to grow via acquisition, a strategy Madeja et al have mastered.
• I’d also expect some much bigger acquisitions. I don’t think Stone Point bought Genex to get into the case management and bill review business; these folks have bigger plans.

A couple of side notes...

Stone Point’s initial investment in Genex back in 2007 was reportedly about $56 million. 

One report indicated a source said that this time around, Genex sold for three times the original equity investment (note Apax paid for Genex with a combination of debt and equity). Without any detail or ability to dig into that, I have no idea if that is accurate or even likely.

To the casual observer, the work comp bill review process is pretty simple:

• make sure the procedure codes are appropriate for the injury,
• compare the billed codes to the state fee schedule/allowable amount,
• apply any reimbursement rules, and you’re done.

The real story is far more complex.  It’s no longer just about making sure the claim exists, the body part matches the medical report, and the procedure makes sense for the injury.

Reimbursement has gotten enormously complicated. Coding and code modifiers, bundled payment logic, clinical appropriateness, duplicate identification, relatedness, location of service verification, surgical groupers are just a few of the issues and considerations often unappreciated – and not considered – during the bill review process.

Far from A to B, it looks more like this – and is unique for some bills…

While some will say this is “not new news”, what is new is the constant focus and attention required to stay abreast of the ever-more creative and sophisticated “revenue maximization” industry. (That’s the label for provider-focused efforts to get as many payer dollars as possible)

I’ve taken a close look at several approaches/techniques intended to help payers keep pace with provider billing. One that caught my eye is Equian’s Clinical and Coding Logic. The folks at Equian were kind enough to spend a lot of time educating me on the research behind their Clinical & Coding Logic (CCL) solution, how it is used, and where it can have the most impact.

CCL has it’s roots in a commercial health application purchased by Equian some time ago, an application that has been adapted for use in workers’ comp. Building on that application, the company continues research to identify emerging billing practices, and develop identification techniques and rules to address those practices; to date more than 100 additional rules and millions of additional edits not found within typical bill review engines are in place.

There’s a LOT behind CCL; while I can’t provide more than a superficial overview, here’s a few things that popped up for me.

• Diagnosis and procedure codes with a “low-likelihood”of occurring in work comp are flagged; when they appear medical records are reviewed in detail
• Experimental and Investigational services typically fall thru the cracks in routine bill review processes; these have been identified and payment logic developed.
• CCL includes identification of services that appear to be body-part related but actually address pre-existing conditions
• Extensive research on the notorious 59 modifier enables reductions for inappropriate charges associated with surgery

Equally important is Equian’s ongoing research and analysis to identify emerging and previously unseen billing practices, development of identification techniques and rules, and evaluation of results.

CCL is a supplement to, not a substitute for the regular bill review process and technology. It requires data transmission to and from Equian via secure link, similar to PPO pend-and-transmit processes. Results shared by Equian demonstrate CCL is most useful for high-volume bill operations. Across the board, reductions average about $45 per bill (I was not able to independently verify savings or impact, and note that results are almost certainly highly contingent on each payer’s unique situation.)

What does this mean for you?

Never stand still.

MCM’s Telemedicine Week continues with a couple more use cases and a quick summary of where things are going – with the caveat that we’re only just beginning to understand what this is, how it can be used, what the obstacles and limitations are, and how accelerating technological changes will affect tele-…

First up, CHC’s white paper authored by colleague Peter Rousmaniere. CHC has a broad suite of tools used for everything from recorded statements to triage to initial clinical “visits”. The case study discussions provide a glimpse into the future, as there’s a lot of crossover between and among the use cases.

HSA consulting client MedRisk launched it’s telerehab program last year, and takeup has been strong. To date, patient reaction is quite positive, driven in large part by high satisfaction from one-on-one interaction between the patient and therapist. The white paper provides a detailed review of everything from technology to applications; a wealth of references are cited for those interested in more detail.

From here, where?

• Wearable technology has yet to be incorporated into services, but I expect it will be soon. Devices that track range of motion, force, and acceleration will be used to monitor home exercise and help assess patient readiness to return to work.
• Other devices will assist in diagnosis and patient monitoring, alerting both patient and clinician to potential problems or conditions that may affect recovery or determine treatment paths.
• Peer reviews can be improved by virtual visits, enabling the peer review physician to interact with the patient without the expense and hassle of meeting in person.

Barriers

• Represented patients may be loathe to schedule tele-visits if their attorneys don’t understand or support tele-services.
• Regulations are going to be playing catch-up for the foreseeable future. Issues related to reimbursement, admissibility, liability, confidentiality and the like will take time to work through.
• Change aversion will be the highest and toughest barrier. We all know workers’ comp can be hidebound and kludgy, with participants looking for “reasons why not rather than opportunities to.”

All that said, the more we learn about tele-services, the clearer it is that this is going to be a major change driver.

What does this mean for you?

Get with it.

A few weeks ago I had the opportunity to virtually sit down with Coventry’s product development folks to hear what they’ve been doing with tele-. 

I checked in again this week, and here’s what they’ve been up to. Quick take – tele-triage is gaining traction, while patients are slower to agree to do virtual office visits.

Coventry, a provider of services ranging from networks to pharmacy benefit management, case management to durable medical equipment, is well into Phase One, of their telemedicine offering which is tied into Coventry’s Nurse Triage program, NT24.

Working with technology vendor KuraMD  Coventry’s nurse triage staff connects with the patient, evaluates the injury or illness, and, based on their findings, recommends an appropriate level of care whether it be self-care, a “live” visit with a clinician, or a telemedicine visit (urgent and emergent cases are identified at call onset). Diagnosis and other factors drive the recommendation.

While the program has been in place for the better part of a year, Coventry has found many customers have yet to embrace the telemedicine office visit. Customers have “a tough time thinking of this as an office visit.” Telemedicine providers provide initial visits where they can send patients to physical locations for physical therapy or for imaging studies. While TM follow-up visits are offered, to date most employers want patients to visit a provider for those follow-up visits.

The program is live with two TPAs; a total of 10 employers have been implemented to date nationally with 4 in single states. Employers are quite diverse, including labor, retail, temp staffing, and construction.

For those patients able and willing to use telemedicine for a virtual initial visit, Coventry uses providers contracted with KuraMD. Care coordinators initiate the tele-visit, ensuring the patient has the right technology, walking the patient through the set-up and sign-on process, then passing the patient to the clinician for the visit.

Concentra will also be working with Coventry in the future

Phase Two involves broadening the number of clinicians that can provide telemedicine and also offering telemedicine visits without the nurse triage component. As one of, if not the largest workers’ comp PPOs, Coventry is working to get information to the company’s contracted network physicians to educate them about the service and requirements, discuss compensation, and provide training. The credentialing process and standards are identical to the company’s “regular” network but there are more questions regarding state licensing to ensure compliance with state regulations.

Down the road, Coventry is looking to incorporate tele- into case management. Ideally, case managers would connect with the patient, provider, and/or employer via video conference and enter information in real-time into the company’s proprietary CM IT system. There’s much work to be done connecting with claims systems to identify the types of and format of information needed by adjusters, build data feeds, and separate out key bits of data that need an adjuster’s attention.

What does this mean for you?

Expect tele-visits to gain traction as patients use similar services for family members and their own care. Telemedicine is moving quickly in group health, and this will accelerate adoption in comp.