Industry: Health Care
Need: Quantify Risk and Respond to Compliance Allegations
Service: Data Analytics
Understanding the situation
A national health system became aware of potential regulatory and compliance risks involving its physicians serving patients at multiple locations. The client hired outside legal counsel to lead an investigation and determine the scope of the situation. The key issue was that the health system’s doctors may have been billing for more patient visits in a day than would be physically possible.
Exploring the challenge
CLA was initially engaged to analyze claims data of specific physicians over a four-year period and measure daily productivity across three dimensions:
- Patients seen
- Work relative value units (wRVUs)
- Hours worked (clinical time plus travel time)
We worked with the client’s IT team to derive the needed data and incorporated the Centers for Medicare and Medicaid Services (CMS) data and other benchmarking sources. In some instances, the doctors were annually outperforming the CMS 90th percentile for wRVUs by more than 400%.
Using advanced modeling and an interactive business intelligence platform allowed the client to evaluate productivity across the entire enterprise and drill down to regional, state, and individual physician activity. The model’s metrics helped the client understand the doctors’ activities and quantify the risk. In addition to calculating the number of patient encounters, wRVUs, and time estimates, a risk score was developed to identify “improbable days,” that is, levels of daily activity that are improbable when evaluated against benchmarks.
After completing the time estimate for the selected doctors, CLA was engaged to build an ongoing monitoring dashboard to track the productivity of thousands of physicians within a segment of the organization. The client’s internal compliance team has full access to the dashboard and is using it to identify those who may be producing at a level that is outside of the company’s risk tolerance. We helped the client develop a strategy to determine which doctors would be subjected to a more rigorous review, in essence, extending the analysis to a concrete plan of action. The client’s compliance team requested that we help them refresh the model on a quarterly basis.
While this engagement had significant financial implications, the analysis centered on quantifying risk tolerance, then monitoring risk and reducing it.
CLA has broadened the scope of its services and continues to develop a long-term relationship.
In the end, the health system was so pleased with how we approached this discreet part of their business that they asked what else CLA might do for them across their entire organization. Matt Anderson, Principal
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