Predictive Modeling | GENEX Services

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Predictive Modeling

RiskID

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Predictive Modeling

Referral Expert®: Early Telephonic Intervention for Predicted Risk

Referral Expert is an automated process to identify claims that would benefit most from telephonic case management. Referral Expert scores new and existing claims for appropriateness of clinical management and responds to claim events as soon as they’re reported for immediate triage and earliest intervention. Our nurse case managers leverage the predicted risk profile produced by Referral Expert combined with their experience to select only appropriate cases for early intervention. We work with our customers to design the approach that makes sense for their program.

RiskID: Deferred Intervention for Demonstrated Risk

Sometimes claims that appear to be on track for a simple resolution change direction and demonstrate risk for higher medical and indemnity exposure than was evident during the first 90 days post injury. RiskID monitors claim-level treatment patterns in the medical bill data to identify opportunities for intervention as soon as clinical risk is evident throughout the life of a claim. RiskID triggers clinical alerts when provider treatment patterns fall outside of guidelines for physical medicine service types.

Early risk prediction (Referral Expert) combined with a continuous data mining for emerging risk (RiskID) enables a focused strategy to maximize claim outcomes while efficiently utilizing resources to support this goal. Focusing on the right claims at the right time not only improves outcomes, but it reduces the overall administrative burden of a workers’ compensation program.

FastTrack Risk AnalyzerTM

FastTrack processes First Reports of Injury (FROI) through a proprietary methodology and the FROI is compared against two years of historical claims data. The result is that each claim is assigned a unique risk score, based on our proprietary referral algorithm and criteria.

FastTrack claim risk scores are a proprietary analytic methodology of the GENEX subsidiary company Optis that was formulated based on the characteristics of past workers’ compensation and employee benefit use that can best predict future benefit use and cost risk. FastTrack risk scores are not based on total cost alone. They are also based on the frequency, duration, and types of workers’ compensation and employee benefits used, as well as the nature of the medical conditions for which injured and disabled workers received treatments. The FastTrack risk score methodology therefore accounts for both the severity and complexity of a workers' medical and lost time benefit use. To learn more, visit Optis.com.