How a managed care network can ensure quality care and save costs for employers

Jeffery Hey, Director, Anthem Workers’ Compensation

The cost for work-related injuries in the U.S. in 2011 was $192 billion, with 60 percent of that directly related to medical treatment for injured workers, according to a recent UCLA-Davis study.
As a result, it is paramount that businesses get a handle on their workers’ compensation expenses, says Jeffery Hey, director, Anthem Workers’ Compensation.
“The best way to do that is to work with a managed care organization that has experience with, and knowledge of workers’ compensation and that has relationships with employers in order to mitigate risks for the company and reduce expenses, while ensuring that the injured worker gets quality care,” says Hey.
Smart Business spoke with Hey about how a managed care network can help you save costs, get workers back on the job more quickly and ensure that injured employees are receiving quality care.

What is the current state of the workers’ compensation market?

Workers’ comp is managed by each state’s government. Half the states allow employers, either directly or indirectly, to channel injured workers into networks, while the other half do not. For those employers that have the capability to channel into a network, you have to consider which networks are good, which have experience with workers’ compensation and which have the right mix of providers and facilities. For most companies, workers’ comp premiums are their second-largest operating expenses, so it is critical that employers gain control over how injured workers are treated.

How can employers begin to channel injured employees to a select subset of providers?

It’s essential that the employer knows how to set up a subset of doctors, facilities, hospitals and clinics to treat their injured workers. Unfortunately, most employers don’t have that experience, nor that expertise, to make those determinations.
Partnering with a managed care network can help you navigate the world of workers’ comp. Managed care networks help ensure that the injured worker receives quality care while emphasizing standard treatment protocols, case management and controlled access to medical care. In addition, they can also help manage the cost portion of the equation.
When selecting a managed care network to partner with, be aware that not all networks have experience working with workers’ comp claims. You need to find a network that has longevity, has experience with workers’ comp claims and is familiar with light duty and return-to-work protocols. The network should also be familiar with the paperwork required by the state and the state fee schedule.
Keep in mind that workers’ comp is a much different, proactive paradigm than the health side, and your PPO networks aren’t necessarily going to be the best fit for your workers’ comp needs, which include aggressive intervention for a faster return to the workplace.
A third party administrator, broker, or agent can help you determine whether a managed care network is appropriate for your needs.

Once you’ve identified a potential network, how can you test its capabilities?

Before making a selection, run test bills through the network and do comparison shopping. The managed care network should be willing to take your bills and run tests and show discounts back to the business. Even though the workers’ comp medical side is not all about discounts, discounts will save you money.
If you find a great provider network that can also help you out with medical case management use and fee schedule compliance, all the better. Discounts are very important in terms of the overall equation of determining whether the network is a good fit for your company.
Also consider how big that network needs to be and what types of reports you should be looking at to make sure not only that workers are getting quality care, but that you, as the employer, are getting a good return on your investment.

What else does an employer need to consider when selecting a managed care network?

Make sure that not only is the network strong but that there are specialty firms that can be brought into play to interface with the network to make sure that injured workers get the quality care they need and that the employer has a good handle on the cost of the treatment provided to the injured worker. Get aligned with the right medical case management, if appropriate, to make sure you are managing your costs and getting that injured worker back to work as soon as possible. In addition, you need to know that, within that network, there are physicians specializing in occupational medicine who are skilled in diagnosing and treating work-related injuries and who understand that getting workers back to work is in line with their functional capacity to provide good medicine.

What things should employers be aware of when working within the workers’ comp system?

If the physician places a worker off work and says he or she can’t come back, with no restrictions and no explanation, that should be a red flag to the employer that something is going on. Or if the physician makes an appointment for the worker to return every four to six weeks instead of for more regular review, that’s not good, either. There has to be consistency in terms of treatment and good communication between the physician and employer to make sure that the system is working the way it is supposed to.
It’s also a red flag if a provider is reluctant to refer the injured worker to a specialist, there are very few written notes, the physician provides narcotics for minor injuries or therapy seems never-ending.
There has to be common sense and integrity in the process, otherwise, the business is going to lose on their part of the deal. In the long run, by partnering with a managed care network, you are providing both yourself and your employees and everyone involved benefits.

Jeffery Hey is director for Anthem Workers’ Compensation. Reach him at (314) 925-6038 or [email protected]

Insights Health Care is brought to you by HealthLink®