If you’re looking to build a workers comp network, you’ll want to focus on WC specialists – occ med docs, orthos, neuros, physiatrists, primary care docs, and a smattering of other specialties – along with ancillary care providers.
And you most definitely don’t want every Dr. Tom Dick and Mary – the ones that can’t spell ‘workers comp’ and think ‘return to work’ is what happens after lunch.
While including these docs in the network will make the directory nice and fat, they won’t know what to do if a claimant actually presents.
In fact, the fatter the directory, the further away you should stay. Growing evidence indicates there’s a lot of good reasons to limit the docs who treat workers comp claimants:
- claimants feel more comfortable with docs who can actually explain how the comp system works; physicians tend to be trusted by their patients, and this trust can translate to lower litigation rates
- docs who know disability management know that getting injured workers back to the job asap facilitates recovery
- comp docs know they are only supposed to treat the comp injury, and although they have to factor in comorbidities, understand that the comp payer isn’t liable for all treatment
Another consistent problem in the comp network world is lousy data – directories are full of docs who no longer take patients, don’t take work comp patients, have moved, are dead, or can’t recall ever signing a network participation contract. (in this last instance, it is likely someone in their office did, at one time, but can’t remember doing so).
Expect to pay the docs you want a reasonable rate. “Reasonable” may be above or below the state fee schedule (in the 30+ states with fee schedules) or an RBRVS-based fee, or some discount based on published U&C data. Make sure, really sure, that the basis for reimbursement is clear, precise, and accurate. There have been an increasing number of lawsuits from providers alleging underpayment by work comp payers. This is a trend that by all indications is going to continue. Without a clear contractual definition of payment terms, networks open themselves, and their payer customers, to a much higher risk of litigation.
Which leads to the final recommendation – payers are getting a discount, or at least an agreed-upon reimbursement rate, and therefore must promise to do something to get that rate. In most cases, that ‘something’ is the promise by the network that it will work diligently to direct patients to the contracted provider. Again, make sure the contractual terms are clear – what will payers do to direct patients to providers, how will they push this ‘downstream’ to their policyholders, and how will this be verified.
Keep the data up to date, carefully select the docs who are in it, have fair and clearly defined reimbursement terms, and hold up your end of the bargain – send the providers more patients.
One other noted comment would be to avoid the Occupational Health (Concentra) and other larger private practices who enter these networks and become whores of the industry. The get worker’s compensation patients and auto injuries and treat for an inappropriate amount of time. Practices aligning themselves with physical therapy, diagnostic centers and chiropractors to keep the patient treating. However much the discount sometimes you have to sometimes get an IME just to stop the treatment. Sometimes the cost of staying in network exceeds what we would pay an honest out of network provider who just want to be paid fairly for the services they provided.
Work comp providers should be paid on a sliding scale that fairly compensates and factors in return to work. With the ability to analyze injury, disease and treatment experience available in very large medical data sets, such reimbursement models are feasible. It will take cooperation among the payors and patient advocates to undertake such an effort but in the end would satisfy injured workers, their employers, health care providers and even the regulators.
I disagree with Jim, I am with a payor and have found that the vast majority of the larger Occupational Medicine groups provide good outcomes, understand the system, and provide much data to the payor for appropriate monitoring of their practice patterns. Some object to what they perceive as high rate of PT referrals. If the average PT visits / claim are less then 4, so what. The hands on care provided by the PT gives the injured worker a tangible feeling that something is being done, and they will benifit. In general our data shows that with these larger groups, our lost time injuries are down significantly, indemnity is down and total claims cost is down. This goes back to paying a little more in medical costs, but saving tremendously in total cost. The key is in relationship development, payor, provider, employer, injured worker.
Discussing the relative merits of Concentra really misses the point and does so in a manner that is the root of the problem. Creating your network involves getting to know the physicians. Physicians have surnames like Jones, Gutierrez and Smith. I am not aware of any named Concentra. One last comment regarding the term “return to work”. The term suggests there was or is a necessary period wherein the worker was “away from work”. Isn’t the goal of work place modifications and reasonable accommodation that the worker remains on the job?
What about referring to our workplace efforts as “Stay at Work” rather than “Return to Work”?
Small point but I’ve found it changes the context of the discussion.
It seems to me that the likely starting place in the development of a work comp network begins with a list of providers paid by the carrier(s). In such a data base, one should expect to see the number of claims submitted and paid by provider and ranked by number of claimants seen as well as dollars paid. Any carrier – TPAs included – can easily provide that basic data. What occurs thereafter is directly dependent on the experience and knowledge of the network development person.
When it comes to reimbursement rates, state fee schedules rely on the AMA codes and in some measure patterns of treatment protocols developed between accredited third party vendors. As we all know, the ultimate cost of care is a function of the diagnosis and prognosis rendered by the attending physician but in practical terms the reimbursement rate (either negotiated or prescribed by a fee schedule) times the number of treatments affects the final number. And finally, utilization review standards built into the claims system ensures that “outliers” are not breeched by member providers.
That is the model built back in the mid-1980’s and only sparingly adopted by the work comp jurisdictions, even those that have adopted the Medicare RBRVS model!