Here in no particular order are a few items of interest from the world of workers comp managed care.
“Consolidation” (i.e. layoffs of former First Health sales staff) has resulted in a transformation of Coventry’s workers comp sales force; it is now dominated by former Concentra reps. And these guys and gals are hitting the phones hard, pushing Concentra’s PBM by offering better pricing on bill review and networks.
Now that the clinics are no longer tied to the network, the sales folks are being a bit more open about payers’ long-voiced complaints about overutilization of physical therapy and over-charging for clinic-dispensed drugs.
Several payers are renewing their interest in competitor Aetna; there is a high level of concern that should AWCA go away, payers will have one, and only one, true national option for a network. Aetna has recently revised their strategy; it appears they are now committed to becoming a full-fledged competitor to Coventry, with the goal of national coverage within two years.
Meanwhile, other networks including Prime Health and Interplan are rushing to fill the market’s need for an alternative.
On the bill review front, Fair Isaac appears to be expanding its relationship with the State Fund in CA (where insiders speak highly of their work). While FI has had significant…challenges with Texas Mutual, the bill review company looks to be forging ahead.
Joe,
If I am not mistaken First Health has a poor reputation in the industry for bill review. The Concentra bill review product wasn’t much better from the people I have spoken with in the past. Also, will First Health continue to use the Concentra bill review product since they would have to pay for it versus using their own system.
Aetna has been trying for years to build their WC network with little success minus a few states. That being said who will they buy in order to compete with First Health in the next two years?
Finally, Prime Health and Interplan lease the majority of their network versus building their own. They can state they have a national presence but if their leased relationships end or legislation changes the leasing environment their network is changed dramatically. There is a bill in the State of Tennessee that is challenging leased networks or silent ppo’s. I am sure Prime Health and Interplan are at the meeting trying to ensure it doesn’t pass.
P.S.- Do you have any more information on the Concentra/Viant news…keep up the good work.
Aetna is building their network, but make no mistake they are having some trouble in well established markets, and are active in leasing the regional players to a large degree.
Hi Dee. Joe, rightly so, does not like to see a sales pitch from a company in this blog. So, I will keep this short and hopefully it will be useful to the discussion. As a PHS employee, I feel the need to correct something in your post. First in TN, I wrote one of the early amendments for the current bill before the legislature in TN, although it was further, and dramatically, amended by the insurance lobby. There were many compromises made for the bill to get in its current form. The original bill filed this year was poorly written, and thus my involvement and the insurance industry to alter it. Yet, the mood in TN is to end any silent PPO activity. I can’t say I am pleased with it in full, but frankly it will have no impact on PHS in current form. PHS is directly contracted in every part of TN. Since I (and thus PHS) was involved in this bill directly, your information is incorrect.
I also strongly disagree with your remaining information regarding Prime Health Services.
Brian,
I may have some inaccuracies in the post but I feel I am correct about PHS leasing. I worked in the work comp space for some time and PHS leased several networks. If the bill does pass in TN as written all networks like PHS will have to list the networks they do lease on their website ans show it on the EOR as well. Then we will see which network has the most direct contracts. Believe me I am not knocking PHS or other network because I feel each is unique and serves its clients needs. Having been in the industry providers complained the most about silent ppo’s and leasing. I understand the reason for leasing such as building a larger network and providing better savings to the client. We all have to remember without the providers getting into agreements no one would have a network.
Do others have issues with FHN implementing their contracts correctly with the payors that they are contracted with?
We are a work comp provider with several clinics and FHN just cannot seem to get it right.
It is such a problem that it would warrant us to investigate the use of the other networks (Aetna/PHN) although we really do not want them in our area. Have noticed Concentra bill review is kicking out everything they can lately, they are more agressive then they have been in the past.
I don’t think anyone in the payer or repricing side of the market is going to disparage the leased network aspect of the strategy. Until legislation outlaws it, payers will demand the increased penetration and resulting savings it generates. Even those of the largest PPO’s with hundreds of thousands of DIRECT PPO contracts still have leased arrangements with regional PPO’s. I think the problem comes when smaller regional PPO’s boost their numbers with leased deals so that they can play in the “national space” when in reality they are really only effective in one or two markets. Its how they represent themselves that I find objectionable. Repricing companies are guilty of this practice on a large scale too. You can fill in the list of offenders…