What comp insurers will pay for

The Hartford wants to pay for what works, not pay for stuff that doesn’t and doesn’t want to argue.
That was the one-line statement from Medical Director Rob Bonner in his talk at the just-concluded WCI.
Bonner went on to discuss how the Hartford defines “what works” and how they evaluate treatment plans that deviate from generally-accepted standards of care/Evidence Based Medicine (EBM).
I reviewed my notes from Dr Bonner’s talk after several comments on yesterday’s posts lamented/complained/squawked/expressed outrage that insurers had any right to determine the medical necessity of treatments much less not pay for treatments deemed not effective.
When you consider the wide variation in practice patterns reported by WCRI’s Dr Rick Victor yesterday, the weakness of the commenters’ arguments become crystal clear.
Notably, Dr Bonner said guidelines don’t work for all patients in all situations; treatment outside of guidelines may be appropriate but only if treatment within guidelines has failed.
Bonner concluded with a very interesting discussion of how payers should – and the Hartford does – look at guidelines and the interaction with providers based on guidelines. It is clear they are central to the way the Hartford medically manages WC claims, and that the use of guidelines is based on driving to better outcomes. It is equally clear that the onus is on the treating doc to develop a treatment plan that gets to a defined result if and only if standard EBM guidelines don’t work, with “work” defined as functional improvement.
I’d add that insurers have this thing called “fiduciary responsibility” that requires them to pay only for services that are deemed appropriate and necessary. That doesn’t include procedures that have been demonstrated to show no positive impact on outcomes; examples may include some cold therapy devices, passive motion machines; certain drugs and surgical procedures.
I’d also add that some insurers are “bad actors”; denying treatments arbitrarily, losing documentation, and generally doing whatever they can to avoid paying as much as possible. That said, in my experience these crappy companies are in the minority.
What does this mean for you?
Practice within guidelines, and if you don’t, be prepared to show why it makes sense to do something different and describe where the treatment is headed.