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Workers Comp Medical Treatment Networks – What Studies Are Missing


Workers Comp Medical Treatment Networks – Claims Adjuster’s Different Paradigms

After reading a few studies on workers comp medical treatment networks, one glaring aspect becomes apparent very quickly.  As I often have commented on claims studies – “Did they interview any adjusters for input?”  The answer remains “no” on most of them.

picture of barber dimes workers comp medical treatment network
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On a side note, Rachel Fikes over at Rising Medical out of Chicago did just that earlier this year.  Get your free copy of the study here – totally worth a read.

One recent study by NCCI (you can find it here) says that some treatment costs are higher for “in-network” medical treatment.

The one huge consideration is  –  do the claims adjusters feel the medical provider is one they can work with over the “long haul” and implicitly trust to treat the injured worker that is their claims responsibility?

Of course, (and this has been challenged by non-claims persons), the worker’s comp claims adjusters want the injured worker with a legitimate claim to have the best care possible even if it costs a little more.

The adjusters want to have:

  • Proper medical care that results in the highest level of care possible
  • Return to gainful employment as soon as possible
  • All benefits paid timely
  • File closure

Proper Care With The Workers Comp Medical Treatment Networks

Very often, workers comp claims adjusters have given a large medical network provided by their employer (carrier or TPA).  The informal network that exists can usually operate inside the carrier’s or TPA’s medical network.    Sometimes the physicians are non-network.

What physicians and other medical providers are contained in this informal workers comp medical network?

Those medical providers are:

  • Trusted to provide the appropriate conservative medical treatment
  • Have an industrial background – think workers comp or industrial clinic
  • Huge one – communicate with the adjusting staff by providing medical notes rapidly
  • Huge one Part 2 – communicates with the employer on the injured worker’s medical status
  • Refer the injured worker to more specialized physicians (orthopedists, neurologists, etc.) that the adjuster is used to working with on claims
  • Return the injured worker to light duty when possible
  • Another huge one – seeks authorization from the adjuster for certain medical procedures such as surgery, referral to another medical provider, etc.
  • Avoids giving the adjuster the Twilight Zone Phone Call 
  • Avoid litigation – Ok, – all employees have the right to consult and hire legal counsel.

When I review adjuster file notes, one aspect I see often is the adjuster is willing to work with an “out of network” medical provider if they cover the above bullet points.

Sideways Cost Savings

Is there still a cost-savings element when working with a physician that is not in the carrier’s or TPA’s prescribed network?  Yes, any claims staff that is reading this will be nodding their head now.

Most medical networks save approximately 10 – 15%.   By working with a medical provider that covers the above points well, the cost savings of an out of work provider can easily cover the 10 – 15%.   I will save you all the math today, it does cover the network savings.

If one looks at the studies by WCRI’s  Dr. Bogdan Savych, the employees tend to have a better outcome if they trusted the employer before the accident.  I think we can add into that equation the trust level of the medical provider whether or not they are in a workers comp medical network.

Who can facilitate many of the above items – one of my favorite risk management techniques, the venerable worker’s comp rehab nurse or case manager.

I am not giving the advice to ignore the prescribed workers comp medical treatment networks.   Then again, the cost-benefit tradeoff may be enough to use non-network physicians and according to NCCI, the non-network physicians may be less expensive.



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James J Moore - Workers Comp Expert

Raleigh, NC, United States

About The Author...

James founded a Workers’ Compensation consulting firm, J&L Risk Management Consultants, Inc. in 1996. J&L’s mission is to reduce our clients’ Workers Compensation premiums by using time-tested techniques. J&L’s claims, premium, reserve and Experience Mod reviews have saved employers over $9.8 million in earned premiums over the last three years. J&L has saved numerous companies from bankruptcy proceedings as a result of insurance overpayments.

James has over 27 years of experience in insurance claims, audit, and underwriting, specializing in Workers’ Compensation. He has supervised, and managed the administration of Workers’ Compensation claims, and underwriting in over 45 states. His professional experience includes being the Director of Risk Management for the North Carolina School Boards Association. He created a very successful Workers’ Compensation Injury Rehabilitation Unit for school personnel.

James’s educational background, which centered on computer technology, culminated in earning a Masters of Business Administration (MBA); an Associate in Claims designation (AIC); and an Associate in Risk Management designation (ARM). He is a Chartered Financial Consultant (ChFC) and a licensed financial advisor. The NC Department of Insurance has certified him as an insurance instructor. He also possesses a Bachelors’ Degree in Actuarial Science.

LexisNexis has twice recognized his blog as one of the Top 25 Blogs on Workers’ Compensation. J&L has been listed in AM Best’s Preferred Providers Directory for Insurance Experts – Workers Compensation for over eight years. He recently won the prestigious Baucom Shine Lifetime Achievement Award for his volunteer contributions to the area of risk management and safety. James was recently named as an instructor for the prestigious Insurance Academy.

James is on the Board of Directors and Treasurer of the North Carolina Mid-State Safety Council. He has published two manuals on Workers’ Compensation and three different claims processing manuals. He has also written and has been quoted in numerous articles on reducing Workers’ Compensation costs for public and private employers. James publishes a weekly newsletter with 7,000 readers.

He currently possess press credentials and am invited to various national Workers Compensation conferences as a reporter.

James’s articles or interviews on Workers’ Compensation have appeared in the following publications or websites:

  • Risk and Insurance Management Society (RIMS)
  • Entrepreneur Magazine
  • Bloomberg Business News
  • WorkCompCentral.com
  • Claims Magazine
  • Risk & Insurance Magazine
  • Insurance Journal
  • Workers Compensation.com
  • LinkedIn, Twitter, Facebook and other social media sites
  • Various trade publications


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