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.
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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