Hidden Gem of Workers’ Comp

By Peter Rousmaniere

Journalist, WorkCompCentral

Big Gem

If you are an employer or workers compensation claims payer, you may be overlooking, or underusing, the most important vendor available to you for better outcomes. We’re referring to the occupational medicine clinic the occ med clinic, the best resource in medicine to initially treat most of the 3 million private sector injuries workers suffer each year.

Successful work injury care absolutely depends on pre-arrangements for immediate care by clinicians versed in this specialty. In personal health, it can take eight to 12 days for an individual to get an appointment with a qualified physician. You can find the right doctor for a work injury by simply walking into an occ med clinic. The good news: roughly 1,500 clinics exist tailored to make sure medical care for injured workers starts and stays on track. These Clinics also can play a vital role in helping prevent injuries, as well as treat them. They are the best medical partners in current advances in claims management, such as predictive modeling, pay-for-performance, and telemedicine.

The bad news: engagement between claims payers and these clinics is less than optimal, often because of a lack of understanding of the value of occ med clinics or a lack of investment in the partnership. Yes, most claims payers know about these clinics and want to use them for injury care. In fact, many have reached out to them, but most claims payers rarely commit the attention or persistence necessary to maximize the partnership.

Why should claim payers amp up their efforts now to optimize partnerships with occ med clinics? Better claims servicing is one reason, of course. But the primary value today stems from the fact that the workers’ comp pie is shrinking, due to declining work injuries.

Workers comp insurers, especially monoline insurers, already face challenges to their franchises. But claims payers may be able to better protect their slice of the pie by building closer ties with occ med clinics, which in turn can foster closer ties with employers specifically employers who are attentive to work injury risk, and, thereby, make good clients.

It is hard to imagine how claims payers can engage quality provider networks, pay for performance, and telemedicine without close collaboration with occ med clinics.

Six Signs of a Productive Partnership: How Well Do You Fare?

Our extensive interviews with occ med clinics suggest these practices are prepared to engage in partnerships with claims payers. But is the reverse true? Are claims payers willing to put forth sustained efforts to engage clinic administrators and medical directors? You will find at the end of this report a profile of how LCTA Workers’ Comp, a Baton Rouge-based insurer, has designed a partnership strategy with occ med clinics. The following six protocols are essential to success in a statewide clinic partnership program. Few insurers can claim three of these standards of practice, much less all six of them. How well does your organization fare?

Note: As a means of comparison, we have included information about Colorado’s Pinnacol Assurance, a source of workers’ comp coverage for approximately 56,000 customers of varying sizes and risks across the state.

1. The claims payer has designated staff to manage relations with clinics. Say a practice administrator at an occ med clinic reaches out to the insured to start a conversation about mutual expectations and a good working relationship. The admin leaves a message. What are the chances that the call will be returned? Almost nil. For this report, we had a colleague contact 11 prominent claims payers, using an email address displayed on the insurer’s website that seemed most appropriate for an inquiry from a medical provider.

The person identified herself as a consultant to occupational medicine clinics in New England and wrote that she had some performance reports of the clinics that she would like to share. The result: was an almost total lack of response (our caller was not even routed to a medical director’s office).The reason: these claims payers appear to have no internal unit coordinating business relations with medical providers.

2. The insurer actively supports links between clinics and employers. These links are vital and should be set up at the time of underwriting. Indeed, if they are not, this oversight should raise flags with the underwriter, given how strong links between the occ med clinic and employer are one of the most effective ways to contain losses.

These Links also play a useful role if the employer and the recommended local clinic find themselves in a dispute. (For instance, the employer may perceive that the clinic is making wrong causality decisions or keeping workers from returning to work for too long a period). Without a designated link, who at the insurer is in a position to address and resolve the problem?

3. The insurer has the flexibility to alter reimbursement speed, rules for utilization review, and other operational aspects. Among our surveyed workers’ comp pros, 20 percent strongly agreed(and 60 percent agreed) on the importance of flexibility in operational rules. For Instance, some claims systems have rules modules that govern whether UR approval is required. Does your claims system allow adjusters to set different rules or override standard procedures, depending on the provider?

4. The insurer has the option to offer occ med clinics additional compensation for extra services.

Among our workers’ comp pros, 18 percent strongly agreed (and 43 percent agreed) that claims payers should be able and willing to increase reimbursement for additional services, such as special reports or actions performed in a particular or timely manner.

On the other hand, tension can easily foment between claims payers and preferred provider organizations when the insurer seeks to unilaterally alter compensation arrangements for a PPO member. To avoid this means involving the bill review and PPO people at the outset.“We’ve been able to work it out,” says Greg Moore, founder and former CEO of Harbor Health. “You have to be thoughtful.”


5. The insurer periodically meets with occ med clinics to discuss performance. Among our surveyed workers’ comp pros, 28 percent strongly agree (and 60 percent agree) that claims payers should share performance results with occ med clinics. Performance reports rank this as their most highly favored method for improving relationships with clinics.

Yet, in interviews with seasoned occ med physicians throughout the United States(some with over 25 years of experience), these clinicians reported only extremely rare instances when they saw or discussed performance reports with an insurer. Private performance reviews with providers are one way to improve outcomes, but what about a more public assessment? While some claims payers are reluctant to publish provider performance documentation, others would prefer a more public accounting, for the reasons cited by this managed care executive in Ohio:

“When we get a request for surgery, and we know the surgeon has a poor record, I cannot reveal this to the patient. But if I Had the ability to direct an injured worker to an independent report on the effectiveness of a doctor, that would be great.

The more you can be transparent, the more you can have usable information for the patients to help them make better and more informed decisions.” (Note: this executive had not approached surgeons directly with documentation of their performance, which should be the first step.)

6. The insurer documents treatment paths of high-cost claims claims payers should study and document the flow of injured workers through the medical care community and highlight where bad claims outcomes begin to emerge. This kind of flow analysis is essential for identifying where to focus attention on improving care. Most likely, initial care will show up as a predictor of claims outcomes.

Final Thoughts

The three most valued core competencies in workers’ comp claims management are:

  • Compensability determination
  • Medical management
  • Return to work

(Source: Rising Medical Solutions’ Workers Compensation Claims Benchmarking Study)

Occ med clinics are hands-down the claims payer’s most important vendor to boost these core competencies. And,occ med clinics are essential partners in key innovations in workers’ comp, such as predictive modeling, pay for performance, and telemedicine. Once again,occ med clinics are the most important vendors with whom to partner. Case closed.

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