Workers Compensation Managed Care By: Laura Deterding, ACAS, MAAA Midwest Employers Casualty...
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Transcript of Workers Compensation Managed Care By: Laura Deterding, ACAS, MAAA Midwest Employers Casualty...
Workers Compensation Managed Care
By:
Laura Deterding, ACAS, MAAA
Midwest Employers Casualty Company
Ratemaking Implications of Managed Health Care on Workers Compensation:
Components and their Ratemaking Implications
The goal of Workers Compensation Managed Care is to integrate cost containment with optimal treatment to facilitate expeditious re-entry into the workforce.
TPA/Claims
Adjuster
InjuredEmployee
Minimal cost to
Employer
Medical Providers
Case Managers
Workers Compensation Managed Care
Employer
Utilization
Review
Specialist
VocationalRehabilitationSpecialist
“Participants”
Workers CompensationManaged Care
• Third Party Administrator (TPA)/Claims Adjuster– Role:
• Investigate compensability of the claim.
• Identify and assign appropriate case managers and vocational rehabilitation specialists.
• Set objectives and measure the results.
• Secure IME/Second Opinions.
Workers CompensationManaged Care
• Third Party Administrator (TPA)/Claims Adjuster (Continued)– Role: (Continued)
• Evaluate vocational rehabilitation involvement and return to work possibilities.
• Settle the claim.
– Goal:• Proper claims handling is essential to cost
containment and indemnity mitigation.
Workers CompensationManaged Care
• Case Management– Definition:
Case management is necessary to insure that proper medical protocols are applied for a specified injury type. The case manager is a registered nurse with professionally recognized designations and experience with industrial disability cases.
Workers CompensationManaged Care
• Case Management (Continued)– Role:
• Develop treatment plans and communicate those plans to:
– Treating Physician
– Injured Employee
– Employer
– TPA/Claims Adjuster.
Workers CompensationManaged Care
• Case Management (Continued)– Role: (Continued)
• Steer injured workers to industrial physicians/PPO/HMO networks
– Industrial physicians have an in-depth understanding of the industrial disability process and the employer’s needs. They serve as “gatekeepers” directing the initial treatment avenues
• Work with employer and vocational rehabilitation specialist regarding light duty and return to work possibilities.
Workers CompensationManaged Care
• Case Management (Continued)– Role (Continued)
• Attend medical staffings and provide input regarding appropriate treatment protocols.
– Goal:• Effective case management results in medical cost
containment and reduced indemnity costs.
Workers CompensationManaged Care
• Medical Provider System– PPO
• PPO networks involve pre-negotiated discounts for the employer by use of selected providers. Networks may include:
–Hospitals–Physicians–Prescription Services
–Physical Therapy Centers–Other Medical Services
Caution: There is a potential for utilization abuse. Should evaluate treatment frequency.
Workers CompensationManaged Care
• Medical Provider System (Continued)– HMO
• HMO providers are paid a flat fee for each covered employee. Providers involved in an HMO are employees of that organization.
Caution: There is an incentive for the provider to reduce the treatment frequency.
Workers CompensationManaged Care
• Medical Provider System (Continued)– Fee Schedules
• This involves a legislated schedule of fees payable by specified CPT codes. Fee schedules establish a schedule of maximum charges applicable to:
Caution: Must verify adherence to fee schedules through in-house review or through an independent vendor who shares in the percentage of savings.
–Physician charges–Hospital Charges
–Prescriptions–Other medical services
Workers CompensationManaged Care
• Medical Provider System (Continued)– Goal:
• An effective medical provider system results in medical cost containment. Indemnity losses may be indirectly affected.
Workers CompensationManaged Care
• Utilization ReviewDefinition:Utilization review is a system to manage, assess, and review the injured employee care.
–Frequency–Duration
–Medical reasonableness/necessity–Appropriateness
–Role:• Care is evaluated based upon the following
criteria:
Workers CompensationManaged Care
• Utilization Review (Continued)– Goal:
• Effective utilization review results in medical cost containment. Indemnity losses may be indirectly affected.
Workers CompensationManaged Care
• Vocational Rehabilitation
Definition:
Vocational rehabilitation is a systematic tool utilized to facilitate re-entry into the workforce. Parameters for vocational rehabilitation are established by the TPA/claims adjuster include setting objectives and measuring outcomes within established time frames.
Workers CompensationManaged Care
• Vocational Rehabilitation (Continued)– Role:
• Provides vocational assessments for feasibility of return to work.• Helps employer formulate light duty positions, both short and long term.• Perform labor market surveys and job searches.
– Goal:• Effective vocational rehabilitation results in reduced indemnity payments.
Workers CompensationManaged Care
• Employer
One of the fundamental principles of managed care involves employer participation.
– Safety programs
– Wellness programs
– Procedures for reporting job-related injuries
– Workers Compensation system
– Light duty/Return to work programs
– Role:• Provide educational materials and training to personnel
regarding:
Workers CompensationManaged Care
• Employer (Continued)– Role: (Continued)
• Formalize light duty programs.• Communicate frequently with injured employees.• Involved in the selection of industrial/panel physicians.
Workers CompensationManaged Care
• Employer (Continued)– Goal:
• The employer involvement results in both medical cost containment and reduced indemnity losses.