In an increasingly competitive market, workers’ compensation insurers are dealing with a multitude of issues, including the COVID-19 pandemic of which long-term effects are still unfolding; as well as soaring inflation; and an evolving workforce (the “Great Resignation”), which has created additional work volume for case managers and adjusters in already busy claims departments.

A strong workers’ compensation PPO network can offset these burdens by proactively mitigating appeals/claim petition disputes, which can cost workers’ compensation insurers millions in administrative and legal fees to resolve.

While many appeals inquiries require quick and decisive issue resolution, some payment disputes may be altogether avoided through careful planning and consideration.

Newly appointed Horizon Casualty Services (HCS) President, Jacqueline Alonso, believes that strong, collaborative relationships are the key to success for workers’ compensation insurers aiming to keep provider appeal and claim petition rates low. A key advantage for HCS is that it leverages the sizable Horizon Blue Cross Blue Shield of New Jersey market presence; and HCS providers are credentialed in accordance with National Committee for Quality Assurance (NCQA) guidelines.

Here are three tips for maintaining a low provider appeal and claim petition rate.

1) Cultivate Strong Provider Partnerships

Collaboration and communication is key for any successful relationship, and that remains true for an insurer working with its PPO network.

“The right PPO network has direct and constant communication with their network providers. In addition to paying providers appropriately and timely, they should closely monitor the quality of the care being provided to the injured worker,” said Alonso.

HCS’ Director of Provider Network Services, Heidi Coluni, explained, “Horizon Casualty Services works closely with our providers to monitor their performance related to early and accurate diagnoses, the use of evidence-based care in accordance with Official Disability Guidelines (ODG), as well as progress towards maximum medical improvement (MMI). In workers’ compensation, the initial point of treatment is critical for the long-term success of the claimant. We work with our providers to ensure our workers’ comp claimants receive timely, appropriate and best-in-class treatment.”

2) Select a Workers’ Comp PPO with an Outstanding Reputation for Provider Data Precision

Accurate provider demographics, such as name, address, specialty and location are critical to ensuring timely appointments and access to care for injured workers. Poorly managed provider demographic data can lead to unnecessary delays in care, or even worse outcomes. At its core, the workers’ comp PPO information technology system must assure that provider demographic and rate load data are pristine.

“Rate load inaccuracies, especially for high dollar facility payments, can cost companies thousands of dollars, coupled with the time and energy to correct these errors. This could also be damaging to provider relationships that took years to build,” said Alonso.

The best practice is for the PPO to perform outreach to its provider offices at least annually to verify provider practice locations and addresses, and more often in the case of large provider groups with frequently used providers.

“We perform a full inspection of our provider data every year, but even more frequently for our high touch, high volume and high performing groups. It is truly a team effort that we are able to achieve a near perfect internal audit accuracy score,” Coluni stated.

The PPO’s systemic provider rate load accuracy is critical and should be audited at point of entry. Moreover, 100% audit accuracy of facility rates is critical to assure that high dollar/high stakes payments are consistently accurate.

Inaccurate rate load data is often a major contributor to provider dissatisfaction in the PPO network. This dissatisfaction may translate to costly provider appeals and claim petitions, an administrative burden for the workers’ comp insurer as well as the provider. Provider education and outreach efforts to ensure contract terms are understood is the first step in a successful and collaborative partnership between the PPO and its providers.

Coluni continued, “Our team works closely with our providers and their administrative staff to ensure that contract language is clear and that the provider agrees with how their contract will be administered. Full transparency and an open dialogue with our network are absolutely critical to ensuring providers remain satisfied with the administration of their contract.”

3) Resolve Provider Bill Payment Inquiries Proactively

Assuring that provider medical bill payment inquiries are handled expeditiously is an important component to minimizing appeals. This includes establishing clear lines of communication between the insurer and PPO appeals team and timely reporting of payment disputes to capture and resolve any such issues promptly, avoiding unnecessary escalation.

Alonso stated, “We routinely meet or exceed our contractual bill processing timeframes at or above 98% accuracy. When there are issues, we are able to quickly review and discuss, identifying solutions and next steps for resolution. We work closely with our clients and our PPO network to ensure that each party is aligned in their understanding of the bill/claim payment system, which in turn keeps our claim petition and provider appeals rates under control.”

With transparency and open lines of communication, provider inquiries received will more likely be about how and why certain bill codes were paid, rather than disputing the results via an appeal. This is why a PPO having a certified professional coder (CPC) on the team becomes an important asset to achieving ‘one and done’ inquiry resolution.

Alonso said, “Our CPC works lock step with our Appeals team to quickly address issues or questions around billing – giving providers a sense of comfort that they were paid appropriately and in line with their contract.”

Customer service training and workflows should be designed to support the handling of these inquiries in real time or with proactive callbacks to provider billing staff to clarify the payment rationale and avoid the submission of appeals, as well.

Finally, extinguishing certain types of appeals is possible through tracking and trending, identifying root causes and resolving the issues identified so that providers, PPOs and insurers are aligned, and can effectively focus on achieving superior medical care and outcomes for claimants rather than billing and payment disputes.

The Difference Between Good and Great

Achieving a workers’ comp appeals rate lower than 1% is possible.

Horizon Casualty Services, Inc. (HCS), New Jersey’s #1 workers’ comp (WC) and personal injury protection (PIP) PPO, has a WC appeals rate of 0.2% of bills processed. HCS’ overall WC savings is 62% below UCR and 99% of its New Jersey based hospitals are in-network.

The difference between a good WC PPO and a great one is millions of dollars.

“We advise clients on how to maximize their service/product offering so results are reflected in their bottom line,” said Alonso.

“It is the people who make the difference in any organization. HCS has a talented and knowledgeable talent pool of industry experts who understand the New Jersey market. In these unprecedented times, our current clients and our prospective clients can rest assured that we will maintain the highest standards of quality, partnering with our network providers and continuing to build our foundation on communication, collaboration and strong relationships.”

To learn more about Horizon Casualty Services and its approach, contact Jed Hoban, HCS Business Development Executive, at [email protected] or visit https://www.horizonblue.com/horizoncasualty/service-offerings/workers-compensation.

 About Us
 Horizon Casualty Services, Inc., a subsidiary of Horizon Blue Cross Blue Shield of New Jersey, in business since 1994, is the #1 New Jersey workers’ compensation (WC) and personal injury protection (PIP) PPO. The company’s 100 percent direct contracted provider network includes 99% of New Jersey acute care hospitals, overall WC savings 62 percent below UCR and with its deep focus on precision; an extremely low WC appeals rate of 0.2%. Its PPO results coupled with its WC health care value Outcomes Focused Network strategy enables insurers to be the best at delivering quality medical care to claimants at the right cost — clearly a win-win for all stakeholders involved in WC claims.

This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Horizon Casualty Services, Inc. The editorial staff of Risk & Insurance had no role in its preparation.