All too often, an injured employee’s absence from work is prolonged by unnecessary surgery, unexpected complications or delayed therapy post-surgery. However, when executed effectively, workers’ compensation health care value strategies assure that the referral process is smooth and outcomes are optimal. This makes it a win-win for workers, their employers, carriers and claim adjusters.

A significant portion of workers’ comp medical spend is due to surgical procedures, most of which are on the spine, shoulders or knees. When keeping care quality in mind, timely referral to the best-suited initial treating orthopedist is critical.

But with so many physicians out there, and the health care industry under so much pressure, how does a claims adjuster know which doctors are best?

“In reality, few people have in-depth, evidence-based insight into a specialist doctor’s quality of care due to the lack of publicly available performance metrics,” said Jacqueline Alonso, president of Horizon Casualty Services, Inc.

The first step is to first have a trusted workers’ comp program with a broadly contracted PPO network. This makes it easier for insurers to achieve the highest possible network utilization and to assess/identify the highest performing orthopedic specialists.

And in order to accurately identify the best specialists, the PPO needs to have a sufficient market size and the scope to monitor and act on medical outcomes data.

The next step is to streamline the scheduling process with top doctors.

With these best practices in place, insurers can trust that they are providing injured workers with superior medical care through their journey from intervention to recovery.

Getting Referrals Right the First Time

Jacqueline Alonso, President, Horizon Casualty Services, Inc.

Since most common workers’ comp loss exposures are spine, shoulder and knee injuries, most orthopedists develop deep expertise treating one of these areas. However, the majority of provider search tools do not specify the provider’s underlying subspecialty (e.g., orthopedic/knee, shoulder, hip, etc.).

It is critical for claim adjusters to find the right orthopedist.

By having subspecialties listed in a provider search tool, it further ensures that referrals are done right the first time. If a referral is made to an unsuitable orthopedist, it is likely to delay appropriate patient care and recovery, as well as prolong lost work time and increase overall claim costs.

When the right orthopedic referral is made from the start, downstream referrals (including ambulatory surgery sites, hospitals, assistant surgeons and anesthesia), are more likely to be 100% in-network, improving cost control and the effectiveness of coordinated treatment.

A Trusted Workers’ Comp PPO Program

Horizon Casualty Services (HCS) has more than 25 years of experience working with New Jersey musculoskeletal-focused providers. HCS partners with adjusters to connect injured workers to the top orthopedists for a given injury.

It has also produced a unique workers’ comp health care value strategy, including an Outcomes Focused Network (OFN), representing a subset of its extensive PPO network. The OFN puts forth experienced doctors who specialize in treating injured workers and people injured in auto accidents. HCS encompasses orthopedists, neurologists, neurosurgeons, psychologists, occupational medicine specialists and more.

“The physicians we use in our network are experts at detecting if an injury is work related and judicious about their use of conservative treatment protocols vs surgical necessity,” said Alonso.

These doctors practice evidence-based medicine, are conservative in their approach to surgery, and understand what it takes to effectively diagnose and treat workers’ comp patients.

Physicians are expected to use in-network resources, adhere to workers’ comp administrative requirements and provide timely appointments and medical reports. The HCS strategy enables adjusters to refer injured workers requiring orthopedic care or early intervention pain management to the best and trusted doctors within its network.

A key advantage for HCS is that it leverages the sizable Horizon Blue Cross Blue Shield of New Jersey market presence, and all HCS providers are credentialed in accordance with National Committee for Quality Assurance (NCQA) guidelines.

Easing the Claims Adjustment Process

HCS makes life easier for claims adjusters by providing scheduling services with OFN providers at no additional cost. This ensures that injured workers get to the right specialist as quickly as possible. Services under this umbrella include orthopedists specializing in spine, shoulder and knee injuries, early intervention pain management, physical therapy and radiology.

HCS is dedicated to efficiency, including offering one business-day turnaround time for appointment scheduling from receipt of the adjuster’s referral. This includes timely injured worker and adjuster notifications and language translation services.

“Scheduling services makes the job easier for the claims adjuster; their claimant gets to see the most appropriate doctor/health care professional. Engaging with the best-suited doctor and prompt care enables increased probability of effective outcomes and recovery,” said Alonso.

The HCS search tool allows adjusters to quickly and easily find OFN providers. The names differentiated by the search are posted alongside their in-network utilization metrics. The system provides specifics on a provider’s specialty and any subspecialties. It also lists their affiliations, such as the hospitals where they have admitting privileges and ambulatory surgery centers where they practice.

Proven Track Record of Results

The Outcomes Focused Network allows almost the entirety of medical care to be delivered in-network. This includes ambulatory surgery centers, assistant surgeons, anesthesia, post-operative care and physical therapy services.

As a result, HCS maintains a very low appeals rate of 0.2%, with the highest levels of network retention, provider satisfaction and collaboration.

By leveraging the HCS Outcomes Focused Network workers’ comp health care value strategy, insurers, self-insured employer groups and third-party administrators have the opportunity to experience top quality results; most importantly, that means a healthier, happier, more productive workforce.

For More Information

For more information, email Jed Hoban, HCS business development executive, at [email protected], or visit https://www.horizonblue.com/horizoncasualty

About Us: Horizon Casualty Services Inc.
Horizon Casualty Services Inc., an affiliate of Horizon Blue Cross Blue Shield of New Jersey, in business since 1994, is a leading PPO in New Jersey workers’ compensation and personal injury protection. The company’s 100% direct-contracted provider network includes almost all New Jersey acute care hospitals, significant overall WC savings and, with its deep focus on precision, an extremely low WC appeals rate of 0.2%. Its PPO results, combined with its WC healthcare value and OFN strategy, enables insurers to be the best at delivering quality medical care to claimants at the right cost — clearly a win-win for all.

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.