The Critical Importance of Getting the First Workers’ Compensation Referral Right
With the onset of the COVID-19 crisis, the importance of health care quality has become even more apparent. The pandemic has highlighted the inarguable connection between physical and mental wellbeing on and off the job, and the importance of maintaining economic stability within families.
Sixty-six percent of the workers’ comp spend results from surgeries, and most of those surgeries are spine, shoulders and knees. Therefore, 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 might a claim adjuster know which doctors are best?
“In reality, few people, including physicians, have in-depth, evidence-based insight into a specialist doctor’s quality of care and results, due to a lack of publicly available performance metrics,” said Ilene Wachs, President of Horizon Casualty Services, Inc., a workers’ comp and personal injury protection (PIP) Preferred Provider Organization (PPO) in New Jersey. Horizon Casualty Services, Inc. is a subsidiary of Horizon Blue Cross Blue Shield of New Jersey, the state’s largest health insurer.
The answer is first to have a workers’ comp program with a broadly contracted PPO network which includes the highest performing orthopedic specialists. This makes it easier for insurers to achieve the highest possible PPO network utilization.
The next step is to streamline the referral process to these top doctors, starting with the first specialty appointment. This is important to best assure the most appropriate, economical treatment and outcomes.
To identify the best specialists, the PPO needs to have sufficient market size and scope to monitor and act on medical outcomes data.
Getting Referrals Right the First Time
The 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 sub-specialty (e.g., orthopedic/knee).
Claim adjusters must get that first orthopedist referral correct. It has to be focused and timely to get the best results. Referral to an unsuitable orthopedist is likely to delay patient recovery, prolong lost work time and increase overall claim costs.
If 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, further improving cost control and treatment effectiveness.
In this vein, Horizon Casualty Services has more than 25 years of experience working with New Jersey musculoskeletal-focused providers. It partners with adjusters to schedule injured workers to the appropriate top orthopedists with efficiency.
The company has also created a unique workers’ comp health care value strategy, including an Outcomes Focused Network, representing a subset of its extensive PPO network. The Horizon Casualty Services network contracts with doctors who specialize in treating people injured on the job and in auto accidents. The network includes orthopedists, physiatrists, neurologists, neurosurgeons, psychologists and occupational medicine specialists.
Thorough Selection Process
The Horizon strategy enables insurers to refer injured workers requiring orthopedic care or early intervention pain management to the best doctors within its network. 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.
“The physicians we use in our network need to be experts at detecting if an injury is work-related, and judicious about their use of surgery. For example, spine surgery can on occasion, in fact, cause further complications and delay recovery,” said Wachs.
Outcomes Focused Network provider treatment plans must result in the appropriate length of disability and lost work time within Official Disability Guidelines (ODG) parameters. Participants are expected to use in-network resources; and act professionally, providing timely appointments and medical reports.
A key advantage for Horizon Casualty Services is that it leverages the sizable Horizon Blue Cross Blue Shield of New Jersey market presence. And all Horizon Casualty Services providers are credentialed in accordance with National Committee for Quality Assurance (NCQA) guidelines.
Easing Claim Adjustment
Horizon Casualty Services makes life easier for claim adjusters by providing scheduling services with Outcomes Focused Network providers at no additional cost. This assures that injured workers get to the right specialist as quickly as possible. Services under this umbrella include orthopedists specialized in spine, shoulder and knee injuries, early intervention pain management, physical therapy and radiology.
Horizon’s dedication to efficiency includes 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.
“This makes the job easier for the claim adjuster, while the claimant gets to see the best doctor and receive the best treatment, thus achieving the fastest and most effective recovery,” said Wachs.
Horizon Casualty Services’ search tool enables adjusters to find Outcomes Focused Network providers easily. The names differentiated by the search are posted alongside their scores on in-network utilization metrics.
According to Wachs, the system provides specifics on a provider’s specialty, whether it be knee, shoulder or spine. It also lists their affiliations, such as the hospitals where they have admitting privileges and what ambulatory surgery centers they work with.
Proven Track Record of Results
The Horizon Casualty Services 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. Standard workers’ comp network penetration across all Horizon Casualty Services clients is 86%.
As a result of Horizon’s efficiency, the administrative costs of rework are minimal. This results in a 0.2% provider appeals rate. Another benefit is a high level of provider satisfaction and retention.
By leveraging the Horizon Casualty Services Outcomes Focused Network workers’ comp health care value strategy, insurers, self-insured employer groups and third-party administrators have the opportunity to experience excellent results; most importantly, that means a healthier, happier, more productive workforce.
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.
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.