‘Top Docs’ are Critical to Quality Outcomes

Have you ever heard the term “doctor’s doctor?” They are considered the best of the best — those who physicians trust and go to based on word of mouth from other doctors. Though physicians have the inside scoop, it can still be a challenge for them to find the right specialists for their unique needs. And however difficult it is for a doctor to find the right specialist, typical patients are feeling it tenfold.

To help address this issue, workers’ compensation (WC) PPOs need to create streamlined referral pathways to the best orthopedists, pain management specialists, physical therapists (PTs) and other healthcare professionals who specialize in work-related injuries — especially in states that allow patient care direction for the life of a claim. WC PPOs should not just be about medical savings: They need to enable people to receive the right care (at the right cost) to achieve quality outcomes.

Referral to Top Doc Is Key

Jacqueline Alonso, President, Horizon Casualty Services, Inc.

Of those WC medical expenses, over 60% are related to surgeries. That means it’s critical to get the first orthopedic referral right. A referral to an unsuitable orthopedist can delay recovery, prolong lost work time and increase overall claim costs. Horizon Casualty Services addresses this issue by cultivating a strong, reliable network of the most qualified New Jersey musculoskeletal-focused providers.

According to Jacqueline Alonso, president of Horizon Casualty Services, Inc., “Our goal is to streamline the selection process for case managers and claims adjusters by connecting them to the top orthopedists and specialists with ease and efficiency, and to assist claims departments with scheduling services.”

Identifying Top Doc and Effective Care Direction to Achieve Critical Objectives

Horizon Casualty Services operates based on a unique healthcare value strategy known as the Outcomes Focused Network (OFN). The appointment scheduling services team assists WC insurers by scheduling appointments for their claimants requiring orthopedic care or early intervention pain management with top doctors in the Horizon Casualty Services WC PPO network.

The OFN selection criteria are as follows:

• Demonstrated use of evidence-based medicine
• Conservative approach to surgery and opioid prescription
• A care approach that results in an appropriate length of disability and lost work time within Official Disability Guidelines (ODG) parameters
• Consistent use of in-network resources to reduce costs
• Monitoring complaints and grievances to ensure quality care is provided to claimants
• Administrative efficiency, including timely initial appointments and medical reports following office visits

Easy Appointment Scheduling for Claim Adjusters

Horizon Casualty Services makes appointment scheduling easy for claim adjusters, at no additional cost, and includes:

• A dedicated scheduling team for orthopedic, early intervention pain management, PT and radiology appointments
• One-business-day turnaround from receipt of claim adjuster referral to appointment scheduling
• Appointments scheduled with OFN providers as first preference
• Claimant and claim adjuster notification when appointments are scheduled

Streamlined and Precise Provider Search

The Horizon Casualty Services provider search tool features value-based sorting with OFN providers at the top of search results for adjuster convenience. This search tool creates a streamlined and precise pathway to top providers:

• Providers are evaluated on in-network utilization metrics
• Orthopedic active practicing subspecialties are included in search results (i.e., shoulder, knee, spine, etc.)

Our Results Speak for Themselves

• We strive to ensure that medical care delivered through the OFN network program is at or close to 100% in-network, including ASCs, assistant surgeons, anesthesia, post-operative care and PT
• Exceptional PT performance benchmarked by ODG and use of comparative provider analysis
• Our quality assurance approach includes a multidimensional assessment of provider performance and education to ensure positive medical outcomes for patients and helps to effectively control costs for payers

WC insurers, self-insureds and TPAs can achieve best-in-class results by leveraging the Horizon Casualty Services OFN healthcare value strategy. “Our innovative healthcare strategy and clinical quality initiatives allow claimants to receive superior care. We offer a comprehensive quality network, and our commitment is to partner with each client to achieve optimal medical and return-to-work outcomes.” — Jacqueline Alonso

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., a subsidiary 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 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.