White Paper

The Critical Importance of Getting the First Workers’ Compensation Referral Right

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 and claim adjusters.

White Paper Summary

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.

To learn more about Horizon Casualty Services, Inc., visit https://www.horizonblue.com/horizoncasualty/.


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

More from Risk & Insurance

More from Risk & Insurance