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Building a Workers' Comp Network?

By Joe Paduda

Thursday, August 28, 2008 | 0

By Joe Paduda

If you're looking to build a workers' comp network, you'll want to focus on WC specialists - occ med docs, orthos, neuros, physiatrists, primary care docs, and a smattering of other specialties - along with ancillary care providers.

And you most definitely don't want every Dr. Tom Dick and Mary - the ones that can't spell 'workers comp' and think 'return to work' is what happens after lunch.

While including these docs in the network will make the directory nice and fat, they won't know what to do if a claimant actually presents.

In fact, the fatter the directory, the further away you should stay. Growing evidence indicates there's a lot of good reasons to limit the docs who treat workers comp claimants:

  • Claimants feel more comfortable with docs who can actually explain how the comp system works; physicians tend to be trusted by their patients, and this trust can translate to lower litigation rates
  • Docs who know disability management know that getting injured workers back to the job asap facilitates recovery
  • Comp docs know they are only supposed to treat the comp injury, and although they have to factor in comorbidities, understand that the comp payer isn't liable for all treatment
Another consistent problem in the comp network world is lousy data - directories are full of docs who no longer take patients, don't take work comp patients, have moved, are dead, or can't recall ever signing a network participation contract. (in this last instance, it is likely someone in their office did, at one time, but can't remember doing so).

Expect to pay the docs you want a reasonable rate. "Reasonable" may be above or below the state fee schedule (in the 30+ states with fee schedules) or an Resource Based Relative Value Scale (RBRVS)-based fee, or some discount based on published usual and customary data. Make sure, really sure, that the basis for reimbursement is clear, precise, and accurate. There have been an increasing number of lawsuits from providers alleging underpayment by work comp payers. This is a trend that by all indications is going to continue. Without a clear contractual definition of payment terms, networks open themselves, and their payer customers, to a much higher risk of litigation.

Which leads to the final recommendation - payers are getting a discount, or at least an agreed-upon reimbursement rate, and therefore must promise to do something to get that rate. In most cases, that 'something' is the promise by the network that it will work diligently to direct patients to the contracted provider. Again, make sure the contractual terms are clear - what will payers do to direct patients to providers, how will they push this 'downstream' to their policyholders, and how will this be verified.

Keep the data up to date, carefully select the docs who are in it, have fair and clearly defined reimbursement terms, and hold up your end of the bargain - send the providers more patients.

Joe Paduda is principal of Health Strategy Associates, an employer's consulting firm in Connecticut. This column is reprinted from his blog on health care and workers' compensation issues, http://www.managedcarematters.com

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