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Moore: Are You A Drive-By Network User?

By James Moore

Thursday, October 17, 2019 | 371 | 0 | min read

Workers’ compensation medical network usage tends to be the drive-by type. What do I mean by drive-by?

James Moore

James Moore

PPO/MPN/cost-savings network

Most employers have an agreement with their carrier or third-party administrator (TPA) if the company is self-insured. Drive-by medical treatment originates with the employer or claims staff just using whomever they find convenient for post-accident treatment.   

The discounts provided by the medical networks never see the light of day. By luck, the injured employee treats with a provider that is in-network. The savings can be significant with workers’ compensation medical networks. The usual preferred provider organization discount pegs at 15% or higher.  

Many networks exist in the marketplace. Some are white-listed by a carrier, TPA or other networks as their own group of providers. The white-listing should not be a cause for concern. Use the network you have in front of you regardless of the source of the providers.  

Emergency services vs. workers’ compensation medical networks 

Please note one exception to the networks: If an injured employee needs emergency medical care or incurs a serious injury, make sure he receives immediate attention. Do not worry about medical networks on this type of claim.   

Attempting to have an employee with severe injuries stay in-network ends up costing insureds more than any network savings. I designed a walk-in clinic medical network for a very large (now defunct) homebuilder. The injured employee had a thumb amputation.  He showed up with his supervisor at a walk-in medical clinic.   

The supervisor said he stayed in-network. I was horrified and told them to go to the nearest hospital emergency room. The walk-in physician had already made the referral.  The hospital — Duke University Medical Center — reattached the thumb. Whew! 

Adjuster and claims department concerns

Rightfully so, the claims adjuster and departments raise concerns about staying in the workers’ compensation medical network while assuring that the injured employee receives treatment from industrial-minded physicians.   

Adjusters like to use certain physicians in certain areas for certain types of injuries.  When I adjusted claims, and now consult on them, I always carry a list of medical facilities in my head for a certain state or area. I think the main attribute was a “successful return to work” with the employees' capabilities regained to enable them to do their jobs in full. The other attribute by physicians and medical providers was the bedside manner.  

The Workers Compensation Research Institute performed a host of studies on the main attribute that employees possessed with a successful return to work. The word "trust" of the employer before the injury and the medical care resulted in better returns to work. 

The second key

The second key of my Six Keys to Workers' Comp Savings was written in the order of the claim. If I had to rank the six keys on savings potential, medical networks would rank the highest. Creating a network for injured employees seems complicated. Being prepared ahead of time make the task much easier.    

At the time the article was published, approximately 41 states allowed the employer to choose the medical network or to provide the injured employee with a panel or list of providers. Even if the employee retains the right to choose the treating physician, the injured employee will treat with a suggested physician. 

Preparation and teamwork for the workers' comp medical network 

The upfront preparation pays off with the proper medical treatment at the lowest cost.   The team members should be:

  • Claims adjuster or staff.
  • Providers in the area.
  • Medical network access for all involved; should be online with the carrier or TPA.
  • Employer representative.
  • Rehabilitation nurse; can be the hub to set up the network. 
  • Original treating physician; in-network referrals for more complicated cases.  
  • Trust. See WCRI study.

The employer representative kicks the medical network into gear by checking with all the above mentioned other parties. When looking for providers in your area, make sure they know that you use a certain network. Many medical providers sign up with medical networks once they learn local employers use a certain workers' compensation medical network.  

This blog post is provided by James Moore, AIC, MBA, ChFC, ARM, and is republished with permission from J&L Risk Management Consultants. Visit the full website at www.cutcompcosts.com.


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