CAS Health and Managed Care Seminar

1. CASHealth and Managed CareSeminar October 18, 1999 Charles M. Potok

3. Late 1980’s, Early 1990’s • Deterioration of workers compensation results • Increasing assigned risk plan market shares • Disastrous residual market loads

4. Residual Market Loss (NCCI)

5. Late 1980’s, Early 1990’s • Charges of rate suppression • Accident Year Combined of 125 • Cost Shifting - Accident/Health Workers Comp • Health Insurance a National Political Issue

6. Case Management Building Blocks of Accident and Health Managed Care Utilization Review Network Management

7. Case Management • Treatment Protocols • Nurse MD • Quality Medical Care at Lowest Cost

8. Appropriate Treatment • Concurrent Review • Retrospective Review • Pre-Admission Certification • Medical Bill Review • Quality Medical Care At Lowest Cost Utilization Review

9. Network Management • Size of Network • Discounts • Capitation • Keep Out of Office-Prevention • Disease Management • Immunization-Wellness

10. Indemnity-Fee For Service PPO Discounts HMO Tight Size of Network

11. Network Management • Size of Network • Discounts • Capitation • Keep Out of Office-Prevention • Disease Management • Immunization-Wellness

12. Building Blocks of Workers Compensation Managed Care Case Management Utilization Review Network Management

13. Treatment Protocols • Different for Workers Compensation • Nurse MD, EE, ER • Quality Medical Care at Lowest Cost • Indemnity Cost early return to work Case Management

14. Appropriate Treatment • Concurrent Review • Retrospective Review • Pre-Admission Certification • Starts with First Report of Injury • Medical Bill Review • Quality Medical Care At Lowest Cost Utilization Review

15. Size of Network • Discounts • Capitation • Keep Out of Office-Prevention • Drug Free Workplace • Disease Management • Immunization-Wellness = Loss Control Network Management

16. Size of Network Indemnity-Fee For Service PPO Discounts HMO Tight=Occupational Medicine

17. Size of Network • Discounts • Capitation • Keep Out of Office-Prevention • Drug Free Workplace • Disease Management • Immunization-Wellness = Loss Control Network Management

18. Late 1990’s, 2000Accident & Health Model • More Choice • Point of Service Options • Financial Disincentives • Less Primary Care Gatekeepers

19. Late 1990’s, 2000Accident & Health Model • More Emphasis on Disease Management • Better Quality • Credentialing • Data • Less Capitation

20. Late 1990’s, 2000Accident & Health Model • Hospitals, MD’s/Reimbursement Rates • Workers Compensation 1998 Accident Year Combined Ratio 122 • Health Insurance A National Political Issue

21. Implications for Workers Compensation • More Difficult Case Management • More Difficult Utilization Review • More Importance on Network

22. Implications for Workers Compensation • 24 Hour Coverage Disability Management • Internet Agents/Brokers Risk Managers Health Providers Claimants

23. Agents/Brokers • Rating • Issuance • Inquiry

24. Risk Managers • First Report of Injury • EOB’s • Loss Control Surveys

25. Health Providers • Medical Bills • Hospitals • MD’s • Provider Notes • Utilization Review

26. Claimants • Content • Protocols • Hospital Process • Questions • Medical Bill Information • Longer Term Case Management • 7 X 24