workers compensation managed care n.
Download
Skip this Video
Download Presentation
Workers Compensation Managed Care

Loading in 2 Seconds...

play fullscreen
1 / 22

Workers Compensation Managed Care - PowerPoint PPT Presentation


  • 78 Views
  • Uploaded on

Workers Compensation Managed Care. By: Laura Deterding, ACAS, MAAA Midwest Employers Casualty Company. Ratemaking Implications of Managed Health Care on Workers Compensation: Components and their Ratemaking Implications.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Workers Compensation Managed Care' - ruggiero


Download Now An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
workers compensation managed care

Workers Compensation Managed Care

By:

Laura Deterding, ACAS, MAAA

Midwest Employers Casualty Company

slide2

Ratemaking Implications of Managed Health Care on Workers Compensation:

Components and their Ratemaking Implications

slide3

The goal of Workers Compensation Managed Care is to integrate cost containment with optimal treatment to facilitate expeditious re-entry into the workforce.

workers compensation managed care1

Employer

Medical Providers

Minimal cost to

Utilization

Review

Specialist

Employer

Case Managers

Workers Compensation Managed Care

“Participants”

TPA/

Claims

Adjuster

Vocational

Rehabilitation

Specialist

Injured

Employee

workers compensation managed care2
Workers CompensationManaged Care
  • Third Party Administrator (TPA)/Claims Adjuster
    • Role:
      • Investigate compensability of the claim.
      • Identify and assign appropriate case managers and vocational rehabilitation specialists.
      • Set objectives and measure the results.
      • Secure IME/Second Opinions.
workers compensation managed care3
Workers CompensationManaged Care
  • Third Party Administrator (TPA)/Claims Adjuster (Continued)
    • Role: (Continued)
      • Evaluate vocational rehabilitation involvement and return to work possibilities.
      • Settle the claim.
    • Goal:
      • Proper claims handling is essential to cost containment and indemnity mitigation.
workers compensation managed care4
Workers CompensationManaged Care
  • Case Management
    • Definition:Case management is necessary to insure that proper medical protocols are applied for a specified injury type. The case manager is a registered nurse with professionally recognized designations and experience with industrial disability cases.
workers compensation managed care5
Workers CompensationManaged Care
  • Case Management (Continued)
    • Role:
      • Develop treatment plans and communicate those plans to:
        • Treating Physician
        • Injured Employee
        • Employer
        • TPA/Claims Adjuster.
workers compensation managed care6
Workers CompensationManaged Care
  • Case Management (Continued)
    • Role: (Continued)
      • Steer injured workers to industrial physicians/PPO/HMO networks
        • Industrial physicians have an in-depth understanding of the industrial disability process and the employer’s needs. They serve as “gatekeepers” directing the initial treatment avenues
      • Work with employer and vocational rehabilitation specialist regarding light duty and return to work possibilities.
workers compensation managed care7
Workers CompensationManaged Care
  • Case Management (Continued)
    • Role (Continued)
      • Attend medical staffings and provide input regarding appropriate treatment protocols.
    • Goal:
      • Effective case management results in medical cost containment and reduced indemnity costs.
workers compensation managed care8

Hospitals

  • Physicians
  • Prescription Services
  • Physical Therapy Centers
  • Other Medical Services
Workers CompensationManaged Care
  • Medical Provider System
    • PPO
      • PPO networks involve pre-negotiated discounts for the employer by use of selected providers. Networks may include:

Caution: There is a potential for utilization abuse. Should evaluate treatment frequency.

workers compensation managed care9
Workers CompensationManaged Care
  • Medical Provider System (Continued)
    • HMO
      • HMO providers are paid a flat fee for each covered employee. Providers involved in an HMO are employees of that organization.

Caution: There is an incentive for the provider to reduce the treatment frequency.

workers compensation managed care10

Prescriptions

  • Other medical services
  • Physician charges
  • Hospital Charges
Workers CompensationManaged Care
  • Medical Provider System (Continued)
    • Fee Schedules
      • This involves a legislated schedule of fees payable by specified CPT codes. Fee schedules establish a schedule of maximum charges applicable to:

Caution: Must verify adherence to fee schedules through in-house review or through an independent vendor who shares in the percentage of savings.

workers compensation managed care11
Workers CompensationManaged Care
  • Medical Provider System (Continued)
    • Goal:
      • An effective medical provider system results in medical cost containment. Indemnity losses may be indirectly affected.
workers compensation managed care12

Frequency

  • Duration
  • Medical reasonableness/necessity
  • Appropriateness
Workers CompensationManaged Care
  • Utilization ReviewDefinition:Utilization review is a system to manage, assess, and review the injured employee care.
  • Role:
    • Care is evaluated based upon the following criteria:
workers compensation managed care13
Workers CompensationManaged Care
  • Utilization Review (Continued)
    • Goal:
      • Effective utilization review results in medical cost containment. Indemnity losses may be indirectly affected.
workers compensation managed care14
Workers CompensationManaged Care
  • Vocational Rehabilitation

Definition:

Vocational rehabilitation is a systematic tool utilized to facilitate re-entry into the workforce. Parameters for vocational rehabilitation are established by the TPA/claims adjuster include setting objectives and measuring outcomes within established time frames.

workers compensation managed care15
Workers CompensationManaged Care
  • Vocational Rehabilitation (Continued)
    • Role:
      • Provides vocational assessments for feasibility of return to work.
      • Helps employer formulate light duty positions, both short and long term.
      • Perform labor market surveys and job searches.
    • Goal:
      • Effective vocational rehabilitation results in reduced indemnity payments.
workers compensation managed care16

Safety programs

  • Wellness programs
  • Procedures for reporting job-related injuries
  • Workers Compensation system
  • Light duty/Return to work programs
Workers CompensationManaged Care
  • Employer

One of the fundamental principles of managed care involves employer participation.

  • Role:
    • Provide educational materials and training to personnel regarding:
workers compensation managed care17
Workers CompensationManaged Care
  • Employer (Continued)
    • Role: (Continued)
      • Formalize light duty programs.
      • Communicate frequently with injured employees.
      • Involved in the selection of industrial/panel physicians.
workers compensation managed care18
Workers CompensationManaged Care
  • Employer (Continued)
    • Goal:
      • The employer involvement results in both medical cost containment and reduced indemnity losses.
ad