Change is Inevitable, That Goes for Networks Too

Amid all the changes in health care — and all the challenges that remain — experienced workers’ comp networks are evolving to meet the needs of providers, injured workers, and employers. Today, we see constructive partnerships between providers and payers that include a wide variety of provider types and a range of specialty services to serve injured workers. Next-generation networks are often tighter, specialty-focused, smaller — right-sized — networks that benefit all involved by grouping together the best of the best. Many such networks pull together smaller groups of providers with specific expertise who can best help injured workers. And, of course, specialty networks focus on narrow areas to let clinicians do more of what drives them and what they’re best at doing. These newer networks present providers with opportunities to keep up with their peers who are utilizing new treatment regimens with emerging technologies such as telemedicine and remote patient monitoring.

Even evolving networks must come with a solid foundation

A successful network is built on a foundation set in provider access, specialization, compliance capabilities, and quality controls. Comprehensive networks leverage industry experience, knowledge, and data analytics to provide greater discounts, specialties, and a geographic footprint that ensures clients have access to providers who support the needs of the injured workers they serve.

Access: Today, thanks to deeper insights into patient trajectories, continual network review allows the best clinicians to rise to the top of the stack. Powerful analytics and algorithms pull data to evaluate outcomes and push data to aid clinicians in taking care of patients to promote network optimization. Processes powered by analysis, savings, geographic coverage, and strategic partnerships within the provider community also assure the best provider relationships remain intact, and network access remains comprehensive.

Compliance: Network compliance requires strong relationships with state agencies and close monitoring of state medical boards, physician practice acts, pharmacy boards, and state regulatory agencies and rules. Networks must be knowledgeable and dedicate significant resources to ensure compliance of filings and reports, and coordinate program requirements with their providers and clients. Experienced resources monitor new legislation and regulation, address compliance of all applicable laws, have audit processes to verify guidelines and measure compliance processes on an ongoing basis.

Quality: Optimal quality assurance programs are comprehensive, systematic, ongoing, and compliant with regulations pertaining to provider network quality improvement processes. Quality networks collect actionable intelligence through strong provider relationships, and monitor policies and procedures to maintain current provider database information across all applications for adjusters, case managers, clients, and injured workers. Networks also need multi-faceted quality management programs that review provider credentials, verify compliance, and regularly confirm provider participation in the work comp network and the ability to accept new patients.

Stronger provider engagement is moving the needle forward

While networks will continue to be the best at what they’ve always done: managing the relationship with the provider, its beneficial for them to take this engagement to the next level. Strong networks need highly skilled, cost effective providers who offer clinically appropriate, quality treatment to injured workers, and when backed with additional clinical resources and support systems can achieve the best possible outcome. Next level engagement is key to ensuring these types of providers are part of the network so injured workers can be channeled to them whenever possible to address every injury type and promote the best treatment. Next level provider engagement expands provider interactions to include personalized training, comprehensive tools, best practice provider programs, and recognition models for very important providers (VIP).

Provider Education: It’s important to educate providers on the benefits of handling work comp claims as an extension of their current referral patterns, and how work comp eliminates patient collection activities and builds continuity of care. In addition, personalized training, work comp specific provider tools, as well as access to state and network specific reference manuals helps build collaborative and trusted partnerships with providers.

Online Tools: Providers often spend more time on administrative tasks than on patient care. Online access to information helps improve front and back office efficiency by allowing those team members to view bill status, repricing information, and Explanation of Reviews (EORs). By providing on-demand access to this information office staff can easily get the answers they need without wasting time making phone calls. Continued investment in online tools improves the way practices complete tasks and benefits both payers and providers.

Evolution is key to successful outcomes-based networks

Outcomes-based networks (OBN) provide a channeling mechanism to health care providers who demonstrate a depth of experience in treating workers’ compensation injuries. One of the most important yardsticks for their success is the ability to help injured workers return to work, and to achieve this highly successful OBNs are always evolving and evaluating new information to arrive at the best-possible mix of effective care. One-way OBNs get consistently better at quantifying outcomes is through powerful data analytics and improved technology. Even a few years ago, the rigor of analysis we see today simply wasn’t possible.

There are many important metrics to consider when determining if providers demonstrate a clear depth of experience in treating workers’ comp injuries including treatment lag, lost-time rate, indemnity and medical paid per claim, as well as other expenses. Providers must show consistently better measures of clinical outcomes, medical utilization, pharmacy utilization, return to work, and financial outcomes when compared to their peers. Reviewing all claim types and comparing providers to their peers identifies those providers with the best overall claim outcomes. It’s also critical to look beyond the injury itself and consider factors such as mental welfare, comorbid conditions, and socioeconomic factors.

Customization is reinventing the way networks are built

Many states allow customization of provider networks to support compliance through built in measures that allow the right custom provider selection for each employer’s specific program. Customized networks can also be integrated with nurse triage, clinical programs, telemedicine, pharmacy, and other specialty networks to deliver even greater overall outcomes.

States that permit direction of care are ideal for network customization and allow injured workers to be directed to preferred providers who are familiar with the workers’ comp system, meet necessary contracting and credentialing requirements, and align treatment plans with nationally recognized guidelines. These networks also offer clients that analyze their own claims data the ability to include providers based on their analytic results.

Traditional networks are expanding to incorporate specialty services

When the network lens is expanded to include specialty services clients gain the benefit of an array of supports at reduced rates through their existing network relationship. In conjunction with provider network rates, contractual relationships with providers of durable medical equipment (DME), diagnostics, physical therapy, home health, and other services within an extended network can further streamline patient care. These models often offer a single point of contact for all specialty equipment and services, scheduling, clinical oversight, and greater injured worker satisfaction. In the past, many of these same providers may have been referred to physicians or adjusters without the benefit of rates below fee schedule or hands-on coordination.

Specialty network services are often foundational to workers’ recoveries and combined with physician networks can add up to a more inclusive recovery experience for injured workers. This already sizable outlay comes as we could be poised for an increase in the types of injuries that specialty services are perhaps best equipped to treat.

Networks continue to make inroads into mental health concerns

To achieve the best possible outcomes for injured workers we’ve come to understand that it’s wise to focus on the whole person, including mental health issues. Today, successful workers’ comp models of care consider these aspects from the start and incorporate strong mental health provider networks. This is important because finding the right provider and gaining timely access to that provider is key to helping injured employees deal with mental health hurdles.

In workers’ comp, behavioral health provider networks often include psychiatrists, psychologists, and professional counselors. Unfortunately, challenges around access to these types of mental health providers are growing, particularly in rural communities. While the outlook for treatment access remains worrisome, incorporating mental health providers into a larger work comp network can help address these access issues. Some mental health professionals hope the societal inequities and short­comings highlighted by the COVID crisis will also lead to further innovations in delivering care such as using telemedicine to reach patients in the comfort of their own location.

Rethinking networks from a more holistic perspective creates value

Expanding workers’ compensation networks to actively recruit highly experienced providers, offer customization, and incorporate additional services creates value and increases the networks ability to comprehensively manage overall network needs including:

• Credentialing providers
• Supporting payers and workers in the community
• Helping providers to grow and diversify their patient base
• Allowing payers and providers to anticipate expected payments and reserve
• Positively effecting overall medical costs
• Channeling to providers with work comp expertise (where allowed)

Today, work comp networks are also doing more to partner with providers than ever before. Supporting providers with administrative tasks and other assistance allows them to focus on providing quality medical care rather than unnecessary paperwork. In essence, a strong network means providers have someone blocking and tackling on a range of issues so clinicians can focus on injured workers. These include offering providers streamlined utilization review programs, scheduling services, and electronic billing. The benefits that workers’ comp networks bring to employees, employers, and providers are clear. What will be most interesting to see is how these networks will continue to evolve to meet the industries ever-changing needs.

By Jill Harris

Jill Harris is the Senior Vice President of Network Operations for Coventry and is responsible for auto and workers’ compensation provider network management, provider dispute resolution and direct network contracting. She has 27 years of experience in network management, contract negotiation, credentialing, training, acquisition management, and project and team leadership, and is a contributing author to Coventry’s Sounding Board Blog.

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