Top Doc Health Care Value

Top Doc Health Care Value strategy boosts employee and insurer well-being.

Have you ever heard the term “doctor’s doctor?” Those doctors are considered the best of the best — the ones that physicians go to based on doctor-to-doctor word of mouth. However, it can be difficult even for physicians to find the right specialists. And ordinary patients generally have little information to go on beyond practice reputation for courtesy, cleanliness, and convenience. 

The most effective workers’ compensation (WC) PPOs are not just about medical savings; they are about enabling people to receive the right care at the right cost and achieve the right outcomes. This is why it’s so important for WC PPOs — especially in states like New Jersey that allow patient steerage for the life of claim — to create streamlined referral pathways to the best orthopedists. 

“At Horizon Casualty Services, we have the most comprehensive WC data trove in the state and more than 25 years of experience working with New Jersey musculoskeletal-focused providers.  And we leverage these strengths to help our clients’ adjusters connect WC claimants to top orthopedists easily and efficiently,” says Ilene Wachs, President, Horizon Casualty Services, Inc. (HCS). 

Referral to Top Docs Is Key

With 66 percent of WC medical expenses related to surgeries, getting the first orthopedic referral right is vitally important. Insurers know that referring to an unsuitable orthopedist is a critical path event likely to delay recovery, prolong lost work time, and increase overall claim costs. 

Identifying Top Docs and Effective Care Direction Achieves Critical Objectives

The unique HCS WC health care value strategy known as the Outcomes Focused Network (OFN) helps WC insurers refer claimants requiring orthopedic care or early intervention pain management to top docs within the HCS WC PPO network. 

HCS WC OFN Top Docs Selection Criteria

• Demonstrated use of evidence-based medicine
• Conservative approach to surgery and opioid prescribing
• Care approaches resulting in appropriate length of disability and lost work time within Official Disability Guidelines (ODG) parameters
• Consistent use of in-network resources
• Administrative efficiency, including timely initial appointments and medical reports following office visits

HCS Makes Appointment Scheduling Easy for Claim Adjusters

HCS Makes Appointment Scheduling Easy for Claim Adjusters - at No Additional Cost - and Includes:

• Dedicated scheduling team for orthopedic, early intervention pain management, PT and radiology appointments
• One business-day turnaround from receipt of claim adjuster referral to appointment scheduling
• Assurance that appointments will be scheduled with OFN providers
• Claimant and claim adjuster notification when appointments are scheduled
• Bilingual schedulers to effectively assist Spanish-speaking claimants 

HCS Provider Search Streamlined and Precise

• Provider search tool features value-based sorting with OFN providers at the top of search results for adjuster convenience.
• Providers are graded on in-network utilization metrics.
• Orthopedic active practicing subspecialties are included in search results (for example, shoulder, knee, spine). 

HCS Results Say It Best

• Medical care delivered through the OFN program is at or close to 100 percent in-network, including ASCs, assistant surgeons, anesthesia, post-operative care, and PT.
• Exceptional PT performance benchmarked by ODG and use of comparative provider analysis.
• Quality assurance approach includes a multi-dimensional assessment of provider performance to ensure positive medical outcomes for patients and helps to effectively control costs for payers. 

By leveraging the HCS OFN WC health care value strategy, WC insurers, self-insureds, and TPAs achieve best-in-class results for WC claimants and all stakeholders by achieving the best medical and return-to-work outcomes at the lowest cost. 

“HCS is committed to its mission of working with medical providers and legislators to do what’s right for the long-term well-being of New Jersey employees and their families,” says Ilene Wachs. “That’s why HCS is New Jersey’s #1 WC and PIP PPO with largest market share, highest medical cost savings and a unique WC health care value strategy that decreases cost and improves outcomes of WC claims.” 

For More Information

For more information, email Jed Hoban, HCS Business Development Executive, at Jed_Hoban@HorizonBlue.com or visit HorizonCasualty.com.

About Horizon Casualty Services, Inc.

Horizon Casualty Services, Inc., a subsidiary of Horizon Blue Cross Blue Shield of New Jersey, in business since 1994, is the #1 WC and PIP PPO in New Jersey. The company’s 100 percent-direct contracted provider network has 99 percent of all New Jersey acute care hospitals in-network; WC savings of 62 percent below UCR; and PIP savings of 32 percent below PIP fee schedule. Its PPO results coupled with its WC health care value OFN strategy enables insurers to be best at delivering quality medical care to claimants at the right cost — clearly a win-win for all stakeholders involved in WC claims.

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