5 Tips for Choosing a Workers' Comp PPO


With medical costs continuing to trend upward, identifying and maintaining best-in-class preferred provider organizations (PPOs) continues to be of paramount importance. 

Medical cost control continues to be the most challenging component of workers’ compensation expenses. For this reason, contracting with best in class workers’ compensation PPOs should be the goal of every workers’ compensation insurer in order to assure superior medical outcomes at lowest cost.  

Though many workers’ compensation PPOs claim to be the biggest and the best, due diligence on the part of executive decision makers is critical as not every workers’ compensation PPO is the same. In addition to executing the basics of having a very high percentage of facilities and providers contracted at competitive rates, best in class workers’ compensation PPOs must achieve more. 

In order to stay ahead of the competition, workers’ compensation PPOs must consistently achieve the medical care quality triple aim.  The triple aim summarized:  

  • Best doctors - Contracting with the best providers at the most competitive rates 

  • Long-term provider retention 

  • Effectively steering injured workers to those PPO providers most qualified to treat their specific work injury 

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Horizon Casualty Services, Inc. (HCS), a subsidiary of Horizon Blue Cross Blue Shield of New Jersey, provides workers’ compensation and personal injury protection (PIP) PPO services throughout New Jersey processing over $2.6 billion in medical bills annually. With that scale, HCS successfully leverages its experience and data to drive the best medical outcomes for injured workers at the lowest cost. 

Here are five tips for making the right workers’ comp PPO network decision:  

Tip #1: Demand providers who put quality first. 

For injured workers and their families, nothing is more important than rapid recovery and timely return to work. And that means the right treatment, from the right specialist, from the very first appointment. Your PPO should be adept at identifying the highest rated providers that are best in class within their specialties. This is especially critical for orthopedics and pain management providers, which should achieve superior outcomes by using nationally accepted, evidence-based guidelines as well as a conservative approach to surgery and prescribing opioid narcotics. 

At HCS, this is our Outcomes Focused Network Strategy. The objective is to achieve lowest per unit costs with best medical outcomes. 

Tip #2: Ask Your PPO to provide the road map.  

Claims adjusters are busy. However, standard provider directories feature provider names displayed alphabetically. They do not make it easy to find best in class providers. Your PPO provider directory should feature premier providers at the top of any search along with their board specialty and principal area of practice (for example, knee, shoulder or spine).  

HCS provides the road map by featuring Outcomes Focused Providers at the top, along with their medical specialty, area of practice, and hospital and ambulatory surgical center affiliations. Consistent referral to best-in-class providers benefits injured workers and insurers – a win-win!  

Tip #3: Make them put their money where their mouth is.

The difference in the results between a good PPO and a great one is many millions of dollars. “Ask your PPO to show evidence of cost savings and positive outcomes,” recommends Jacqueline Alonso, President of Horizon Casualty Services, Inc. “We partner with our clients and network of providers in a collaborative effort to identify savings opportunities while streamlining the administrative process. At the end of the day, we want to make it easy for our customers to do business with us, and we work closely with them to shepherd appropriate patient treatment resulting in positive outcomes.”

Workers’ compensation claims may last from one day to a lifetime. Long tail claims can result in significant cost and reserving challenges. However, significantly controlling medical cost requires selecting a PPO with a sufficiently large provider network, with high quality providers and with contracted rates far below what insurers would pay if there were no PPO in place.

HCS, a subsidiary of the largest health insurer in New Jersey, has the size, referral volume and goodwill of the provider community to enable the company to successfully contract at extremely competitive rates with the best health care providers in New Jersey.

Tip #4: Network utilization (or penetration) is an important metric – 82 percent to 92 percent is easily achievable. 

Under New Jersey workers’ compensation law, the insurer has the ability to steer injured workers to providers of the insurer’s choice. This provides opportunity to leverage contracted PPO rates and optimize results. For this reason, network utilization is a key metric. Because payments to facilities such as acute care hospitals, rehab hospitals and ambulatory surgery centers represent a significant portion of the medical spend, a broad PPO facilities network is important. 

Network utilization is calculated as the sum of all in-network medical expenses prior to application of a PPO discount divided by all in-network and out-of-network medical expenses prior to application of a PPO discount. 

HCS has 99% of all acute care hospitals in-network, and contracts with all major rehabilitation hospitals and a vast array of ambulatory surgery centers. The company also contracts with physicians and other health care professionals specializing in musculoskeletal medicine. As a result, its clients’ network utilization levels are extremely high at 82% to 92%.

Tip #5: Do they sweat the details? 

A disorganized PPO operation, with unacceptable levels of medical bill processing and other errors, can create reputational damage for carriers and employers and unnecessary administrative cost. The best workers’ compensation PPOs process bills promptly and accurately. The leading indicator of an efficient PPO is the appeal rate. 

At HCS, flawless execution is key. The company’s workers’ compensation appeals rate is 0.2%. This reflects HCS’s focus on maintaining pristine provider demographic data, precise medical bill pricing results and excellent relationships with its provider network participants. 

In summary, your workers’ compensation PPO should be strong and stable to enable the delivery of the best possible health care to injured workers. This critical component of an effective health care value strategy produces the best possible result for people, for business and for overall wellbeing. Since 1996, HCS has provided results-based services to large workers’ compensation insurers and self-insured entities. 

For More Information For more information, email Jed Hoban, HCS Business Development Executive, at Jed_Hoban@HorizonBlue.com or visit or visit https://www.horizonblue.com/horizoncasualty/service-offerings/workers-compensation.

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 New Jersey workers’ compensation (WC) and personal injury protection (PIP) PPO. The company’s 100 percent direct contracted provider network includes 99 percent of New Jersey acute care hospitals, overall WC savings 62 percent below UCR and with its deep focus on precision; an extremely low WC appeals rate of 0.2 percent. Its PPO results coupled with its WC health care value Outcomes Focused Network strategy enables insurers to be the 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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