Five Misconceptions in Workers Compensation

Transcription

1 Five Misconceptions in Workers Compensation Contrary to popular belief, a child cannot catch a cold by refusing to wear a coat on a winter day; people cannot get warts from touching toads; and it is not medically necessary to wait 60 minutes after a meal before jumping into the pool. Myths and misconceptions are around us everyday and the same goes for workers compensation. From pharmacy, to managed care networks, to bill review systems, many employers and payers have preconceived notions in terms of products and service. With rising healthcare costs a continuing problem, it s more important than ever to understand the services provided to patients, the medications they are taking, how much and how often they are being administered and refilled, as well as how companies are billing for their services. As the economy struggles and the costs of medical care and pharmaceuticals skyrocket, employers are looking to provide workers compensation services that offer the best care for their injured workers, without breaking their budgets. In this position paper, experts from Healthcare Solutions identify and debunk five common misconceptions in workers compensation, and explain why a thorough understanding of these issues can help improve injured worker outcomes, decrease administrative burden, and reduce costs.

2 Misconception # 1 Acetaminophen, the active ingredient found in over-the-counter Tylenol and many pain-relieving prescriptions, is harmless for injured workers. Too much acetaminophen, defined as more than 4,000 mg a day as recommended by the U.S. Food and Drug Administration, can lead to major medical complications like liver damage, and it s easier than one might think to take too much. More than 600 products, both prescription and over-the-counter medications, contain acetaminophen. With many injured workers receiving prescriptions from more than one doctor and filling prescriptions at multiple pharmacies, there is plenty of room for a very dangerous and potentially fatal error. In fact, acetaminophen is the leading cause of Acute Liver Failure (ALF) in the U.S. and the National Institutes of Health reports that more cases are being reported each year. A recent study by the United States Acute Liver Failure Study Group found acetaminophen responsible for ALF in 46 percent of the cases it researched. In workers compensation, acetaminophen is most commonly found in pain-relieving prescription medications like Vicodin or Percocet. However, as noted above, different levels of acetaminophen are included in a variety of products often prescribed to or purchased over-the-counter by employees after a work-related injury. To help protect their injured workers, companies should look for a pharmacy management partner who has a prescription processing program with automated triggers embedded in the system that can monitor and address appropriate dosing levels of acetaminophen for injured workers. When acetaminophen daily dosages get close to this 4,000 mg per day limit, the system should flag the claim, alert the pharmacist and prompt a discussion with the prescribing physician. Based on the results of Healthcare Solutions acetaminophen dosage monitoring program, the right monitoring program can reduce the number of claimants receiving excess amounts of acetaminophen by more than half. Further, aside from the decreased health risks, significant savings can also be realized due to decreased pill count. By incorporating a proven monitoring system and other proactive measures, employers and payers can decrease the risk of liver damage to injured workers, reducing with it the unnecessary grief and high healthcare costs caused by complications related to an inexpensive medication with very costly ramifications. Jim Andrews, R.Ph Executive Vice President Pharmacy Benefit Management Acetaminophen is not as risk-free as some may think.

3 Misconception # 2 Employers should look only at certified networks when shopping for a managed care network for workers compensation. A number of states offer the opportunity for managed care networks to become statecertified to manage healthcare for injured workers. In most certified networks, injured workers are restricted to seeing providers within the state-certified network. As a result, employers often limit their searches for healthcare networks to companies that are certified because they think it will retain more control over their injured workers healthcare costs. While this is one way to narrow a search, employers may not be getting the control they think. Although certified plans offer employers the ability to direct care, many certified network contracts also allow an employee to opt out of the PPO after 30 days, after an initial visit, or for a variety of other reasons freeing the injured worker to see a non-network provider and raise claim costs. Certified plans like this include: the Massachusetts Preferred Provider Arrangement, the Minnesota Managed Care Plan, New York s certified plan and Wyoming s certified plan. And there are other potential downsides to choosing a certified network. For example, no research has been conducted and no empirical evidence has been found to demonstrate that the outcomes of a certified network are better than those of a non-certified network. However, it has been noted that participation in a certified network can be administratively burdensome. Rather than focusing solely on certified networks, employers should look for networks that can be customized to their individual needs. They should focus on networks that offer access to quality providers through national affiliations and/or regional and proprietary networks. Additionally, employers should look for a network that has a detailed credentialing process and measures provider performance on a regular basis. The right network, whether certified or not, should bring employers robust network penetration, improved healthcare outcomes for injured workers, as well as preferred rates and a seamless administrative process. Healthcare Solutions offers both state-certified and non-certified networks to best meet customer needs. While some employers may be leaning toward certified networks exclusively, it may be best for them to explore their options. Other networks could provide employers with the control they are looking for by providing injured workers with a broad network of top providers that will meet their every need. Nicole D Ettorre Senior Vice President PPO Network Services Actually, there are both pros and cons to using a certified provider network for workers compensation. A certified network may not always be the best selection depending on an employer s needs.

4 Misconception # 3 As long as a company is using a bill review service for workers compensation claims, it is realizing maximum savings. Improper bill review is costing payers. While 75 percent of all bills may clear easily through a bill review system due to the application of fee schedules and formularies, there are another 25 percent that are left up to interpretation. In fact, across workers compensation programs, payers frequently miss out on maximum savings on roughly 10 percent of the bills processed and there are a number of reasons for this. For example, although states may have set fee schedules, those fee schedules do not cover everything. The language usual and customary is still very common on bills because states cannot put a price on every service provided. As a result, bill reviewers use formularies to determine a fair price. It is a common belief that all bill review providers use the same formularies resulting in the same price reduction, but this is not the case. Not only are bill review software and formularies inconsistent; not all bill reviewers use qualified experts to edit the software s conclusions. The people operating the software can make a significant difference on savings realized by the payer. When looking for a bill review provider, employers and payers should look for a partner who uses the best bill review software available and has a dedicated team of experts who know state rules and regulations to work in tandem with the system. A sophisticated bill review package should offer document management and workflow capabilities, broad imaging, scanning functionality, advanced PPO applications, and paperless record storing, among other things to help clients realize the most savings. By partnering with a bill review provider that employs superior software and a team of medical bill editors, employers and payers can realize maximum savings and experience optimal patient outcomes. Jeff Sommerfield Vice President Medical Bill Review Bill review services use different bill review models with different databases some better than others. What makes the real difference is the use of up-to-date bill review software coupled with qualified people who know the software and the state rules and regulations that can have a significant impact on payments.

5 Misconception # 4 Professional case management is only for serious physical injuries in workers compensation cases. Psychological-related illnesses are more accepted by society now than they were even a decade ago. As a result, more psychological and emotional cases have been seen in workers compensation. According to the American Psychological Association (APA), mental health issues led to nearly 160 million office and hospital visits in Rising levels of stress experienced by workers is one key reason for the growing numbers of mental health claims in workers compensation. Roughly 75 percent of American workers surveyed by the APA said they experienced physical symptoms of stress due to work. Further, stress related illnesses, including depression and heart disease, cost businesses up to $300 billion a year. A mental health claim in workers compensation can be a component of a physical injury, the result of an employee experiencing or witnessing a traumatic event at work, or simply a mental health claim on its own. One of the best ways to impact rising costs related to this growing number of workers compensation mental health claims is to employ the services of a professional case manager. Typically, psychological injury claims do not show objective physical findings that can be measured like in a bone fracture or torn meniscus claim. The subjective nature of psychological injury claims poses a challenge that requires an intermediary to assist in assuring an accurate diagnosis and compensability. The case manager will work with the injured worker and the treating provider to establish a goal directed treatment plan, within a documented timeframe, that includes return to work and pre-injury activities. A case manager will monitor the injured workers care and help them experience optimal outcomes while making sure employers and payers are keeping costs in line. Case managers working with mental health claims should offer telephonic and/or field-based services to identify effective and cost-efficient patient solutions, and help them avoid unnecessary or inappropriate care. A good program should offer registered nurses who specialize in mental health issues to navigate the subjective and often costly elements of a psychological claim. While case managers can play a key role in helping to resolve mental health claims appropriately and cost-effectively, employers also need to be sure they are taking stress and psychological claims seriously. Addressing issues at the onset with early communication can help keep the situation from growing and curtail future medical problems and healthcare costs. Tina Downey Senior Vice President Managed Care Services Professional case management can be very effective in workers compensation cases with psychological or mental claims and produce significant cost savings, particularly as this segment of healthcare continues to grow.

6 Misconception # 5 Injured workers find auto-refills of durable medical equipment and medical supplies convenient and necessary. A recent article from the Times-Union demonstrated how auto-refills can get out of hand and contribute to rising healthcare costs. The Albany newspaper reported that in two separate cases deceased individuals racked up $30,000 worth of expired medications and thousands of dollars worth of unused mail-order diabetic test strips and other medical supplies. Just as unnecessary and costly auto-refills are for the healthcare system as a whole, it is a very important issue for workers compensation. Stopping unnecessary and unwanted auto-shipments of durable medical equipment (DME) in workers compensation cases can result in millions of dollars in savings. Eager suppliers often offer discounts for bulk orders on items like TENS (Transcutaneous Electrical Nerve Stimulation) units, gels, and adhesives, but one out of three injured workers does not need the auto-shipped refill after a certain number of deliveries, and suppliers continue to ship the items. For example, electrodes for TENS units are offered in a one-month s supply, and all too often, suppliers ship a supply good for many extra months when most low-end TENS units are only used for 90-days or less. Unfortunately, the problem of auto-refilled supplies in workers compensation is only likely to get worse under healthcare reform. With cost reductions mandated by the new healthcare reform law, suppliers are looking for alternative reimbursement areas. Because the suppliers will now see lower reimbursements from other impacted customers, and workers compensation is not affected by this phase of the law, suppliers may be more aggressive in pushing injured workers harder for auto-refills and bulk shipments. To avoid burying their injured workers under a heap of unnecessary medical supplies, employers and payers can partner with a specialty benefits expert who can monitor these refills, understand which are unnecessary or inappropriate, and cancel those orders. In fact, a good partner should be able to provide injured workers with superior patient care while discontinuing roughly one-third of their automatically refilled medical supplies. By taking a closer look at auto-refills on medical supplies, employers and payers can realize significant savings on durable medical equipment, and their injured workers can free up room at home taken up by repeated shipments of unneeded medical supplies. Eileen Ramallo Executive Vice President Product Development Most injured workers do not want or need all the medical supplies they automatically receive and much of it gets wasted.

7 About Healthcare Solutions Healthcare Solutions, Inc. is the parent company of Cypress Care, ScripNet and Procura Management. Through its subsidiary companies, Healthcare Solutions delivers integrated medical cost management solutions to over 750 customers in workers compensation and auto/pip markets. The company s clinical and technology based services include pharmacy benefit management, specialty healthcare services, PPO networks, medical bill review, case management and Medicare Set Aside services. With over 22% compounded annual growth rates, Healthcare Solutions has twice been recognized as one of the Fastest Growing companies in Georgia by Georgia Trends magazine and has received recognition by the Technology Association of Georgia for technology innovation. Utilizing market leading technology, Healthcare Solutions delivers demonstrated benefits and savings complemented by deep industry expertise. For more information, contact marketing@healthcaresolutions.com 2736 Meadow Church Rd Suite 300 Duluth, GA Phone : Fax: