How the Best PPO Networks Help Employers with Medical Cost Containment
Written by: Dr. Michael Miller, Executive Director
AlaMed Workers’ Compensation Network
In the workers’ compensation community, Third Party Administrators (TPAs) often offer the services of a Preferred Provider Organization (PPO) network in order to assist self-insured employers, funds, and associations with their medical cost containment. However, not all PPOs are created equal. While each PPO does have a list of providers, not every PPO has the same coverage area or the same standards for providers in their network. PPOs do help to reduce employer costs, but the real benefit is in getting an injured employee back to work as safely and as quickly as possible through the use of excellent providers who are available and who have the training and expertise to facilitate the injured employee’s recovery—and the best PPOs play a significant role in helping return patients to work.
Let us explain some of the different functions you should expect from your workers’ compensation PPO here in Alabama:
1. Screening. Your PPO should check with its providers and staff members to make sure they understand workers’ compensation and how care for a workers’ compensation patient should be delivered. For instance, does the provider understand the difference between what medical services qualify as First-Aid and what medical services are OSHA recordable? Another good measure of a PPO network is whether or not they monitor the Alabama Board of Medical Examiners to check for physicians who have had disciplinary actions taken against their license.
2. Training. If a provider feels they may not understand as much as they would like or if they don’t know anything at all, your PPO should offer to help assist and train providers on the different aspects of workers’ compensation in Alabama. This can include basic information to in-depth workers’ compensation law, OSHA standards, staff training on how to submit claims and communicating with the payer, etc.
3. Recruiting. Check with your PPO to ensure they have coverage that suits your needs in the areas of convenience to the patient’s home or work and provider expertise. If you have a need of a provider in an under-served area, your PPO network should be willing to recruit providers as quickly as possible to ensure your injured employee’s needs are met.
4. Listing. When it comes to PPO networks and their databases, how are the providers listed? Are providers listed by the primary specialty and/or sub-specialty? Having a provider’s specialty and/or sub-specialty listed means the adjuster or case manager assigned to your patients will be able to more effectively and efficiently choose the right providers to get your injured employee back to work. If for some reason an injured worker is not satisfied with their provider and their adjuster needs to provide a panel of providers for the patient to choose, it is important to choose a provider that would be the best-suited to oversee care for the patient.
5. Monitoring. An important aspect of a PPO network is to maintain the correct fee schedules so the payers can pay claims correctly and within the guidelines set forth by the State of Alabama Department of Labor. The DOL updates their fee schedules for hospitals and facilities on a quarterly basis so monitoring the DOL for these fee schedule updates and making the payers aware of the changes helps to maintain a payment adjudication system on a real-time basis.
6. Resolving. In the case of a dispute between a provider and a payer, the most proactive PPO network can play a vital role in resolving the dispute quickly. Your PPO network will know the provider’s contract and will have the latest fee schedule updates, making them a well-informed mediator between the two parties and reducing the dispute resolution to a matter of days rather than a week or longer.
7. Connecting. When a provider needs the services of an outside vendor, for example, a clinical or diagnostic laboratory for drug testing, their PPO network should be able to assist them with a recommendation of a high quality in-network vendor. This ensures that the vendor is preferred by their payers and can also help deliver the requested services with a reasonable pricing structure—all the while building and strengthening the relationship between the PPO and the provider by providing quality vendors when they are needed.
8. Coordinating. The best PPO networks can help to coordinate the care of an injured worker. One aspect of an excellent PPO is listing a Workers’ Compensation Coordinator for each practice in its database. A Workers’ Compensation Coordinator is a direct point of contact within the provider’s office who works with the adjusters directly in the coordination of care for the injured worker. This includes collecting intake information, sending any requested information, and ensuring effective and efficient communication between all parties involved, just to name a few. However, the role of the Workers’ Compensation Coordinator can be as broad or as narrow as it needs to be, and more than one can be assigned for a provider.
When it comes time to choose a TPA, these eight points covered in this article can help to ensure that all of your needs as an employer are met. Choosing a TPA with the best PPO network for your workers’ compensation injuries is important because not all PPO networks are the same, and the best PPO networks can provide services beyond general coverage and discounts.
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