August 26, 2008

Planning Is Vital to Nonsubscriber Success

There's never a bad time to talk with your clients about Nonsubscription services, but now could be especially timely.  

Susan Hopper, a career nurse and Anchor Claims case manager, addressed the Texas Alliance of Nonsubscribers in Austin Aug. 20 to outline medical cost containment strategies essential for a successful opt-out program. Such heightened awareness, plus a sluggish economy, should put more companies in play.

Employers of all sizes use Nonsubscriber plans to manage job-related injuries. They know the best way to manage injuries is to have none, but you must plan for the worst. Good training and strict adherence to processes can eliminate most potential accidents, but not all.

When an employee does have an occupational injury, the employer – your client – must have a plan for dealing with it quickly and effectively. Let's take a look at that now, and also consider the role Anchor Claims plays in case management and adjustor oversight.
 

• Have a medical plan in writing: Know exactly what actions to take in case of on-the-job injuries. This includes having nearby physicians pre-selected and authorized by the employer. Negotiate what you will pay physicians, what services they will render and protocols they will follow. Anchor will be pleased to review your plan.
• Take care of the injured employee: The employee's welfare is paramount, so make sure the injured employee gets prompt, proper care. At the same time, protect yourself against possible abuses. Confirm that treatment given is directly caused by or related to the workplace injury and verify the necessity of the treatment. Have steps in your plan to determine the need for pre-certification or diagnostic tests and to authorize referrals to specialists, if necessary.
• Case management: Anchor Claims assigns an adjustor to each claim to help the employer through the process. The adjustor may call on an internal nurse case manager for recommendations, and may use medical professionals outside of Anchor for some tasks. If a physician recommends a complex procedure we have the case peer reviewed by other doctors, or get a complete second opinion. Close teamwork between the employer and Anchor Claims is key to success.
• Adjustor oversight: An Anchor Claims adjustor calls the employer as soon as a case is reported, and maintains three-point contact among the employer, employee and the physician. The adjustor monitors compliance to make certain the employee is going for treatment and following guidelines. If on-going care appears likely, the adjustor will establish a reserve with the carrier to cover that contingency. At all times, the adjustor works for proper medical treatment and an early return to work. Getting an employee back on the job as soon as possible, even in a different capacity, is vital to the employee's continued career. Studies consistently show the longer an employee stays out, the less likely he or she is to return.
• Review bills: The Anchor Claims adjustor reviews all bills for validity to make certain the employer is billed only for treatment directly related to the workplace injury. The claims manager also double checks that services being billed came from an employer-authorized provider. Physician peer review may be part of the review process to determine if the treatment billed was reasonable and necessary.
• Bill audit: Finally, the medical bills should be audited to verify the accuracy and validity of charges. Do they comply with usual and customary charges. Are PPO discounts available that go beyond usual, customary and reasonable?
  
   

If you would like a handy, printable claims kit for use as a sales aid, you can download one from our Website now.