Medical Provider Networks (MPNs) have recently received negative publicity for leaving a bad taste in the mouths of employers and employees, often being seen as mere provider discounting mechanisms or profit centers. However, EK Health, a leading managed care company, firmly believes that a properly formulated MPN goes far beyond cost-saving measures. Their “secret sauce,” outcomes-based approach hinges on high-quality providers who are carefully vetted and credentialed and proper management of guidelines. By ensuring understanding and adherence to the expectations of the MPN and the employers, trust is built and accuracy is promoted across the board – providing value for all, most importantly, for the injured worker.
Prepping the Essentials
“The basic recipe for success is that MPNs should not be your typical large, unmanned, discounted networks; they should be hand-crafted, custom-built networks that prioritize value and quality,” stated Dr. Douglas Benner, EK Health’s Chief Medical Officer. “For instance, the providers in our network are specifically nominated by EK Health’s trusted clients who have first-hand experience with their expertise in workers’ compensation and receive positive feedback. This ensures that the right providers are in the right areas, offering the right care to injured workers at the right time.”
EK Health’s MPNs are developed over several years with providers that agree to the specific performance metrics and expectations. EK Health regularly evaluates providers’ performance and ensures appropriate payment for performing providers. This helps strike the ideal balance between access to care and the quality of services provided. “We manage providers via back-end data, reporting, and metrics from utilization review and bill review, as well as through issues/complaints raised by patients and claims adjusters. With this information, we can identify potential problems and opportunities to engage and counsel providers. We remove providers from the MPN for repeated offenses, including when they do not uphold our standards. Continuous monitoring of providers for any state or federal license actions, malpractice payments, or adverse clinical privilege action keeps information accurate with accountabilities and verification,” stated Robyn Calvetti, Provider Network and Provider Relations Manager for EK Health.
Infusing Guidelines and Creating Controlled Environments
Lack of governance outside of MPNs can lead to delays in treatment and create frustration for injured workers. EK Health addresses this issue by filling its MPNs with specialty doctors that have a genuine interest in working in the workers’ compensation sector. By not requiring provider discounts, this model actively promotes trust and accuracy, while ensuring smooth and streamlined processes for both providers and patients and removing some of the back-end friction providers face in workers’ compensation. Treating inside a quality MPN ensures that participating providers understand workers’ compensation and billing/reporting requirements, and have a clear path for making specialty referrals within the MPN, as needed.
“The impact of not having an MPN in California is the employer’s lack of medical control. That, in and of itself, can lead to confusion and an absence of direction on where employees can go for treatment,” stated Kerri Wilson, EK Health’s President & Chief Operating Officer. “To further enhance communication and relationship-building within the MPNs, we actively communicate directly with our network doctors, providing them with information about new clients and their specific needs. This facilitates better care provision and understanding of the expectations throughout treatment. ”
While ensuring compliance with regulations and guidelines can be missing in some networks, EK Health has targeted the extreme benefits of their inclusion. Wilson continued, “Infusing guidelines is such an important aspect of MPN management. Using data from utilization review (UR) and bill review (BR) we can see which providers are treating within the expected guidelines and transparently examine the appropriateness of treatment requests and billing practices. This not only keeps people honest, it also helps to educate providers on ever-changing guidelines and improves practices that are not meeting the established expectations of our network.”
By adopting this mentality and these practices early on, before it was mandated, EK Health not only had a well-oiled MPN in progress, they were also able to be the first approved MPN under the designation of an ‘entity that provides physician network services’ once it was allowed due to their adherence to the guidelines and regulations.
Adding a Dash of Excellence and Quality (EK Health’s Approach)
“Our MPNs are built to achieve better overall outcomes – that means a whole lot more than just savings – it means better treatment outcomes, better claim outcomes, and better bottom-line outcomes,” Wilson stated. “Quality treatment done quickly and efficiently is more cost-effective than traditional networks can deliver. Empowering injured workers and providers is an essential ingredient for proper treatment, payment and claims management.” An example of this empowerment is the early and swift implementation of MPN Medical Access Assistants (MAAs). These assistants play a crucial role in supporting injured workers and their advocates by helping find appropriate providers for treatment needs. They also ensure that directories are kept up-to-date and facilitate the scheduling of appointments and record sharing. “Our MAAs go above and beyond for the injured worker. They will call ahead to make sure that appointments are available, advise of unique patients’ needs, make appointments, and send records when permitted. Their purpose is to help. Their goal is to see the injured worker have improved quality of life,” Wilson explained.
Going the extra mile to enhance convenience for injured workers is what this industry should be striving towards. We can do this by investing in robust programs, transparent networks, and integrated claims management systems. By implementing these types of custom options swiftly, we ensure coverage access and expedited treatment. Combining these efforts smooths the process for injured workers to have access to quality care when they need it the most.
A successful approach to MPNs emphasizes the importance of access and quality care. By focusing on great outcomes through high-quality providers, careful vetting, and clear communication, EK Health has seasoned success in managing MPNs. This has resulted in reductions in billed and paid claim charges, decreases in duplicates and recons, and overall satisfaction of providers with their reimbursements. Now, that is a dish we would all want a second serving of.
This is a sponsored post from WorkCompWire marketing partner EK Health.