Regulations and red tape are inherent in the workers’ compensation industry. When asking providers who treat occupational injuries and illness how they feel about the workers’ compensation system, they shared a common sentiment: a disdain for the workers’ comp system and process.
To better understand their perspective, we decided to walk a mile in their shoes. After all, treating providers are essential in successfully returning an injured worker to work, restoring their quality of life and reducing costs for the payors in workers’ compensation.
When probing, here is what we learned from providers:
- The work comp process is overly complicated.
- The time required to work through the work comp system is time consuming.
- Control is taken away from the treating provider.
- The work comp process requires more time on the phone, filling out paperwork and the reimbursement rates don’t justify the additional work.
- The payment process is burdensome and requires hand holding to get paid for treatment, even when approved and the process was appropriately followed.
At EK Health, we recognize the benefit of empowering medical professionals to do their job with as little friction as possible. We have designed our utilization review solutions to promote provider advocacy. In the same way we advocate for the injured worker to receive the medical care they need, we advocate for the provider to be free to deliver necessary care as quickly and simply as possible.
Based on over 20 years of industry experience, we have learned to assemble all the pieces like a workers’ comp jigsaw puzzle. Knowing the end result, we lay the foundation first, by starting with the regulatory components that dictate the law and process. In the same way a puzzle is assembled from the outside border inward, beginning with a regulatory framework ensures compliance and optimal performance. By working methodically with all the pieces and finding the right intersection points, we provide a clear path for payors and providers alike to the end result – a full picture of recovery and return to work for injured workers. We leverage our regulatory expertise and occupational health experience to help optimize providers’ experience in treating workers’ comp patients.
Provider Advocacy in Utilization Review at EK Health
Long ago we saw the need to recognize provider disturbance and the various “pain points” providers experience in treating occupational injuries and illness. We then attempted to mitigate those pain points with a more efficient process that reduces friction.
At the root of most pain points for treaters is the reality that so much of the process is heavily regulated and cumbersome. In our experience, the vast majority of doctors who choose not to participate do so because the rules are so complex and they lack time to keep up with the ever-changing protocols. As they prioritize patients over paperwork, a quality provider is focused on two things – what their patient is experiencing and how to make it better. They do not have time to sit on the phone to discuss a treatment request with a URO and they certainly don’t have to time to submit and re-submit paperwork over and over to get the approval they need so the patient can recover and the provider can be paid.
How do we help?
- We actively teach doctors how to properly document treatment requests and reports to objectively reflect pain level and recovery progression to demonstrate functional improvement.
- We take time to explain the benefit of the UR process in terms of establishing treatment according to nationally recognized evidence-based medicine guidelines.
- When provider request treatment that falls outside of guidelines, we take the time to reach out, have a conversation to determine if there is just cause for the treatment and discuss the treating provider’s perspective pertaining to the treatment path.
- Our first level utilization reviewers save the provider time by creating a records summary that lays everything out for them for a more expedient and informed conversation regarding treatment determinations, when follow-up is warranted.
- Our in-house counsel reviews regulations as they change to accurately interpret them and prevent treatment delays. We share these findings and updates with our provider community, helping them stay abreast of legislative requirements and changes, so they do not have to seek out the information on their own.
- We expedite provider payment by shortening bill review turnaround times, promoting provider compliance in an attempt to limit the back-end friction for providers’ administrative staff. This reinforces our commitment to efficiency for the provider community.
- We strategically leverage automation and intelligent design to efficiently integrate processes, which limits providers’ need for multiple validation points.
- Our Medical Director, a board-certified physician, is actively involved; and our utilization review leadership is comprised of clinicians with experience navigating the workers’ comp process. We are intentional to invite real-world experience into our mission to solve problems for the provider community.
Everybody Wins
In our experience, the focus on provider compliance and efficiency has a mutual benefit for all parties involved. The patient gets the care they need, the provider gets paid for their services timely and fairly, and the process is allowed to exist for the purpose of the desired intent – control, and accountability is established for the benefit of payors. At the end of the day, we all want the same thing, including the provider – for injured workers to get the care they need to recover quickly and to safely return to work. When that is the goal, and consideration for all aspects of the process and involved parties is realized, the workers’ comp jigsaw puzzle falls more easily into place.
As the puzzle’s picture becomes clear, everyone feels satisfied the end result. When all the pieces come together as designed, the view from all sides is sharper, clearer and able to be appreciated. At EK Health, we are striving toward the ultimate – a world in which providers choose to co-exist in a mutually beneficial process. Sometimes the work exists in explaining the benefit, sharpening the benefit and building the benefit. That is our role. To transform managed care with everyone in mind!
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