Page 8 - PFFW December 2018
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                                         Physicians are asking more than ever before how they can help streamline treatment requests, obtain decision outcomes electronically and more quickly, and provide timely appropriate care for patients.
 should be a part of the evolving health model discussions and early stage planning, especially as health models change.
Evolving claim models
There are significant discussions nationwide around the evolving claims mode. The industry realizes that a need to focus more on the injured worker as
a consumer. The model needs to focus more on advocacy, but what does this really mean? Is this a person who assists the injured worker in understanding the claims process, or is there a need to change the culture of our industry to be less adversarial?
Utilization review
Nationwide, there are industry buzz
and sidebar conversations around utilization review (UR) and the current approach deployed by employers, payers and service providers. Physicians are asking more than ever how they can
help streamline treatment requests, obtain decision outcomes electronically and more quickly, and provide timely appropriate care for patients.
Utilization review should ensure that injured workers receive appropriate care within the right setting and for the correct duration. But what is the right UR model? Should all treatment be subject to UR
or select treatment requests? Is UR a
8 December 2018 - PFFW.org
process strictly addressing the request for treatment and medical documentation submitted against guidelines of care or collaborative with adjusters, providers and the injured workers? Are denials of care driving up litigation unnecessarily? Do UR referral trigger change if the physician providing care is part of a high-performance network or known to be a top performing physician? These are questions being raised by industry veterans and novices and are likely worthy of a review and further dialog.
In our consumer-driven health world, there is greater interest from injured workers to understand treatment options and outcomes. If not a part of UR, is your case management or claim model providing medical treatment option education, inclusive of outcomes awareness? Transparency is becoming increasingly important to consumers
Bureaucracy
Workers compensation is one of the most highly regulated lines of insurance, and regulators are increasingly aggressive in pursuing fines and penalties. Every form filed, and every payment transaction is an opportunity for a penalty. Electronic data interchange allows regulators to automate fines and penalties. Some states perform retrospective audits on activity 5–10 years old. The independent medical review process in some states add administrative cost to claims without
necessarily improving outcomes, and states with self-imposed penalties may be driving up the cost of doing business beyond the benefit of the penalty payment. Lobbying is becoming an increasingly important area for payers and service providers to consider.
The significant costs associated with the bureaucracy of workers compensation regulations are not improving the outcomes on claims. Most of the money collected from the fines and penalties is paid to the states. The programs may cover the operating costs of the state workers compensation division and not go to pay the injured worker or medical provider.
The PFFW is committed to being vigilant on these topics. Our focus is on finding ways to enhance our membership’s rights under workers comp. We are also committed to find ways to make sure health care is affordable to all. And, we will work with legislators to bring forward our difficulties with our presumptive laws.
If any of our membership is experiencing problems in these areas, please contact the PFFW office, 608-251-5832. The PFFW leadership continues to investigate ways to help our membership. We continue to work with all our legal partners to develop protections for each of us. Stay strong Brothers and Sisters, we will carry on the fight. f
 














































































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