Workers' comp cases without utilization review
Insurance overview replaced with aggressive pace
Occupational health nurses in Louisiana play a critical role in a network approach to handling workers' compensation claims, keeping the method's aggressive pace going.
Louisiana's statewide network, Omnet Gold, coordinates each phase of treatment in workers' comp cases, with the cases overseen by physicians specializing in occupational medicine and the physical demands of work. Managing injured workers with this specialized network of health care providers-without third-party utilization review-has reduced missed work days and lowered health care costs in the state, according to a published study of the approach.1
After several studies suggested that specialized health care networks could lower costs and disability in workers' compensation cases, Omnet Gold was created to see if such a network could produce similar savings on a statewide basis. Under the Omnet Gold approach, network health care providers are free to make diagnostic and treatment decisions without utilization review by the state workers' compensation insurance company. According to the study authors, the outcomes of 176 cases managed in the Omnet Gold network were compared with 1,464 cases managed in the traditional way, including utilization review.
Claims managed by Omnet Gold were associated with significantly less missed work time than cases managed in the traditional way, the authors found. The average number of missed work days was 53 for workers managed in the network, compared to 99 days for traditionally managed claims.
"Nurses are monitoring cases in all our lost-time cases," says Larry Yuspeh, director of research for the Louisiana Workers Compensation Corporation and one of the authors of the study. "The pace of the Omnet Gold method is aggressive, and occupational health nurses help ensure we keep up that pace."
The fast pace, Yuspeh says, helps ensure lost time cases are monitored intently and treatment does not lag.
"Utilization review seems to have little impact on the behavior of experienced healthcare providers pre-selected for their ability to appropriately treat and manage workers' compensation cases," the authors of the study wrote. With their experience and expertise in treating injured workers, occupational health specialists appear to be able to reduce patient disability, using fewer medical resources, without insurance company oversight, they conclude.
"We remove utilization review and rely on [occupational medicine specialists'] judgment, and if you have good practitioners, it works fine," says Yuspeh.
Yuspeh and his co-authors report the costs of care were lower for claims managed in the network than those handled via utilization review — about $12,500, compared with $20,400 for traditional claims. Average costs for medical care were $3,995 with Omnet Gold versus $9,850 for traditional care.
1. Bernacki E, et al. An investigation of the effects of a healthcare provider network on costs and lost time in workers' compensation. J Occup Environ Med. 2006;48:873-882.
Larry Yuspeh, director of research and development, Louisiana Workers Compensation Corporation. Phone: (225) 231-0715.