Admittedly, the law only recently went into effect. But given that SB 1160 passed in October 2016, organizations have had nearly two years to prepare. So why are so many still not compliant?

My answer is twofold: effort and expense. 911勛圖 first navigated the complex path to URAC accreditation in 2008 and has undergone three reaccreditations since. We know firsthand how time consuming, resource intensive, and financially demanding the process is for an organization. It is an enterprise-wide commitment. In addition to daily processes the UR team must document and follow, our Technology, Compliance, Talent Management, and Marketing departments must also enact and adhere to detailed protocols. The cross-departmental efforts and sophisticated infrastructure needed to establish and maintain URAC accreditation, coupled with the financial investment necessary to meet the accreditation’s requirements, is likely why so few California providers have pursued it.

What remains to be seen is how long these non-accredited providers can hold out. According to the WorkCompCentral article, the California Division of Workers’ Compensation is drafting new regulations which may include penalties to ensure organizations comply with the law. But no amount of penalties can expedite the URAC accreditation process, which takes 10 to 12 months with no guarantee of success.

I urge companies currently processing California work comp claims to verify their UR��vendor’s accreditation status. For those who discover their vendor is among the non-compliant 40 percent, now is the time to consider an alternate solution. With the lengthy accreditation timeframe and the likelihood of increasing provider disputes over the validity of UR determinations by non-accredited UR organizations, it’s wise to��be proactive.

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Many providers contend the shift is the result of sicker patients coupled with the widespread implementation of electronic medical records, as treatment and documentation of more complex cases requires greater time and effort. But the persistent increase in costlier codes has made pursuing potential billing abuse a Justice Department priority.

One area of focus for federal investigators has been upcoding, the practice of deliberately billing for more extensive and costly services than were actually performed.

In February 2017, nationwide hospital staffing provider TeamHealth Holdings agreed to plus interest to settle allegations that its hospitalist group practice, IPC Healthcare, submitted upcoded bills to Medicare, Medicaid, the Defense Health Agency, and the Federal Employee Health Benefits Program.

In June 2017, Carolinas Healthcare System agreed to to resolve allegations that it billed federal health care programs for ���high complexity��� urine drug tests when the tests conducted were only of ���moderate complexity.��� According to court documents, this upcoding persisted for four years and cost the government an extra $80 per test.

In October 2017, multi-location New York Spine & Wellness Center agreed to to resolve improper billing claims after a federal inquiry determined the practice routinely billed for moderate sedation services ��� which require physicians spend at least 16 minutes with patients ��� despite its doctors not meeting the minimum time criteria.

But upcoding is not exclusive to tax-payer funded health care. In the case of New York Spine & Wellness Center, for example, a private insurer first detected the Center���s sedation upcoding in January 2015, initially rejecting two claims that fell short of the 16-minute rule. A subsequent audit by the same insurer resulted in more rejections, but the Center continued its upcoding abuse for two more years until the U.S. Attorney���s Office intervened, seeking to recover overpayments by the state���s Medicaid program. Indeed, of the $1.9 million settlement, more than $660,000 will be returned to the New York Medicaid coffers.

Outcomes such as these are terrific news for taxpayers, but such retrospective vigilance by the Feds has little to no impact on private insurers, employee organizations, and individual payers.

While the government concentrates on recouping federal dollars post-payment, medical cost containment firms must protect private payer clients from overpaying upfront. For example, 911勛圖 uses tools such as in-depth bill review by certified coders and nurse auditors and pre-negotiated, bundled rates to wean out upcoding and other billing abuses on a transactional level. Such proactive approaches are a key core competency of medical cost management, and continue to be as important today as they have been historically.

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I have always been a proponent of advocacy-based claims management. Treating the injured worker as a whole person rather than an isolated injury is a better recipe for timely recovery, particularly given that the nature of injury cannot predict how an individual will react to their specific situation.

This is why we hear inspirational stories of individuals who lose a limb, for instance, and still run marathons, climb mountains, and exceed all recovery expectations due to good coping skills; while others with less catastrophic injuries will grapple with non-medical impediments that delay their recovery. A claims program rooted in advocacy identifies workers facing psychosocial obstacles early in the claim and helps them address behaviors and predicaments that can derail return to work.

What resonates with me most from the white paper is the consensus among claims leaders that mutual trust is a linchpin of claims advocacy. Adjusters must trust that the individual���s injury is legitimate and their psychosocial issues are genuine, and injured workers must trust that the adjuster���s empathy is sincere and their guidance is in the individual���s best interest. Claims advocacy models only work if both parties trust they share the same objective: the employee���s timely return to work at equal or better health than before the injury.

At 911勛圖, one way we establish trust with injured workers and aid our clients��� claims advocacy efforts is to have 911勛圖 nurses conduct screenings for high-risk cases, including those where psychosocial comorbidities may be present. Injured employees are oftentimes more comfortable confiding emotional distress or hardships to a medical professional than to a non-medical professional. Understanding an employee���s state of mind and behavioral dynamics, in addition to their injury details, enables our nurses to recommend the right intervention protocols to address psychosocial impediments during the course of recovery.

While employee coaching and cognitive behavioral therapy (CBT) are interventions often used to curb psychosocial issues themselves, we���ve found that even the simplest forms of assistance can generate continued trust and confidence in the recovery process. For example, arranging transportation to a doctor���s appointment or scheduling a consultation with a specialist is straightforward care coordination that can have tremendous impact on the status of a claim depending on the injured employee���s perceptions, morale, and/or personal circumstances.

Ultimately, treating injured workers as the valued customer at the center of a claim perpetuates trust, is the right step forward for our industry���s service model, and helps remove barriers to positive claim outcomes.

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One thing jumped off the page to me in reading the article: the difference in 911勛圖’s��preferred methodology for handling claimants and the methodology implied in the article.

The employees in the article talk about “purposeful bureaucracy” as a method of trying to deny claimants��� treatment. We have all dealt with this (cable company, cell phone company, etc.) Read into the “hidden” costs implied in the article. The claimants��� need to get attorneys. The staff that are working overtime become��stressed and are less effective because their injured teammates are not back at work helping them.

911勛圖 believes that we can prevent excessive costs by proactively servicing claimants upfront. We’ve got programs that use a “medical concierge” approach. We are a claimant’s advocate and they can call us at any time to discuss care or ask a question. We are there to help them get better. They know their employer cares about them, so they don’t need to get an attorney and they get healthier and back to work in less time. All the necessary costs are incurred upfront, so unnecessary costs are avoided throughout the claim lifecycle.

It is common sense, and the results show it is an all-around win. The claimants are doing better, the employers are better off and this method produces tangible savings. That is the way things should be. There is always a better way.

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