Medical Management & Cost Containment
The Trust provides both Claims Administration and Managed Care Services. Our Wallingford office is designed to maximize communication between the Claims and Managed Care staff.
Medical Care Plan– owned by the Trust since 1995
The Trust has had an approved medical care plan since January 1995. The plan was filed under the name of The Connecticut Hospital Association Workers’ Compensation Trust. Since that time, the Trust has created an approved medical care plan for over 500 employers.
In order to establish these plans, the Trust works with organizations to provide education and training to both managers and employees. A customized employee brochure is distributed to each employee, outlining his or her rights and responsibilities. A poster is provided for each work area, so that current information is always available. Training sessions are held for management staff. The Trust will provide these services to your organization at no additional charge.
Medical Provider Network – owned by the Trust since 1995
One of the most important components of our Managed Care Program is the preferred provider network. This network guarantees high quality and prompt medical treatment. The network has been in existence since January 1, 1995 and is contracted directly by the Trust.
When immediate medical care is provided to the injured worker, he or she is likely to remain with the employer’s choice of provider. This ensures continuity of care along with a focus on return to work.
The Trust’s Provider Network consists of over 700 physicians/providers statewide in the following specialties:
The providers were invited by the Trust to join the program for their:
- ability to provide quality care
- understanding of workers’ compensation law
- understanding of the value of early return to work
The provider network is specific to workers’ compensation and not a carve out of a Group Health Network. Instead, providers were hand selected by the Trust based on our prior experience and knowledge of their ability to provide quality medical care and understand the value of early return to work. The providers are contracted directly through the Trust.
Should an injured worker require treatment beyond a general medical practitioner, the First Treatment Center physician refers to a specialist in the Preferred Provider Network. All members of the network refer only to others in the network.
It has been our experience in using this model that when immediate, assured medical treatment is given, and return to work is available in some capacity, lost time from work is minimized or eliminated. Communication with all parties in a timely manner can be the key to this success.
The providers are paid based on the Workers’ Compensation Commission Fee Schedule or other negotiated rates. Physicians are added when we see a need. We have attempted to keep the network as small as possible in order to maximize management controls over the end result. A physician is removed from the network when it has been determined that he/she is unable to meet the plan’s objectives, expectations, or fails to meet workers’ compensation statutory requirements.
The network is fully credentialed. Credentialing is based on a combination of the NCQA and
Nurse Case Management – our own staff since 1995
The Trust’s nurse case managers provide both telephonic and on-site services aimed at ensuring quality medical care while containing claim costs, in an effort to assist the injured worker in reaching maximum medical improvement and returning to gainful employment.
The nurse case manager coordinates medical and rehabilitation services for injured workers receiving workers’ compensation benefits. Cases are referred to the nurse case manager at any time during the claim. A nurse is available 24 hours per day.
Cases are referred for a variety of reasons. The following are some examples:
- Poor, inappropriate or ineffective treatment is evident
- Lack of medical progress exists
- Pre-existing condition is complicating the work-related injury
- Prolonged disability
- Case involves hospitalization
- Heart & Hypertension claims
Telephone contact is made with the injured worker within 24 hours of referral. At that time, the following information is gathered:
- Past and present medical information
- Future handling plans
- Family/social issues
- Vocational and employer information
Contact is then made with the treating provider and employer. The information gathered is noted in the computer system and is available via on-line access. Information and progress is shared with the claims team at a weekly meeting to ensure an ongoing effort directed at early return to work.
The Case Manager, in coordination with the Claims Adjuster, will be responsible for encouraging a light-duty clearance with appropriate restrictions from the treating physician. This clearance will be communicated to your organization to determine placement.
The Trust, with the assistance of your organization, will develop and coordinate a customized Return-to-Work Program for injured workers. The development and coordination of a Return-to-Work Program is included in our fees.
Pre-Certification / Utilization Review – owned by the Trust since 1995
The managed care program provides Pre-Certification/Utilization Review services. This program provides a reduction in medical cost by managing such medical services as hospital stays, treatment plans, and other procedures. The Trust is licensed by the State of Connecticut to provide Utilization Review.
We recommend pre-certification be required on at least the following services:
- Physical Therapy
- Chiropractic Care
- Surgery (inpatient or outpatient)
- Formalized Pain Management
We require all chiropractic practitioners and physical therapists to present, within two weeks, a written treatment plan that highlights the following:
- Treatment modalities
- Treatment timeframes
- Return-to-work dates (if applicable)
A nurse reviews this treatment plan for conformity with standard treatment protocols which have been approved by The Connecticut Department of Insurance, and are specifically designed for workers’ compensation injuries. They are pre-loaded in our Pyramid system and are accessed by our Managed Care staff, which consists of 1.5 employees.
Providers are aware of our pre-certification requirements. Request for treatment and/or services are called into the Managed Care Unit. The nurse reviews the medical reports and contacts the provider for information, as well as verifies eligibility with the adjuster. All approvals and denials are communicated in accordance with standard utilization review procedures.
All pre-certification information is documented within the Pyramid claims/managed care computer system. As bills are presented to be paid, they are verified against the pre-certification documentation to ensure prior approval of treatment.
Medical Bill Review – Trust staff performs all activities using specialized software
The Trust’s medical bill review uses sophisticated computer software that allows us to reduce bills to the State Fee Schedule, reasonable and customary rates or any other negotiated rates. In additional, the Trust has a professional coder on staff who reviews all bills for up-coding and for those bills that fall out of the normal range. There are currently 3 employees in the Bill Review area.
Medical Bill processing:
- verifies the completeness and accuracy of incoming bills for services rendered
- checks for appropriate levels of treatment/services based upon diagnosis and severity
- indicates the appropriate amount of payment
- identifies duplications of bills
- records appropriate information necessary to manage the provider network
- generates anticipated savings of approximately 40%
Hospital / ASC Facility Bill Auditing – Performed by Fairpay Solutions
The Trust screens all hospital bills to eliminate improper charges. Large hospital bills have an additional level of screening which reviews all the detailed charges and compares them to the medical chart. Bills are reviewed for:
- reasonable and customary charges
- billing errors
- unbundling and up-coding
- unreasonable or unrelated amount
Price Management Networks – contracted with the Trust since 2000
The Trust maintains relationships with a number of Price Management Networks that offer substantial savings on services such as complex medical imaging studies and durable medical equipment.
Prescription Drug Program – MSC / ExpressScripts since 2005
The Trust has a fully operational prescription drug program. This program is based on a statewide network of pharmacies which include the major chains as well as independent pharmacies.
The Trust’s Workers' Compensation Prescription Program is a uniquely designed program for reducing the prescription drug costs associated with workers' compensation claims. In addition to saving money on prescription costs, the program's reporting features allows for comprehensive reports on workers' compensation drug costs and usage.
The program is very simple to use. When an employee is injured, he or she receives a prescription drug card that gives them temporary access to the network of pharmacies. By presenting the card at the pharmacy, they receive their medication without cost or claims to fill out for reimbursement. This paperless transaction encourages the employee to fill their prescriptions at a participating pharmacy. The pharmacist queries out of an electronic data system. Eligibility and limitations are immediately identified; including a restricted formulary that includes only prescriptions most likely associated with workers' compensation injuries. The claim is verified and entered into the data system.
The Trust’s Workers' Compensation Prescription Program results in:
- Extensive savings of pharmaceutical costs
- Elimination of out-of-pocket expenses to the injured worker
- Review and flagging of over-utilization and incorrect usage of drugs
- Claims staff having on-line and real time access to injured worker’s prescription
Medical Director – contracted since 1995
The Trust’s Medical Director is Dr. Mark Russi, a board certified occupational health provider employed by Yale New Haven Hospital, provides another level of medical knowledge to our staff.
Vice President, Quality & Provider Relations – since 1994
The Trust has established a unique full time position that is solely responsible for managing the network and the oversight of the medical cost containment programs. Assisting this position is a utilization review assistant, a clinical utilization nurse, a professional coding professional and two medical bill processors.