In addition to my focus on work comp medical management I’m deeply involved in governmental programs (Medicare/Medicaid/dual eligibles) and related businesses.

Here’s a few things work comp would do well to understand/explore/pursue.

1. Auto-adjudication of medical bills – the standard target for auto-adjudication of medical bills is 90%.  That’s far higher than any workers’ comp bill process, and about twice as high as the average.
2. Medical bill turn-around time (TAT) – average is at or below 20 days from receipt of complete “claim” (defined as a medical bill and needed documentation)
3. Administrative expense ratio – <10%. yes, I understand work comp is a lot more litigious, blah blah blah. But seriously – 28-35%??
4. Value-based care – is taking over the big governmental programs and corporate plans as well. Yes there have been a ton of misjudgments, errors, problems and failures, but make no mistake – in the near future VBC will be the dominant form of contracting and basis for reimbursement. (those who declare VBC isn’t going to happen in work comp may want to look outside their bubble)
5. The impact of provider consolidation – this is one area where recent articles/briefs/research are starting to scratch the surface – but only just. Reality is consolidated markets are much more expensive and WC payers have way less ability to “manage” care in those markets. WC needs to get a whole lot smarter and more agile.

Whether this actually happens is up in the air. We veterans with decades in this business recall all too well what happens to claim counts/claimdurations when recessions hit.

What does this mean for you?

This is rarely helpful.

CMS – aka Medicare – has published details on the pending cut to physician reimbursement and some physician groups are howling.  The cuts aren’t uniform; Any changes to the fee schedule done via rulemaking must be budget neutral; if some payments go up, others must go down.

Overall reimbursement is slated to drop by about 4%.

Surgery and radiology are two of the specialties especially vocal about the changes, which MAY be altered or retracted if Congress passes a law revising the reimbursement change.

(Details on this are here…)

A couple other things of note…

• Of interest to workers’ comp are new codes (CQ and CO) and payment for services rendered by PTAs and OTAs supervised by PTs and OTs at 85% of the PT/OT rate. there are modifiers and time requirements, so make sure your BR entity has got this coded correctly.
• The CPT Codebook listing of bundled services are not separately payable.  I’d note that this is NOT universally understood by work comp bill review entities; yes it is complicated and yes it changes, so payers would be well-advised to make darn sure they are handling these bills correctly.
• Critical care services may be paid separately in addition to a procedure with a global surgical period if the critical care is unrelated to the surgical procedure. Again, this is why reviewing provider notes is key, because facilities/practices often bill these separately in the hope that the payer won’t catch the “unrelatedness” issue. Separately, a denial of payment for critical care services should NOT result in an additional fee to the payer; that is basic bill review – or should be. Also, watch out for PPO fees attached to those separate charges – BR and PPO companies make money on those “reductions” while they DON’T make more $$ on just denying the critical care service as part of a code review.

So, what does this mean/what are the implications?

Watch out for creative billing/increased utilization as providers look to make up for lost revenue/lower reimbursement from Medicare and Medicaid.

Ensure that A)  your bill review program is prepared to handle these changes and B) you aren’t paying extra for that “management.”

(for more on the issue of how Sequestration effects reimbursement, go here.)

Is going to be a lot clearer when Congress finishes work on the Connect for Health Act.

The bill has Bipartisan backing from 57 Senators, and would:

• permanently remove geographic restrictions on telehealth,
• allow patients to do visits from their homes and
• grant the Secretary of HHS permanent authority to waive telehealth restrictions.

It is possible a competing bill  – which would only temporarily extend telehealth waivers – will be passed instead of the Connect for Health Act. Regardless, it’s clear telehealth is going to be a major part of US healthcare going forward.

Emergency regulations that lifted restrictions on telehealth are likely to extend thru the end of this year; these were a response to COVID.

One key issue is whether phone calls will “count” as telehealth, a change that would certainly expand the availability of these services, as even today many patients don’t have access to reliable internet and/or a video-connected device.

One likely change is reimbursement; expect Congress/HHS to reduce reimbursement for telehealth visits.

Impact…

I’d expect most workers’ comp fee schedules to follow Medicare’s lead – even those that aren’t directly tied to Medicare.

What does this mean for you?

When Medicare does something, everyone else soon follows.