Setting Medical Expectations presented by Aimee AbergTraining Coordinator

Setting Medical Expectations presented by Aimee Aberg-Training Coordinator

Objectives • • • The participant will be able to answer: • • • What is our billing expectation? What is a medical expectation? How will setting medical expectations improve medical outcomes? What is the medical expectation for DWC 25’s? What is the medical expectation for physician dispensing of medication? Why don’t we want the physician to dispense medication and how do I answer dispensing questions from the provider? How do I handle DME orders? How do I handle Physical therapy referrals? What should I expect from our business partners? When should I use QA Medical Management?

What Are Expectations? Setting expectations with someone is about communicating and helping that person to understand what the expectations are and how those expectations can be met.

Setting Medical Expectations with the provider Medical Expectations should be set with the provider at the time the appointment is being scheduled. This will enhance our relationship with the provider and avoid misunderstandings. Communicating the roles/responsibilities of each party is extremely important for a successful claim outcome.

Setting Medical Expectations Communicate to the provider our expectations and the extent of our authorization We need to communicate to the provider: The importance of receiving the DWC 25 timely The extent of our authorization-ie: what body part/ eval/treat/IME/limited authorizations Our position on dispensing medications How we want to be billed and when to expect payment Notes must be attached to bills in order for payment to process How we handle DME/therapy orders etc TIP: Sharing expectations is particularly important when a provider does not normally take workers’ compensation

Setting Medical Expectations The DWC 25 We need the DWC 25 in order to: Authorize treatment as quickly as possible to avoid delays in recovery Return the injured worker to work safely within his/her restrictions Provide TTD benefits and file the NOI timely We share the same goal as the injured worker, employer, and physician. Return the injured worker to their pre-injury status as quickly as possible. Delay in receiving the DWC 25 will delay that goal.

Setting Medical Expectations Dispensing When scheduling the initial appointment ask the provider if they dispense medications in their office. If they do, let them know that we would prefer they not dispense from their office and to flag the chart do not dispense. Explain why we do not want them to dispense If they insist on dispensing advise QA Medical Management

Why not allow the doctor to dispense medications ? What is the importance of using our Pharmacy Benefit Manager? It’s about the data…. . It is important the provider not dispense medications for the safety of the injured worker. Our PBM receives pharmacy data as long as medications are filled by a pharmacy. This data includes: High dosages Multiple prescribers ordering the same or similar medications Concerning drug combinations Treatment durations- has the patient been on the medication longer than recommended ? Our PBM does not have access to E-Force so it is imperative that medications be processed through our PBM, Health. Esystems , to ensure they have the medication data. Cost savings are realized by using our PBM but this is not the main reason for asking a provider not to dispense.

The importance of using our Pharmacy Benefit Manager Better patient outcomes When our PBM identifies areas of concern they may: Send letters to the ordering physicians about the concern Recommend an IPE plus to Johns Eastern Send letters requesting generic over brand name for cost savings Report to Johns Eastern concerning trends Utilize other letters to providers as indicated on a case by case basis The safety of the injured worker is of upmost importance ! Data insures Safety!

Setting Medical Expectations How to bill us The provider may submit their bill by mail, wcfax@johnseastern. com , or regular fax. In order to ensure prompt payment the provider must attach the notes to the bill. If faxing, each patient should be faxed separately. We normally pay within 30 days but by law we have 45 days to issue payment. The date of injury should always be on the bills along with the claim number.

Setting Medical Expectations handling DME Generally we do not authorize providers to dispense DME from their office. We have partnered with DME providers for this service. If the DME is required before the patient leaves the appointment we may ask the provider to bill the DME through one of our DME partners (most practices are able to do this). In many cases the injured worker does not have an immediate need for the DME. In those cases we may provide the RX to our business partner to fill and mail to the injured worker. Our business partner is able to request the RX from the physician if we do not have it. An RX is required before DME can be provided.

Current DME Partners include: Orchid Medical Optum (PMSI) Carlisle Medical EZ Health Care H-Wave Review your business partner handout for all approved partners TIP: Use business partners for approved services only

Handling Questionable DME When do I ask about Medical Necessity? When there is any doubt that the DME is related or due to the injury

Setting Medical Expectations Handling Physical Therapy orders SPNet is our exclusive Therapy network We do not authorize a physician to do therapy in their practice. Explain to the provider that all therapy orders are authorized through our exclusive therapy network, SPNet is able to obtain the RX from the provider if necessary and they will schedule therapy with the patient directly Always authorize the lower side of what is being ordered Ex: Dr orders therapy 3 times a week for 4 -6 weeks. Our authorization should be for 3 times a week for 4 wks. SPNet will contact you if the additional 2 weeks are needed. Tip: Some of our clients do not participate with SPNet… Know your client !

Business Partners What should I expect from them? In short, we expect business partners to provide service and savings to our clients and Johns Eastern. Agreements with business partners include their rates and service expectations. Business partners should not ask you for authorization above our contracted rate with exception of specialty Doctor or Dental services. If this should happen the adjuster/NCM should: 1. check with other partners to see if they are able to provide the item. Remember: Not all partners are contracted with the same facilities. 2. Forward any correspondence from our business partner asking you to approve rates to Medical Management. TIPS: Adjusters/Nurses should avoid using only one partner for a service. Partners should only be authorized for the service they are approved to provide us. Our business Partner panel should not be shared with anyone outside of Johns Eastern

Internal Expectations Working with QA Medical Management Johns Eastern’s QA Medical Management Dept. works directly with medical providers and our business partners to resolve issues as they come up It is important that the adjuster and/or nurse know when to involve QA Medical Management

When should I expect to receive help from QA Medical Management? Any issues with a medical provider such as: Slow to provide notes or respond to letters Higher than expected PIR’s When a provider is dispensing medications, ordering expensive drugs or topicals and/or compound drugs. Issues/concerns with field case managers If you feel the provider needs training on workers’ compensation When a client wants to add or delete a provider from their carve-out network When you are asked to sign a letter of agreement. Medical Management must review all letters of agreement. (copies of prior approved agreements may be found in the Bradenton WC folder). Issues or concerns with one of our business partners When you want to negotiate pricing down When an excess carrier wants us to use a provider not on our business panel. These situations should be brought to the attention of Medical Management If you are not sure…. Ask

Questions ? ? ? ?