Tag Archives: managed care

A Horror Story on Health Insurance

A few months ago, all I knew about glaucoma was that it was a disease of the eye and, by definition, couldn’t be a good thing. I have been wearing glasses since fifth grade and have been tested for glaucoma every time I got new glasses. I was always told that I had very healthy eyes but was near-sighted — growing up, I didn’t know you were supposed to be able to see the kids across the street, but I could read a book.

I found out the hard way that glaucoma was the leading cause of preventable blindness — and that bit of knowledge was just the start of a disastrous journey through the healthcare and health insurance system.

Think of glaucoma as causing your eyes to act like a kitchen sink whose drain is blocked. In your eyes, IOP (intraocular pressure) can build up from fluids that don’t drain properly, causing permanent optic nerve damage and vision loss. That is why someone invented Drano for kitchen sinks and, luckily, optometrists and ophthalmologists for me.

My introduction to glaucoma came when I stepped on my glasses after they fell off my dresser. Swell. I called my health insurance company to see if I was covered. No problem. And a network optometrist/eye glass store is walking distance away. Everything seemed routine until the eye doctor asked me back to take more tests. Turns out I had a bad reading on the glaucoma test for increased pressure. The normal IOP range is 18-21 (mm Hg). My reading was 24 in both eyes. That can’t be good, I thought.

At that point, I needed to see an ophthalmologist specialist for more testing. I learned that I was at risk for developing glaucoma. Still no problem. There were eye drops I could take, and the eye clinic I needed to go to was also right down the block.

This is where I began to experience the nightmare known as managed care.

I couldn’t get an appointment with the eye specialist without prior authorization from my primary care physician. Two problems: I don’t have a primary care physician, and why should I need “authorization” when a certified optometrist in my network referred me to a network specialist right down the street?

Fine, I thought. It was time to get a primary care physician (PCP) anyway. It took me a week or so to get an appointment with my new PCP. Great guy. He basically says, yes, you ought to get your eyes checked out. Now, after this delay, I have to wait a month before I can get an appointment with the specialist for further testing. I am not a happy camper. I have researched glaucoma at this point and found out this isn’t good.

I finally got a thorough eye examination and multiple tests with all the latest technology. I was told the eye specialist wanted to see me in a private examination room. I couldn’t help but notice that all the staff technicians who tested me were in the room. One of them wouldn’t look at me. I saw the equivalent of an MRI of my eyeballs. Where my right eye ball should be all white, it was mostly blackish grey. Severe glaucoma, advanced stage. I had already lost 50% of the use of my right eye and 10% of my left eye. The damage is irreversible, and there is no cure. Scared the wits out of me.

I just took early retirement and was looking forward to enjoying the summer. I am in great health. I work out six days a week. I don’t take any medications and haven’t needed to see a doctor in years. I feel great. But the doctor wanted to do laser eye surgery immediately on my right eye, so, okay, let’s have the surgery now.

Guess what? I am told I need to have the laser surgery pre-authorized, and that will take another month. In the meantime, I get a prescription for eye drops. What’s your pharmacy? I don’t have one, remember? I don’t take any medications.

See also: 5 Apps That May Transform Healthcare

I get my eye drops and immediately get mad. Why do I have to wait for pre-authorization? My specialist, who I just got referred to by my new PCP, says I need laser-eye surgery today.

I began my career designing health benefit programs 35 years ago. I spent my entire career in the employee benefits consulting industry. I know health benefits like Lebron James knows basketball. I call the 800# on my benefit card and ask to speak to a patient advocate and ask for a reason. This requirement for pre-authorization can’t be right.

Staying calm, I explained the basic fact: Without laser surgery and prescription eye drops, I will go blind. It’s that simple. (The good news is that my doctor says laser eye surgery is successful 80% of the time. There is no cure, but the laser can basically try to open the clocked drain in my eyes.)

I set up a three-way call with my health insurance company and the eye specialist’s office to see if I can speed up the pre-authorization process. I make great progress. My patient advocate explains that the health insurer can pre-authorize the laser eye surgery within three to five days if my specialist states it is urgent, and he has said the need is urgent.

But I get a call back from the specialist’s office. I have to make another appointment with my PCP to get the laser surgery pre-authorized. I couldn’t believe it. I just waited a month to have the glaucoma testing pre-authorized. Now I have to go through the process again?

I get in to see my PCP the next day. He completes a patient history and physical and approves the need for laser eye surgery both in writing and in the health insurer’s computer data base. I immediately hand deliver the pre-authorization letter to the eye specialist’s office with instructions to fax it to the insurer’s UR/Pre-Certification department. This a now a done deal, right?

After receiving no word for a week, I decide to call. No pre-authorization has been requested or approved. Even though I had hand delivered the pre-authorization report a week before, the insurer tells me: “Never got it. Besides, that is not what we needed.” I am told a much simpler pre-authorization request, similar to a RX script, is all that is required.

I’m now six weeks into this, but at least I now have someone who knows how to handle the process. He assured me that my PCP’s office would be contacted within 24 hours to get pre-authorization (for the third time). Sure enough, the next day I get the call back: I am pre-authorized for both eyes.

I asked why pre-authorization took so long. The answer floored me: “No pre-authorization was actually required in the first place because your eye specialist was already in your network.”

Great managed care communications. The actual reason it took so long to get prior authorization for my in-office laser eye surgery was because I didn’t need it in the first place!

This is not what I had in mind when I designed the first second surgical opinion programs in the employee benefits health industry.

See also: Is Transparency the Answer in Healthcare?  

With both laser eye surgeries scheduled, I began using the eye drops every morning as prescribed, one drop in each eye. The problem was that putting drops in my eye was new to me. My natural reaction is not to put anything in my eyes, so half the time the drops ended up on my cheek instead of in my eyes. My prescription was just a little bottle, with drops that were supposed to be a 31-day supply. On day 21, still awaiting laser eye surgery, I ran out of drops.

I called the pharmacy, which said I couldn’t get more drops for 10 days. The pharmacist asked: “What are you doing with the drops?” Like I am selling them on the black market or something. I replied: “I put them in my eyes, but I miss a lot.”

The pharmacy called back to say my health insurer still wouldn’t cover the prescription, but they only cost $3.99; could I pay cash? Quickest $3.99 I ever spent.

Can you imagine? The health insurer would prefer I go blind rather than spend $3.99 10 days sooner than expected.

The Glaucoma Research Foundation and my eye specialist went out of their way to state how important it is for me to use the drops every day without fail for the rest of my life and to always have an extra bottle handy. Try telling that to my health insurer.

Now the good news. I had laser eye surgery in both eyes, and I have a spare bottle of eye drops — but don’t tell anybody at the pre-authorization department that I am self–insuring my spare bottle.

More good news. Although my peripheral vision in my right eye is shot, I can see straight ahead just fine for now. I will likely need to have laser eye surgery every 90 days on both eyes, one at a time, and use eye drops every day to keep my glaucoma in check and save my vision. (Before Obamacare, I may have been told: You have a pre-existing condition; too bad, but you are not covered.)

The Moral of the Story

The moral of the story is to get your eyes checked for glaucoma. It’s simple and painless and not just for people who wear glasses. Anyone who has had a head concussion (which I decided was the root of my problem) should also have their eyes checked on a regular basis for several years. There are no real symptoms in early stages, and you don’t feel the increased pressure in your eyes. There are millions of nerve fibers that run from the retina to the optic nerve that send signals to the brain. As fluids build up in the eye, the increased pressure can damage the optic nerve and result in vision loss, which can be sudden and without warning. With regular eye exams, early detection and treatment, vision loss can be prevented.

Who gets glaucoma? Anyone can at any age, but the highest risks include; a family history, diabetes, age 60-plus, severely nearsighted (myopic), extensive steroid users and people of African, Asian or Hispanic descent. Obviously, anyone with high IOP is at high risk, although people with normal pressure can experience glaucoma and vision loss, too.

When should you get checked? Every two to four years before age 40, every one to three years between age 40 and 54, every one to two years from 55 to 64 and every six months to a year over age 65.

As for me, I’m just glad I stepped on my glasses.

Ironically, I had been trying to help Chris Adams, CEO of Ceeable, the recent winner of both the 2015 HITLAB Healthcare Technology Award and NASA Science Award, to launch a technology designed to help prevent blindness. He asked for my help, and I wanted to do what I could for a great cause. I never thought it would be me in severe danger of going blind a week later.

I want to thank my outstanding medical team, Dr. Alan S Gellerstein (PCP), Dr. Reena A. Patel (optometrist) and Douglas K. Grayson, MD, FACS (medical director and chief of glaucoma and cataract surgery — Omni Eye Services).

For more information contact The Glaucoma Research Foundation and Catalyst for a Cure (CFC) based in San Francisco.

How Advocates Can Reengage Workers

A historical challenge in workers’ compensation has been creating the best possible approach to communication: consistently reinforcing transparency, putting the injured employees’ needs first and reassuring them that their claims team is working in their best interests.

Employers today, more than ever before, are engaged in the workers’ compensation process and, in partnership with Sedgwick, have developed efficient healthcare and treatment solutions that provide the highest quality of care. They have also developed return-to-work programs that not only accommodate potential injury-related restrictions and ensure compliance with state and federal employment laws (e.g. Americans with Disabilities Act) but that also encourage employees to come back to work as quickly as possible. This approach ultimately results in an improved experience and outcome for all parties. The responsibilities of claims and managed care professionals encompass many activities that already assist with this process, but there is an emerging need to take employee care above and beyond the standard claims management efforts.

This expanded approach involves being an advocate for the employee by listening, communicating, providing information and proper medical care, explaining how this complicated process works—and being there to assist them at every turn. From the time an injury occurs to the moment the claim is closed, the examiners, the nurses and the colleagues who assist the employee all serve important roles that can have an impact on the outcome of the claim. It’s through their experiences that our industry can see the value of employee advocacy and the advantages it can bring for all parties involved.

Exploring the Shift in Philosophy 

There seems to be a change in the philosophy of employers as it relates to workers’ compensation injuries. Today, businesses are more interested in making sure their injured employees get everything they need to recover, and they are willing to spend the money and do all the right things as a part of their responsibilities as an employer. Instead of questioning claims, they are more focused on restoring the health of their employees. To do this successfully, employers must work closely with claims administrators to develop and implement a process around employee advocacy. This may include assigning a trained, knowledgeable member of the claims team to guide employees through the process or connecting them with a nurse who can assist with their medical concerns. There are different options based on the individual employer’s needs, but each one is designed around the same objective: improving injured employees’ health and well-being.

Surrounding the Employee With Support

The employee advocate typically performs an outreach to the employee after receipt of the first report of injury. The advocate is someone who asks how the employee is doing and offers a sympathetic ear. The advocate is also someone who has information on their claim and is connected to all of the resources available to assist the employee. This initial call can offer several advantages, including:

  • Reassuring the employee that the employer cares and that the employee is not going to lose his job for filing a workers’ compensation claim;
  • Providing guidance to the injured employee that could prevent a minor claim from becoming something major;
  • Answering initial questions to resolve possible issues that could lead to litigation—if the employee needs additional information, the advocate can get what she needs and call back; and
  • Keeping everyone calm at the outset of the injury and having a positive impact on the employee’s attitude.

In this role, the advocate becomes the employee’s key contact and will make sure the employee does not feel alone in this process. The topics for the advocate’s outbound calls may include explaining workers’ compensation; setting expectations related to claim investigation, medical bills, prescriptions, benefit payments and return to work; or explaining the roles of the adjuster or nurse case manager assigned to the employee’s claim.

Providing Specialized Clinical Advocacy

Clinical resources may be needed for an employee based on his injury. This type of advocacy includes a phone call from a registered nurse who will ask the employee how she is doing, answer her medical questions and direct her to the best provider for her injury. At this time, the nurse may also identify any psychosocial issues or other concerns that may affect the employee’s ability to recover or return to work, and the nurse may then direct the employee to behavioral health or return-to-work specialists.

Benefits and Proven Results

When employees are injured at work, this can be an unsettling time for them—filled with many questions. Providing upfront communication and a healthcare team focused on their well-being can make the process better for everyone. Employer benefits include reductions in litigation, medical costs and lost time. With the average cost of litigated workers’ compensation claims about 65% more expensive than non-litigated claims, reassuring employees and keeping them as happy as possible throughout the claims process can have immeasurable value.

We have experience working with several employers that have implemented successful advocacy programs. One is a retail company that has an advocate who contacts every employee on the first day of an injury to see how they are doing. This company’s goal was to reduce litigation, and it has accomplished that through this process. The company feels having someone reach out gives each employee a sense of security, as well as the reassurance that he won’t lose his job due to filing a claim and the feeling that he is part of a system that protects him.

Focusing on the Employee

Examiners, nurses, assigned advocates and other members of the claims and managed care teams all work together to ensure the injured employee has the best possible outcomes. Having a team to surround the employee with care and recovery solutions provides significant dividends related to the continuation of productivity and employee morale—and it can positively influence the overall view of their employer.

Managed Care Isn’t Managed or Care

It is time to get angry. I plead with you all to recognize the king’s new clothes as he stands indignantly naked between the 300-pound gorilla and the elephant in this room called workers’ compensation. I am hereby calling out an industry that has turned “managed care” into “manipulated cost,” with a shameful lack of transparency and a churning mass of workers’ compensation claims.

Decades ago, the cottage industry of bill review provided a legitimate and needed service directly between healthcare provider and payer. Fast forward to the scheme that has evolved, with some healthcare networks and other consortiums that purchase services conspiring with some insurers and third-party administrators (TPAs). These arrangements may set up shadowy deals where medical goods and services are marked up by intermediary agents and where perpetrators split the profits — at the expense of unknowing employers.

Sadly, there is little outrage from employers. Perhaps the amounts seem negligible while the methods seem to be an acceptable cost of doing business. Risk managers have so much else to think about. Maybe managed care is considered to be essential, so no one in their right mind would question it.

I believe the employer-buyer holds a false sense of security that we need to get beyond. The drip-drip-drip of money siphoned from actual employee care needs to finally strike a collective nerve so that real change can happen. To that end, I want to list some considerations that I hope will spark outrage and lead to change.

Quick Tip: Managed Care Food for Thought; Indigestion Guaranteed:

Cognitive Dissonance: Claims providers justify bill-review fee schemes based on the notion that there are no controls from provider-sources… but wait a minute… they also take network fees because they apparently can control bills from provider sources! Anyone feel mildly conflicted trying to reconcile this logic? How can both facts exist?

Deliberate Mystery: Bill review as founded decades ago should no longer be necessary. Today’s technology obviates the premise that all WC bills need to be hand-checked against a fee schedule or that licenses for CD-ROMs holding schedules or “reasonable and customary” data are valuable. When it comes to group health, providers make it their business to know what deductibles and reimbursements apply while you stand at the window. Why is WC a deliberate mystery?

Technology Hypocrisy: The WC claims industry purports to have data and IT capability that can predict and fast-track claims, allowing ever higher (arguably untenable) adjuster caseloads, yet when it comes to monitoring fees pretends we are still in the 1990s. I submit that today’s technology can lock healthcare providers into correct billing. Aggregate provider monitoring/auditing by the adjusting entity can support accuracy. High automation and negligible cost should make fee oversight an included aspect of claim service, with network affiliation requiring providers to contribute to the technology. As our national provider base moves into more hospital-centered conglomerates, there are far more IT resources available on the provider end.

Core Responsibility: TPAs and insurers are paid to adjust benefits per state statutes. But charging a percentage of savings for medical care in a state with a fee schedule is as ridiculous as would be charging a percentage of “savings” for reducing an average weekly wage to the statutory comp-rate. What is the difference when it comes to core claim adjusting obligations?

No Repeat Value Added: We can agree that complicated in-patient bills are worthy of review and that fees for that review are justified. But there routinely are recurring bills from the same providers on the same file. After the initial adjustment, why should claim payers charge a fee for adjusting the exact same bill repetitive times? Seriously… there is no value added in charging for a task already performed. Here is an exercise: Look at your claim payment register to see the same $1.15 bill review fee and $5.32 network fee charged on the same $48 physical therapy bill over and over and over. Maddening, isn’t it?

How Would You Feel?: Let’s make it personal. What if your homeowners or auto insurer mandated your use of a repair-provider-network? Your damaged car gets fixed, and you are presented with a bill marked up by the network — not knowing what the actual body shop charged. You pay your deductible, leaving “profit” for your insurer and network to split… Hmm…

Low-Quality Reality: Network discounts have come to roost, leaving healthcare provider frustration high and quality of care low. I submit that higher quality deserves higher fees.

New Network Charge: Efforts to define, seek and sustain quality should be at the forefront of network effort. Can you imagine providers competing based on quality to join exclusive, well-paying networks? Astute, unbundled and self-administered employers that seek medical quality often pay more with confidence and get better results. Today’s bundled programs beget providers willing to work cheap and approach profit on a volume-of-treatment basis. More visits means more weeks/months/years open equals more money for the entities otherwise trusted to resolve claims. Isn’t this reality the opposite of what should be managed care?

Employers… Get angry: Start asking questions and making demands. Let’s start with disclosure of end-provider fees. Ask your legislators to crack this issue open and make corrections accordingly. I call upon some major broker to take the lead and create a “Managed Care Bill Of Rights.” Wouldn’t that be a great distinction?

Bottom Line: The insurance/claims/managed care industry cannot beg for the trust of those served while skimming treatment dollars. Fix the problem.

End the Dysfunction in Functional Exams

Functional capacity exams (FCEs) are in dire need of quality standards. Employers who want better workers’ compensation claim results must take the lead.

The FCE is intended to objectively test a patient’s thresholds of pain, strength and movement. An FCE should play a major role in things like qualifying a claimant to return to work, ascribing reasonable permanency awards, calculating objective settlement valuations, indicating malingerers, providing defense evidence and essentially helping you close cases.

As I see it, the FCE has been under a quality assault because of fee-squeezing managed care schemes. Managed care means only steering work to those “in-network,” which emphasizes use of the lowest-fee providers. The overriding value premise of “managed care” is fee reduction, not quality assurance.

As such, the peripheral specialty of functional exams has gone unchecked. They have become a perfunctory step in a chain of litigation activities, conveniently extending an adjuster’s diary with the appearance of action. When was the last time your WC case turned on FCE results? When was the last time your defense counsel’s essential witness or deposition list included the FCE provider? The answer may escape you, just as has the missed opportunity to leverage and move churning cases.

Quick Tip: Demand Quality FCE Standards and Expect Actionable FCE Results

Institute FCE standards in your claim account service instructions. Craft them from the checklist to follow. Require that you or your WC coordinator pre-approve FCE referrals to ensure quality in the application and outcome expectations. Along with selecting a quality provider, you need to provide adequate medical history and other background while asking specific questions.

When it comes to provider selection, apply this quality-question checklist:

Who is performing the test and what is her certification? Demand licensed physical therapists, optimally with enhanced related certifications. Do not accept PT assistants, sports trainers, vocational counselors or others who are less qualified.

Is modern computerized instrumentation used for validity? Do not accept manual systems, which involve subjectivity and simple gauge reading. For example: A manual hand-squeeze test shows pounds of squeeze strength, while modern testing measures isometric contraction and provides an actual “force curve” indicating effort, true point of muscle fatigue and pain. Simply stated, modern computerized systems can indicate real physical capacity while pointing out faking subjects.

Will raw data be fed into appropriate computer applications for reliable objective results? Functional exams need to process individual body-part tests and things like coefficient of variance formulas to ascertain whole-body determinations such as “lifting capacity” or other job-specific activities. Calculating these aspects by hand, based on assumptions, is not reliable, and the results may crumble under legal cross-examination.

Will heart rate and blood pressure be monitored during testing? This is essential to establishing consistency and overall patient effort.

Will the process measure distracted testing? This is a specific technique whereby one test is cross-checked by the appearance of a separate test. For example, back-bending angles are first tested; later, a “straight leg raise” test is performed, which actually re-creates the back bending angles and can be compared with the thresholds of prior back-angle results. This is a critical part of establishing patient credibility.

Will the results be admissible as strong evidence? Adherence to aforementioned aspects combined with early communication and input from defense counsel will strengthen evidence.

In conclusion, employers must confront a status-quo claims service process to demand FCE standards. Agree to pay for higher-priced FCE providers if you can establish the appropriate quality level. Pick your cases wisely and use detailed oversight. The power of a good FCE will help you move cases.

Why Is Workers’ Comp Managed Care Hard?

There are many reasons why workers’ compensation managed care is so difficult, ranging from general economic cost pressures to the regulatory complexities faced by many large employers with multi-state work locations. Issues such as the ability to direct medical care, fee schedules, dispute resolution and the use of treatment protocols and provider networks vary from state to state.

Workers’ comp medical costs have continued to outpace overall medical inflation for years. Twenty years ago, the typical ratio was 60/40 indemnity costs (lost-wages benefits) to medical costs. Today, that ratio has reversed.

Furthermore, workers’ comp has always been susceptible to considerable cost-shifting both by injured workers and medical providers. Many injured workers without health insurance or with limited coverage have been suspected of submitting claims under workers comp to receive 100% “first dollar” coverage with no co-pays or deductibles. This is often known as the “Monday Morning Syndrome” — weekend injuries from recreational activities get reported first thing Monday morning as “work-related.” The support for this theory is that for years it was documented that the No. 1 time of reported injuries is between 9 and 10 Monday morning. In addition, if an injury or illness is reported as work-related the employee may be entitled to lost-wage replacement benefits, which results in a double incentive.

Medical providers also historically have had an incentive to shift costs to workers’ comp. The best example are HMOs financed by pre-paid capitated rates for group health benefits. Work-related injuries are not included in group health plan coverage, allowing HMOs to bill additional charges on a fee-for-service basis. My former HMO had a large sign at the registration desk that read, “Please let us know if your medical care is work-related.”

I was once hired by a major defense contractor during a competitive bid process and was told that all the other consultants had recommended it run its workers’ comp program through its HMOs. My response was, “That is the last thing you want to do.” The risk manager had a big smile on his face.

Many people in the industry were hoping that the ACA and the goal of universal coverage would eliminate the incentive for cost-shifting in workers’ comp. In theory, that may be true. In reality, the ACA may have limited impact or, worse, actually create more incentives for cost-shifting.

The ACA has no direct impact because the various federal mandates for health insurance do not apply to workers’ comp laws. Unlike Clinton-era health reform efforts, the ACA did not attempt to roll workers’ comp into “one big program.”

The ACA may exacerbate cost-shifting if health coverage costs will rise significantly for both employers and employees, which is widely predicted. The ACA premium rating factors virtually eliminate experience rating in favor of community rating for small employers, which helps pay for the added costs and mandated benefits. This will significantly drive up costs for many employers, with estimates as high as 50% above normal yearly premium increases.

Employees are also faced with the prospect of narrower networks and increased incentive to cost-shift, including the growing trend of consumer-driven health plans with high deductibles and other out-of-pocket costs.

Medical providers under intense cost pressures under the ACA may very well continue to cost-shift to the state workers’ compensation systems and “first dollar” coverage to increase revenues. I fear that the high hopes that the ACA will help eliminate cost-shifting may go the way of “if you like your current health plan you can keep it.”

One prominent proponent of the ACA just predicted that 80% of employers will actually eliminate company-paid health benefits by 2018 in favor of directing employees to the state exchanges because paying the $2,000 fine under the ACA for not providing health coverage will be cheaper than providing coverage.

Workers’ compensation managed care is far more complex than managed care in group health benefits for many reasons, including; 50 different state laws and jurisdictional requirements, cost-shifting, fraud and abuse, overutilization of unnecessary or even harmful health services, excessive litigation and friction costs, historical animosities between labor and management, bureaucratic state agencies and an insurance industry and claim administrators who get a grade of C+ from many industry analysts.

If employers think the answers in containing workers’ comp medical costs are in Washington, D.C., or the various state capitals in which they operate, they need to think again. The answer is in the mirror. Many employers are still searching for the cheapest claims administrator and not the best. Remember that “you get what you pay for.”

The same goes for the overwhelming popular use of PPO “discount arrangements.” If employers think they are saving money by looking for the cheapest doctor in town they couldn’t be more misguided. The treating physician plays a key role in diagnosis and treatment, helps determine causation, degree of impairment and the length of disability and return-to-work. Family physicians and other primary care providers are rarely trained in occupational medicine or workers’ comp laws and requirements and are notorious for granting indiscriminate time off work.

Employers must take a much more active role and provide the best and most appropriate medical care for sick and injured workers from the moment of injury or illness and establish better real-time communications between injured workers, medical providers, work supervisors and insurance companies and claims administrators.

Unfortunately, there is no magic bullet. But there is a rule of thumb: Do not even discuss medical cost containment with outside vendors or consultants who recommend broad-based group health networks and strategies. They simply do not apply to workers’ comp and will do nothing but hurt an employer’s ability to address the real cost drivers and complexities of state workers’ comp laws, requirements and systems.