We were advised by leading state officials:
1. The IWCC should promulgate the required form for WC PPO’s very soon—we were told it may be posted on their website as soon as today or tomorrow. Once we have it, we will send it to all of our readers.
2. There is almost certainly going to be more guidelines or an approval process for WC PPO’s from the Illinois Department of Insurance. We understand they may be reaching out to the PPO industry to let them know what they are going to have to do.
Either way, we expect them to push hard to make the 2011 Amendments to the Illinois Workers’ Compensation Act a reality. As the WC PPO is a major cost-saving change, we are confident they are working hard and won’t want the Governor to be calling about putting the details into place.
Another major issue pushing the WC PPO into place in this state is the almost impossible disparity in the cost of medical protocols. If you had a choice of paying $300 or $1800 for an abdominal CT scan just by going to a clinic or a doctor in a nearby town, would you? It seems like a trick question but Illinois businesses are paying the higher cost every day basically because transparency in health care costs just isn't there. This lack of transparency gives rise to a situation where businesses can pay as much as 500-600% and more for the exact same medical procedure in the same town.
In a WC PPO, the folks setting up the PPO are seeking the best possible cost for each procedure in a fully “transparent” setting. We are certain Illinois and all U.S. businesses have a direct stake in the cost of healthcare. The unit cost of services and procedures has largely been a matter between the patient and the provider—we feel this is going to stop in the WC PPO setting.
Second, medical care is a highly complex service with little in the way of tools available for comparison shopping. It's complex enough even treating physicians themselves are often in the dark about costs about specific procedures, tests, or medications.
We are confident the WC PPO, once fully implemented by our government and the insurance industry is going to provide strong cost controls at every step of the workers’ compensation medical process. We are told the top PPO’s provide contract pricing below the already-cut Illinois WC medical fee schedule.
WC PPOs can be ranked by:
· Provider Management: This is an understanding of the support in handling problematic providers, related to inappropriate billing, including unbundling, upcoding, undocumented charges and unreasonable “mark-ups”.
· Geographic Access: This concept reviews the volume and location of different providers used most frequently by covered participants and those which if not contracted could result in extensive out-of-network cost for the plan.
· Provider Disruption: This concept reviews the contracting strategy related to lesser discounts for a broader network versus deeper discounts for a more limited network.
· Contract Quality: This concept reviews the contract structure of the most utilized and highest potential cost providers to determine if the arrangement places the provider at risk to deliver services cost effectively.
· Actual Contract Savings: This concept reviews the reported savings between billed charges and amounts allowed by the contract. Significant effort is placed on gaining accurate reporting of savings minus disallowed charges and coding adjustments.
We are certain a WC PPO is going to be in your future. The more you learn about them, the better and more competitive your organization may become in the Illinois WC system.