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Choosing a workers’ compensation network that fits

In 2005 the Texas Legislature passed a sweeping reform of the workers’ compensation system. Perhaps the most talked about aspect of the reform is the inclusion of health care provider networks.

At last count the Texas Department of Insurance (TDI) had certified 27 workers’ comp health care networks. With so many choices out there, it can be difficult to determine which network is right for each client. Some of the things an agent may want to consider are:

• Treating doctors: Under network rules, an injured employee may select a treating doctor of their choice from the network’s list of providers. The treating doctor’s role in an injured employee’s treatment is critical. The treating doctor determines if the employee needs diagnostic tests, treatment from specialists, physical therapy, etc.
• Provider locations: TDI requires each certified network to include providers from a wide range of medical specialties, some of which may never be needed in a workers’ compensation setting. How often do injured workers need a referral to a pediatric oncologist? It’s important to find out not just how many provider locations are available in a given area — but the type of medical treatment available at each location. In general, you may want to look for occupational medicine or urgent care clinics within a close proximity to workplace locations.
• Provider specialties: Depending on an employer’s industry and the job duties of employees, you may want to consider if the employer has a special need for specialized medical treatment for certain injuries. For example, some employers will have more experience with injured workers sustaining burn injuries and as such you may want to review a network’s provider list for providers experienced in burn care.

The new legislation includes a shift to a more proactive approach to workers’ compensation claims management to reduce over-utilization of medical services provided to injured workers. The rules allow for a great deal of medical control by the networks; thus, it is imperative that an agent understands the differences in the networks being offered. In September, the Division of Workers’ Compensation will begin issuing network report cards, which will be a good source of information on the various network choices.

Stephany Alexandra Concha is manager of Networks and Compliance at Zenith Insurance Company. Concha is responsible for leading Zenith’s Texas branch through successful certification and implementation of The Zenith Health Care Network, a growing worker compensation health care network consisting of over 2,500 providers.