Kentucky Managed Care Programs
Of all the medical cost containment measures enacted in the amendment of KRS 342.020 in 1994, managed care is of the most historical significance. For the first time employers are granted input into the matter of physician selection through managed care plans approved by the executive director. Employees still have choice of physician but within the confines of the provider network. 803 KAR 25:110 are the administrative regulations established as the standards for certified managed care plans.
Managed care emphasizes controlling utilization through gatekeeper physicians, pre-certification of services, strong case management and coordination of medical treatment, and return-to-work policies. Internal grievance procedures are required.
Managed care affords insuring interests a strong voice in selecting network providers and results in the exclusion of some physicians from the workers compensation process whose practice patterns have proven to be outside of the norm as to utilization or outcomes.
Managed care provides aggressive case management to coordinate the delivery of health services and return-to-work policies to promote an appropriate, prompt return to work and facilitate communication among the employee, employer and health care providers.
- Participating providers go though an extensive credentialing process (license, malpractice coverage, education, board certification and DEA number are verified)
- Injured worker is required to seek non-emergency treatment from a network “gatekeeper” provider
- Providers agree to accept discounted fees below the Kentucky Fee Schedule as part of participation in the Managed Care program.
Early Intervention Telephonic Case Management (TCM)
- Supports timely and accurate claim determination
- Creates employee goodwill by having a nurse to assist in treatment and recovery
- Immediate communication with provider secures treatment plan and RTW restrictions
- Coordination of Modified Duty RTW
- Direction of care to PPO network providers
- Contributes to reduced disability duration as case manager expedites treatment and referrals
Utilization Review (UR)
- Decreases duration of disability though timely approval of medically necessary treatment
- Eliminates treatment that is excessive and/or medically unnecessary
- Complies with Kentucky UR requirements outside of the MHCS progra
Compensable claims are subject to utilization review when any of the following occur:
- Upon a medical provider's request for pre-authorization
- Upon notification of a surgical procedure or resident placement pursuant to an 803 KAR 25:096 treatment plan
- When total medical costs exceed $3,000
- When total lost work days exceed 30
These are minimum criteria. Some utilization review programs review additional claims based on the program's own internal criteria.
Dispute Resolution Process
- Disagreements between provider and case manager/employer are resolved without litigation
- Should litigation proceed after DRP is exhausted, a strong foundation has been established in support of initial decision
- Medical director support of TCM/UR Decisions improves position with provider
- Peer review of treatment plans can support reductions in the duration and frequency of treatment
Medical Bill Review
- All bills receive thorough analysis to establish accuracy in coding
- Technical modifiers are applied to determine potential for bundling, unbundling, and upcoding of line item charges to insure appropriate fee reductions