Managed Care in Risk Management


Photograph by Ian Hooton/Science Photo Library/Corbis

Helping Control Medical Costs Throughout a Claim.

Good health is holistic: our body’s systems are interconnected and interdependent. Good medical management is the same way, as many parts—utilization review, preferred provider organization (PPO) penetration and bill review, for starters—need to work together to produce optimal results for the patient while keeping costs down. With its team-oriented “One Zurich” approach, which unites expertise from across the company, Zurich is ideally suited to that task.

Utilization review (UR) is a cost management process that looks at only one question: is a procedure or treatment medically necessary? Zurich’s UR program has been accredited for more than a decade by URAC, an independent nonprofit organization widely accepted as the “gold standard” for evaluating healthcare quality standards in terms of policies, procedures and best practices. Part of what makes Zurich’s UR one of the leaders in the field is that its in-house nurses have access to the internal claims systems, which assists in prompt and effective communication with the claim professional and allows the nurses access to all medical records received from medical providers.

For UR to most effectively manage the total cost of risk, as much review as possible needs to occur prior to treatment, by way of precertification, rather than concurrently with treatment or, worse yet, retrospectively. Precertification also ensures that the procedure or treatment proposed for the injured worker is both medically necessary and appropriate.

“There is a perception in the field that UR may present an obstacle to care because it takes time,” says Dr. Nina McIlree, Vice President, Medical Management, Zurich in North America. “We have an industry-leading turnaround time, with our initial precertification review typically done in two to three business days.”

Zurich also sports a strong 75 percent PPO penetration, or utilization of approved PPOs. The use of these providers can lead to additional control over medical costs, as well as better outcomes for the insured and the worker.

“Not only does driving the use of these providers help manage the total cost of risk, but they’re typically more work-comp savvy,” says Neal Fusco, a 12-year company veteran and Zurich’s Director of Managed Care, a new position created in February to put the right programs in place for customers, and to assist in their smooth operation. “They make sure they’re in line in terms of getting that worker back to work as soon as medically possible.”

Helping make the right managed care program choices for customers demands a holistic approach, according to Cheri Perches, Customer Service Account Executive, Zurich in North America. One way in which Zurich monitors these choices is via monthly or quarterly stewardship meetings with customers. There, strategies are formed to help control loss costs by studying cost-containment and benchmarking reports to find potential areas for improvement. Likewise, a dedicated claim professional, acting as the claimant’s quarterback and using all the tools at his or her disposal to manage the total cost of risk while minimizing any potential confusion on the claim, showcases the advantages of a fully integrated team approach.

Carve-out vendors, a subset of PPO, are one example of how cost control and better service can go hand-in-hand. Specific vendor programs for specific types of services—such as diagnostic services, durable medical equipment (DME), pharmacy benefit managers and physical therapy—are selected and managed by a dedicated in-house Zurich staff. For example, a nationwide MRI vendor with a network of facilities may be able to offer services for well below a state fee schedule or even a general PPO network’s contracted rates—and help schedule an appointment at a specific facility.

“These programs allow us the potential for cost control in the billing process, as well as to make sure that we’re utilizing the best possible providers through those particular networks,” says Fusco. “Carve-outs make sure we have the right costs and the right breadth of providers to help meet our customers’ needs, as well as the ability to identify areas where we may need to think about offering a different program or product.”

“We’re extremely focused on communication, and when there are issues we work quickly to resolve them,” says Zurich’s Perches. “Customers know when they hand bills to us that they will be dealt with timely. That’s the ‘One Zurich’ approach in action.”

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