Knowing Your Provider

As a LNC/NCM I am often asked to help identify physicians to assist/work on a file/case OR help navigate the provider-client-payor waters. This is especially true in the Workers Compensation arena. Most recently this topic was discussed at length in a LinkedIn discussion group. Several excellent points were made.

Noted in the discussion group:

• Does a provider have experience in your desired service?
• Be aware of reimbursement issues.
• Learn the State Rules and Regulations concerning WC. Check out the State website for details and reporting guidelines.
• Check out guidelines such as ODG, or MD Guidelines to verify that the client is tracking along with their recovery or rehab.
• ACOEM (American College of Occupational and Environmental Medicine) provides a guide to help assess outcomes.

Some of the more basic ones that I utilize are:

• Check with other adjusters and attorneys for their experiences with the provider.
• Local NCM/LNC are very knowledgeable about the physicians in the area and can give solid insight as they often deal with the providers on a first hand basis.
• An employers will also know which doctors are easy to work with, take a certain type of case, etc. especially providers that will provide front line care such as family practice, occupational medicine, etc.
• If possible ALWAYS pre-screen the physicians. Learn how they report, communicate, how they interact with a NCM/attorney/insurance company, etc.
• Try and learn the “particulars” of the office staff.
• Periodically re-assess the physician and support staff. People change within a practice; physicians get busier and become unable to communicate as well; practice philosophies, and goals change.
• Seek feedback from the employers as to how their provider choices are or are not performing.
• Ongoing assessment of the physician(s) should be done.
• Help to educate the payor, employer, and provider on what to expect in regards to reporting, State regulations, employer RTW philosophies, etc.
• Does a physician embrace modify duty?

We sometimes forget that the medical arena is consumer based. Knowing how your
provider is performing is critical to successful outcomes.