AUGUST 5, 2021 – WORKCOMPWIRE – The workers’ compensation system has many attributes that make it challenging to navigate─unique state-mandated treatment guidelines and state-regulated fee schedule reimbursement structures are just two examples. However, there is one aspect that is the same in any sector of health care: People injured at work need high-quality care as much as any other group of patients. Whether the injury occurs at home or on the job, access to quality providers is the key to better outcomes.
In this context, specialty networks serve a key function in the workers’ compensation space since a large number of these cases require highly specialized treatment. From post-acute care to pain management to orthopedic and spine care, the need for specialized care increases the complexity, length, and cost of a workers’ compensation claim. The goal of any network should be to reduce those three factors, but the way a network is built and operates has a significant impact on outcomes.
The importance of quality over quantity in identifying specialty providers
A high-quality specialty network should be designed to not only achieve the best outcomes that expertly address the needs of injured workers but also to deliver value-based care for payers. Accomplishing both of these starts with a deliberate, defined methodology for identifying and selecting the best providers in each field of specialty.
Traditional provider networks typically use a “pay-for-access” and “pass-through” reimbursement model. The foundation of this provider contracting approach is to accept as many providers into their network as possible. Quantity outweighs quality and provider selection, outcome scoring, and supportive analytics take a back seat to delivering broad discount penetration. Although traditional networks provide real strategic value to payers in workers’ comp, their overarching methodology is not designed to deliver condition-specific specialty care.
Specialty networks take a selective “quality over quantity” approach that includes only those providers that meet stringent qualifications and credentials. Specialty networks provide value that is beyond a quantity-driven, discount-only approach. They provide access to a developed network of high-performing, outcomes-focused physicians as well as appropriate sites of care.
Rigorous methods for reviewing—and verifying—provider ratings, credentials, and certifications
Building a high-value network for any specialty requires an in-depth and deliberate inclusion methodology. For instance, across our dedicated areas of expertise, Paradigm’s Specialty Networks use a combination of criteria, external, industry-specific source analytics, and proprietary data to help ensure targeted identification and network inclusion of the best providers.
Additionally, individual providers and facilities need to be properly credentialed. Examples include certifications from industry accreditation organizations and licensing from state and federal oversight agencies. It is important that verifying and reviewing credentials be an ongoing process to ensure adherence to best practices. Of equal importance, providers in a workers’ compensation specialty network should demonstrate the adoption of industry-standard best practices that help to ensure predictable, accountable results for patients and payers alike.
From quality provider selection to true full-service management and risk transfer
Identifying and selecting top providers is a crucial step to positive outcomes, but it should be seen as the foundation for the role of a specialty network. Through each of our segments of care, Paradigm Specialty Networks directly contracts with our providers once we have selected them using our rigorous process and standards. This means acting as full guarantor of payment—in contrast to more common pass-through reimbursement network models.
This dynamic alters the relationship among payers, networks, and providers in a crucial way. In a pass-through, or pay-for-access model, the original payer retains much of the risk for the claim. Resolving issues, whether treatment or billing-related, requires the payer to assume a sizable administrative burden. With this type of specialty network, claims professionals can spend a disproportionate amount of time resolving and clarifying line items on bills and ensuring that recommended treatment is both necessary and carried out properly.
A full-service specialty network essentially takes on the role of the payer, assuming risk on a broader level. This creates the incentive to adopt a more proactive role in managing providers and ensuring care. The result is a network model that achieves accountability and value, improving outcomes for patients and payers alike.
Administrative support and provider collaboration lifts the burden for payers
Paradigm manages each of the segments of our workers’ compensation specialty network directly. This includes spine and orthopedic, comprehensive pain management, addiction recovery, post-acute care, and behavioral health care. This type of model is unique to the workers’ compensation industry and allows for detailed and close measurement of processes. By simultaneously acting as manager and payer, Paradigm has an unparalleled ability to collaborate on treatment plans where payers may want to add clinical expertise and monitor outcomes.
Having a comprehensive administrative system in place across networks to guarantee and expedite payments to providers strengthens the position of the network manager. By joining the network, providers agree to follow rigorous guidelines for treatment and utilize proven billing and reimbursement practices. Paradigm is there from the very beginning—to approve treatment plans and monitor the delivery of care—to the very end, ensuring optimal outcomes. This eases administrative workload not only on the payer side but also on the provider side, allowing for an increased focus on delivering quality care.
Separate networks with a specialized focus allow each of the care segments to ensure quality within the unique characteristics of that service line. For example, post-acute care has highly specific billing practices that require expert oversight, compared to orthopedic and spine care or pain management. Each of the Paradigm Specialty Networks operates independently, with a specialized and expert-based approach to ensure quality outcomes, while adhering to a guiding principle to act as a full-service representative for stakeholders in the claims process.
Outcomes-based value-based care is in the Paradigm DNA
The ability to take on full risk transfer and build accountable relationships with providers is made possible by being part of an organization with leading clinical expertise and decades of workers’ compensation-specific data. By taking the same value-based, expert-guided, and data-driven approach that innovated the catastrophic care segment, Paradigm is achieving improved outcomes for some of the most challenging, expensive, and unmanaged segments in workers’ compensation.
Within specialty networks, Paradigm is redefining quality care and cost-effective outcomes, with industry-leading standards of provider selection and a wholly unique approach to full-service network management. This philosophy brings Paradigm’s commitment to life-changing outcomes and value-based care to the workers’ compensation industry.
About Stan Smith
Stan is Vice President for Paradigm with over 31 years of health care management experience in post-acute care within long-term acute care hospitals, inpatient rehabilitation hospitals, skilled nursing facilities, inpatient rehabilitation units, assisted living, and home health services. This includes providing multi-facility, multi-state executive oversight, and single-site executive director/administrator leadership.
Stan is a licensed long-term care administrator and speaker at national workers’ compensation and post-acute care conferences on topics including continuous quality improvement and risk management best practice programs, the effects of the aging workforce on the workers’ compensation industry, post-acute care discharge planning, and identifying workers’ compensation healthcare billing fraud and abuse
Stan received an MBA in Healthcare Administration from the University of Dallas and has been recognized by the state of Missouri’s long-term care industry as its Administrator of the Year.
About Jennifer Brockman
Jennifer Brockman is Vice President of Orthopedic and Spine for Paradigm. Since joining Paradigm in 2017, Jennifer has been instrumental in the expansion of Paradigm’s high-value, orthopedic and spine network and oversees product development, network provider relationship management, and supports business growth initiatives.
Jennifer has held leadership roles supporting product development, account management, and sales in worker compensation and managed care for over 20 years. Jennifer received her B.S. in Marketing from the University of Tampa.
About Paradigm
Paradigm is an accountable specialty care management organization focused on improving the lives of people with complex and catastrophic injuries and diagnoses. The company has been a pioneer in value-based care since 1991, offering deep clinical expertise, high-value specialty networks, behavioral health support, payment integrity solutions, and robust data analytics to generate the very best outcomes for patients, payers, and providers.
Paradigm is headquartered in Walnut Creek, California, with offices across the U.S. For more information, please visit www.paradigmcorp.com.
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