WHAT IS MANAGED CARE? In 1991, the New Hampshire Legislature passed a Managed Care pilot program as part of a Workers’ Compensation reform bill. Managed Care was successfully utilized in other states to help control workers’ compensation costs by using nurse case managers or injury management facilitators (IMFs) to assist the injured worker with accessing the most appropriate and specialized medical treatment available within a network of providers immediately after an injury occurs. The providers within the network have been trained to treat injured workers promptly, even in areas of specialty, which can otherwise be difficult to access on a timely basis. Based on the success of the pilot program, in 1994, the New Hampshire Legislature passed legislation making Managed Care part of the Workers’ Compensation Statute. Approval to operate a Managed Care Organization is granted by the New Hampshire Workers’ Compensation Advisory Council on the recommendation of the Department of Labor. RSA 281-A: 23-a of the Workers’ Compensation Statute and Labor Department Regulation, Lab 700, govern managed care in New Hampshire. WHY DO EMPLOYERS PARTICIPATE IN MANAGED CARE? Managed Care is a proven method in reducing the premium employers pay for workers’ compensation coverage and, for NHADA, it increases the money available for rebates. The network medical providers have been trained over the years to understand the importance of returning injured workers to work in a safe and prompt manner. The Injury Management Facilitator’s relationship with the injured worker and the medical providers is also critical to the success of the program. That relationship allows for prompt medical appointments within the appropriate medical specialty. In turn, the injured employee promptly receives the best treatment available and returns to work in a timely manner. IS IT LEGAL TO TELL EMPLOYEES WHERE TO TREAT FOR A WORKERS’ COMPENSATION INJURY? If the employer is a participant in a formal Managed Care program, then their injured workers must choose from providers within the network. There are some special circumstances, outlined in Lab 700, in which an injured worker may be treated outside the network; this includes prior treatment for the same or similar injury within the last six months or if the specialty they require is not available within the network. Except in these special circumstances, the workers’ compensation carrier will not cover treatment outside of the network. WHAT IF AN INJURED WORKER IS NOT HAPPY WITH THE PHYSICIAN THEY CHOOSE? Not everyone “clicks” with their provider. An advantage to having an injury management facilitator is that they are there to assist the injured worker with this situation. Transfer of care or a second opinion is available to the injured worker within the network of providers. The injury management facilitator can assist the injured worker with finding another provider or verifying the network status of one with whom they may be interested in treating. An injured worker may not treat with more than two similar providers within the managed care guidelines. Injured workers should always contact their injury management facilitator if they are interested in changing physicians. WHAT CAN NHADA MEMBERS DO TO GET THE GREATEST BENEFIT FROM OUR MANAGED CARE PROGRAM? Employees need to be trained in advance of an injury so that they know they are participants in a formal Managed Care program, and they need to know what to do when an injury occurs. Employees must be provided with the NHADA Workers’ Comp. Managed Care brochure at the time of hire and an NHADA Managed Care poster should be hung in clear view of all employees. THE MOST IMPORTANT TOOL IN OUR WORKERS’ COMP. TOOLBOX: MANAGED CARE BY PETE SHEFFER VP AND DIRECTOR OF INSURANCES, NHADA 12
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