Hello again Mark and thanks for your thoughtful note. I appreciate your willingness to engage and value your perspective
An observation re "big work comp networks tiering providers based on pricing/discounts and not outcomes."
One network did settle a lawsuit with a small PT organization; it was not clear if the network - One Call - prioritized net revenue over other metrics. I do know MedRisk does NOT do this...they have invested heavily in outcomes assessment, development of clinical guidelines, research into optimal treatments and provider assessment and use this research to route patients to specific providers/practices.
MedRisk has been sued by a provider organization - that suit went nowhere.
I posted today on RCM and have written about it extensively. I was on the Board of a Medicaid/Medicare duals health-plan for 7+ years...it relied heavily on payment integrity technology, both pre- and post-payment. With margins in the low single digits, it had to.
That kind of diligence is completely absent from workers' comp. There are a few companies that do some of this, but payers - and bill review companies - have been woefully slow to adopt sophisticated approaches to provider RCM. Coding and reimbursement - especially for facility-related bills - can be devilishly complex, with a fee schedule governing the physician services except for surgeries and UCR for some facility charges plus different rules for multi-site surgeries, assistant surgeons and on and on.
It's an arms race, and most work comp payers don't seem to care their arms are tied behind their backs.
be well and I do hope we can meet in person and continue the dialogue.
This quote “ I do know MedRisk does NOT do this...they have invested heavily in outcomes assessment, development of clinical guidelines, research into optimal treatments and provider assessment and use this research to route patients to specific providers/practices.” Is the most ridiculous statement I have seen regarding WC and has nothing to do with reality in California. Medrisk is the absolute worst middleman siphon. They provide zero value to the injured worker or the care provider. Their research in optimal care is to route patients to the lowest bidder. One can only hope each and every lawsuit against Medrisk and the other WC middlemen succeeds and bankrupts them out of existence. The would be the single best thing that could happen to injured workers here in California.
Just talk with practicing physical therapists, talk with CPTA, or any private practice groups. PT’s persuaded legislators successfully to change the workers’ comp fee schedule and have it tagged to the Medicare Fee schedule. This was a victory for injured workers in California as it was expected that if payment for care of injured workers was on par with the broader public, competition by quality providers would improve the quality of care injured workers received. Unfortunately, unforeseen loopholes in the legislative language has allowed 3rd party middlemen like Medrisk, profit off the backs of both injured workers and the healthcare professionals providing care. In some circumstances Medrisk will extract up to 50% of the payment for a given PT session, while literally providing the injured worker no value. Nothing. No care. What Medrisk may call oversight, practicing PT’s know it as expensive administrative barriers to treating injured workers. Maybe I am wrong, I am sure the Medrisk supporters will jump into the comments and contradict what I have argued.
The fact that there is a lawsuit does not indicate there is any proof of your assertions. In fact that lawsuit has gone nowhere since it was filed in October of 2019.
The plaintiff contacted law enforcement officials in an effort to get them to follow up...after an investigation those officials took no further action.
I'd again suggest you provide credible documentation of those assertions. I've worked with MedRisk for over two decades; in all my discussions with MedRisk personnel at all levels I never heard anything whatsoever that would indicate your statement "Their research in optimal care is to route patients to the lowest bidder." is accurate.
In fact, the opposite is true.
If you cannot provide the requested support I suggest you withdraw your comment.
I did not realize you worked with MedRisk. I am sure you have better insights as to how that company works than I ever will. I am just a provider that sees the impact of MedRisk on community, my profession and my practice.
Lawsuits are exactly where assertions and arguments are adjudicated. You are correct, if there is not enough evidence the case will be dropped, but if there is a finding of wrongdoing the accusers will be vindicated. I guess we will have to see how that plays out.
As I stated, if my experience is the outlier, I am sure the internet will correct me and the numerous supporters of MedRisk will share how this company so positively impacted their wellbeing.
But since you do work with MedRisk, I would respectfully request you actually talk with the providers your company contracts with. Talk with iPTCA, CPTA or other Physical Therapy organizations. Should the middle man company profit more than the care provider for the services rendered? Should we create a race to the bottom of quality of care on the backs of injured workers? I suspect we could do better.
Joe, I always appreciate your thoughts and opinions. I can't argue with some of your points about shopping for efficiency and cost. However, I can tell you from direct experience that a provider in these types of networks just feels like a number. In 10 years I have never had a discussion with an actual therapist or peer or asked about my outcomes. They may be trying now as I have not participated in a 7 or 8 years. I like the Bardavon model better, but they are struggling to get providers to use and integrate their software which is really the only efficient way to track real performance. Also, my experience is in AZ and CA and I know providers here have had issues with the big work comp networks tiering providers based on pricing/discounts and not outcomes. Money matters, of course, to these private equity firms.
Yes, I know I am speaking from a PT perspective and we are small change in the whole scheme of things. However, in AZ and CA we are regulated by the same regulator these big health systems are. I agree some providers and health systems try and take advantage of wc, but there is only so much they can do with the checks and balances in place. Some bill reviewers are better at it than others and put human capital to work and not just computers. It really is not that hard to review a billing and see what is going on. Just takes time. I just do not see them making up the lost revenue on work comp.
Again, all I can speak to is my little world of therapy and rehabilitation. I saw the EOB's from payers and I can tell you in AZ we were being discounted around 65% or more of our fee schedule by these networks. I am just not sure how this can be justified. We do the work and they take more than half our money. Not a bad business model...lol. That was our bad and one of the main reasons we said bye bye. The other reason was it was like pulling teeth to get what money was owed to us.
I know cutting Medicaid is a complex multi-faceted problem and I do share your concern about people losing their healthcare. If it happens it will have serious ramifications for our economy. Stay well and some day perhaps we meet in person at a meeting or conference to talk further.
I agree with the comment from NewFiGuy. 30-40% is a low number. Try over 50% in many states. These middlemen PPO and speciality PPO networks that are backed by private equity are a big part of the problem. And they are extorting serious $$ from providers to benefit themselves. They care nothing about injured workers. Joe, you have addressed this topic before and have disclosed you consult with one of these types of networks I refer to. We providers are no fans of them and I think you know that.
To suggest providers will go out of their way to rip off employers/payers is just not something I understand. Most states like the one I am in (AZ) has a regulated fee schedule and utilization review checks for any runaway case. AZ uses ODG. I can tell you from a PT perspective our cases and visits are monitored closely by adjustors and case managers. Frankly, we really do not need these third-party middlemen keeping an eye on us. I do not feel they offer any value to the process while just extorting $$ from providers. Not just some $$, but a lot! I don't think any diligent and good intentioned provider would have a problem doing business with any of them if they paid us fairly and did not treat us like imbeciles. There is one PT/therapy network out there that tries to do things differently, but there model is still using discounts. I get why. It's easy. But tracking outcomes and value in these cases is the only way to really get results in my opinion. Stay well.
First, you and a few others have narrowly focused on PT - that was not and is not the focus of my post.
Health systems and large provider groups/vertically integrated systems control most of the healthcare in this country, and they are damn good at maximizing reimbursement via coding etc. I've written about this extensively - feel free to search my posts. RCM is the fastest growing part of healthcare - and there are many RCM entities focused on workers' comp.
And check out margins from HCA and Tenet healthcare...they are thriving while most not for profits are in serious financial trouble - I've written about this extensively.
I'm quite familiar with work comp bill review...in general it is woefully unable to compete with effective RCM. Provider RCM can often run circles around a bill review operation due to the constantly changing complexity of WC billing and reimbursement regulations and case law.
Re PT, I'm quite familiar with pricing and margins in this sector, and I can assure you middlemen's margins on average are well below 30%. Much higher in some states (NJ), and a lot lower in others (NY).
I'm not sure I understand - or perhaps define - the problem the same way you do.
I strongly disagree with your statement that the people working at the intermediaries/middlemen I work with don't care about the injured workers - they absolutely do. That includes everyone from the scheduler to the CEO. They focus on outcomes, track it diligently, monitor practice patterns, share data...
Employers and taxpayers pay the bills. Injured workers get the care. The rest of us are supporting those two constituencies.
Employers and their payers want care delivered by qualified providers, scheduled, followed up on, documented and billed quickly, accurately, and consistently. That's a ton of work, work which they have ceded to intermediaries...because the work comp payer industry is very mature, and shows all the signs of that - margin compression, price competition, consolidation...
You may see this as "extortion", yet this is what our economy has become - you want convenience and cheaper stuff, so you shop at Wal-Mart and Amazon and Target, and small mom and pop shops are history. Do consumers or businesses seek out smaller, less efficient, and more costly suppliers? Of course not.
Employers shopping for PT are doing the same thing. Yeah, I know healthcare is different...but has any healthcare provider effectively demonstrated it is better in a way that appeals to the buyer? Very few.
It's easy to point the finger at- it's also pretty unproductive. If you want to break away from this, you have to figure out a way to differentiate.
I work with private practices. They have no leverage. Concentra is a large corp that provide terrible care. They have enough leverage to get a few more dollars from the middleman. I’m just amazed what consumers think about healthcare providers. They have no idea that a private practitioner has to live paycheck to paycheck and can hardly pay their bills. Anyone that’s in the healthcare space knows that there’s a massive corporate roll up. When you have to pay for the C suite, they extract that money from somewhere. It’s patient care. And no, economies of scale don’t make up for it.
Do you have some evidence or research supporting your claim that Concntra provides "terrible care"?
I understand your frustration re individual providers' lack of leverage. As I noted responding to your last comment, differentiation is the best tool you have to compete. If care is "terrible", show your employer clients the data. Show how you do a better job.
Also, I don't understand your comment regarding economies of scale. What are you trying to say?
Some PT providers can and do raise prices; Concentra is pretty darn good at leveraging its network to get higher margins. Some of the large groups are also successful at this.
Some small practices have allied with local businesses and built very strong ties that negate any potential pricing power large networks have.
As to middlemen doing nothing, perhaps from your perspective that may appear to be the case. From the payer side the networks credential, contract with, schedule patients for, and handle communications and billing with the hands-on provider. That is a big chunk of the "value" payers see.
Lastly, its all about differentiation and looking ahead. 29 years ago I worked for UnitedHealthcare...suffice it to say I did not look forward to spending decades in that environment, so I made the leap into a sole proprietorship.
I get the small operations are at a disadvantage - they don't have bargaining power. This is a classic mature industry problem - mass = negotiating power on the other side of the table; leading to consolidation, and more bargaining power on the your side, and on it goes.
If you don't want to compete in that arena, I completely understand. Differentiate.
Well, Joe, yes I am in reality and the reality is that the legalized organized crime of health insurance has screwed American consumers, but you’re on their side I get it. You enjoy your day while other suffer and die. I don’t have to complain about it but I will advocate. I was part of the $2.7 billion lawsuit win against Blue Cross and that’s following the $2.5 billion lawsuit that Blue Cross lost. But hey, you guys are the good guys Joe.
Well that was a totally uncalled for personal attack. I responded to your request and questions and you accuse me of enjoying life making others suffer.
Hello again Mark and thanks for your thoughtful note. I appreciate your willingness to engage and value your perspective
An observation re "big work comp networks tiering providers based on pricing/discounts and not outcomes."
One network did settle a lawsuit with a small PT organization; it was not clear if the network - One Call - prioritized net revenue over other metrics. I do know MedRisk does NOT do this...they have invested heavily in outcomes assessment, development of clinical guidelines, research into optimal treatments and provider assessment and use this research to route patients to specific providers/practices.
MedRisk has been sued by a provider organization - that suit went nowhere.
I posted today on RCM and have written about it extensively. I was on the Board of a Medicaid/Medicare duals health-plan for 7+ years...it relied heavily on payment integrity technology, both pre- and post-payment. With margins in the low single digits, it had to.
That kind of diligence is completely absent from workers' comp. There are a few companies that do some of this, but payers - and bill review companies - have been woefully slow to adopt sophisticated approaches to provider RCM. Coding and reimbursement - especially for facility-related bills - can be devilishly complex, with a fee schedule governing the physician services except for surgeries and UCR for some facility charges plus different rules for multi-site surgeries, assistant surgeons and on and on.
It's an arms race, and most work comp payers don't seem to care their arms are tied behind their backs.
be well and I do hope we can meet in person and continue the dialogue.
cheers Joe
This quote “ I do know MedRisk does NOT do this...they have invested heavily in outcomes assessment, development of clinical guidelines, research into optimal treatments and provider assessment and use this research to route patients to specific providers/practices.” Is the most ridiculous statement I have seen regarding WC and has nothing to do with reality in California. Medrisk is the absolute worst middleman siphon. They provide zero value to the injured worker or the care provider. Their research in optimal care is to route patients to the lowest bidder. One can only hope each and every lawsuit against Medrisk and the other WC middlemen succeeds and bankrupts them out of existence. The would be the single best thing that could happen to injured workers here in California.
Interesting comment Jeff. Please provide substantiation for your claim. what documents, materials, or credible research do you have?
As you may or may not know, the publisher of false and defamatory statements is at risk unless statements are supported by credible documentation.
Please provide said materials at your earliest convenience. Be well, Joe.
This blog post actually discusses a current lawsuit against Medrisk. https://blog.daisybill.com/workers-comp-reimbursement-iptca-medrisk?utm_source=DaisyBill&utm_campaign=c019a61638-MedRisk-Slashing-Worker-Comp-Reimburse-Rates-&utm_medium=email&utm_term=0_87b8d178f9-c019a61638-95103233
Just talk with practicing physical therapists, talk with CPTA, or any private practice groups. PT’s persuaded legislators successfully to change the workers’ comp fee schedule and have it tagged to the Medicare Fee schedule. This was a victory for injured workers in California as it was expected that if payment for care of injured workers was on par with the broader public, competition by quality providers would improve the quality of care injured workers received. Unfortunately, unforeseen loopholes in the legislative language has allowed 3rd party middlemen like Medrisk, profit off the backs of both injured workers and the healthcare professionals providing care. In some circumstances Medrisk will extract up to 50% of the payment for a given PT session, while literally providing the injured worker no value. Nothing. No care. What Medrisk may call oversight, practicing PT’s know it as expensive administrative barriers to treating injured workers. Maybe I am wrong, I am sure the Medrisk supporters will jump into the comments and contradict what I have argued.
Thanks for the prompt reply Jeff.
The fact that there is a lawsuit does not indicate there is any proof of your assertions. In fact that lawsuit has gone nowhere since it was filed in October of 2019.
The plaintiff contacted law enforcement officials in an effort to get them to follow up...after an investigation those officials took no further action.
I'd again suggest you provide credible documentation of those assertions. I've worked with MedRisk for over two decades; in all my discussions with MedRisk personnel at all levels I never heard anything whatsoever that would indicate your statement "Their research in optimal care is to route patients to the lowest bidder." is accurate.
In fact, the opposite is true.
If you cannot provide the requested support I suggest you withdraw your comment.
be well Joe
Thank you for your prompt response as well.
I did not realize you worked with MedRisk. I am sure you have better insights as to how that company works than I ever will. I am just a provider that sees the impact of MedRisk on community, my profession and my practice.
Lawsuits are exactly where assertions and arguments are adjudicated. You are correct, if there is not enough evidence the case will be dropped, but if there is a finding of wrongdoing the accusers will be vindicated. I guess we will have to see how that plays out.
As I stated, if my experience is the outlier, I am sure the internet will correct me and the numerous supporters of MedRisk will share how this company so positively impacted their wellbeing.
But since you do work with MedRisk, I would respectfully request you actually talk with the providers your company contracts with. Talk with iPTCA, CPTA or other Physical Therapy organizations. Should the middle man company profit more than the care provider for the services rendered? Should we create a race to the bottom of quality of care on the backs of injured workers? I suspect we could do better.
Joe, I always appreciate your thoughts and opinions. I can't argue with some of your points about shopping for efficiency and cost. However, I can tell you from direct experience that a provider in these types of networks just feels like a number. In 10 years I have never had a discussion with an actual therapist or peer or asked about my outcomes. They may be trying now as I have not participated in a 7 or 8 years. I like the Bardavon model better, but they are struggling to get providers to use and integrate their software which is really the only efficient way to track real performance. Also, my experience is in AZ and CA and I know providers here have had issues with the big work comp networks tiering providers based on pricing/discounts and not outcomes. Money matters, of course, to these private equity firms.
Yes, I know I am speaking from a PT perspective and we are small change in the whole scheme of things. However, in AZ and CA we are regulated by the same regulator these big health systems are. I agree some providers and health systems try and take advantage of wc, but there is only so much they can do with the checks and balances in place. Some bill reviewers are better at it than others and put human capital to work and not just computers. It really is not that hard to review a billing and see what is going on. Just takes time. I just do not see them making up the lost revenue on work comp.
Again, all I can speak to is my little world of therapy and rehabilitation. I saw the EOB's from payers and I can tell you in AZ we were being discounted around 65% or more of our fee schedule by these networks. I am just not sure how this can be justified. We do the work and they take more than half our money. Not a bad business model...lol. That was our bad and one of the main reasons we said bye bye. The other reason was it was like pulling teeth to get what money was owed to us.
I know cutting Medicaid is a complex multi-faceted problem and I do share your concern about people losing their healthcare. If it happens it will have serious ramifications for our economy. Stay well and some day perhaps we meet in person at a meeting or conference to talk further.
I agree with the comment from NewFiGuy. 30-40% is a low number. Try over 50% in many states. These middlemen PPO and speciality PPO networks that are backed by private equity are a big part of the problem. And they are extorting serious $$ from providers to benefit themselves. They care nothing about injured workers. Joe, you have addressed this topic before and have disclosed you consult with one of these types of networks I refer to. We providers are no fans of them and I think you know that.
To suggest providers will go out of their way to rip off employers/payers is just not something I understand. Most states like the one I am in (AZ) has a regulated fee schedule and utilization review checks for any runaway case. AZ uses ODG. I can tell you from a PT perspective our cases and visits are monitored closely by adjustors and case managers. Frankly, we really do not need these third-party middlemen keeping an eye on us. I do not feel they offer any value to the process while just extorting $$ from providers. Not just some $$, but a lot! I don't think any diligent and good intentioned provider would have a problem doing business with any of them if they paid us fairly and did not treat us like imbeciles. There is one PT/therapy network out there that tries to do things differently, but there model is still using discounts. I get why. It's easy. But tracking outcomes and value in these cases is the only way to really get results in my opinion. Stay well.
Hello Mark and thanks for the thoughtful note.
A couple observations.
First, you and a few others have narrowly focused on PT - that was not and is not the focus of my post.
Health systems and large provider groups/vertically integrated systems control most of the healthcare in this country, and they are damn good at maximizing reimbursement via coding etc. I've written about this extensively - feel free to search my posts. RCM is the fastest growing part of healthcare - and there are many RCM entities focused on workers' comp.
And check out margins from HCA and Tenet healthcare...they are thriving while most not for profits are in serious financial trouble - I've written about this extensively.
I'm quite familiar with work comp bill review...in general it is woefully unable to compete with effective RCM. Provider RCM can often run circles around a bill review operation due to the constantly changing complexity of WC billing and reimbursement regulations and case law.
Re PT, I'm quite familiar with pricing and margins in this sector, and I can assure you middlemen's margins on average are well below 30%. Much higher in some states (NJ), and a lot lower in others (NY).
I'm not sure I understand - or perhaps define - the problem the same way you do.
I strongly disagree with your statement that the people working at the intermediaries/middlemen I work with don't care about the injured workers - they absolutely do. That includes everyone from the scheduler to the CEO. They focus on outcomes, track it diligently, monitor practice patterns, share data...
Employers and taxpayers pay the bills. Injured workers get the care. The rest of us are supporting those two constituencies.
Employers and their payers want care delivered by qualified providers, scheduled, followed up on, documented and billed quickly, accurately, and consistently. That's a ton of work, work which they have ceded to intermediaries...because the work comp payer industry is very mature, and shows all the signs of that - margin compression, price competition, consolidation...
You may see this as "extortion", yet this is what our economy has become - you want convenience and cheaper stuff, so you shop at Wal-Mart and Amazon and Target, and small mom and pop shops are history. Do consumers or businesses seek out smaller, less efficient, and more costly suppliers? Of course not.
Employers shopping for PT are doing the same thing. Yeah, I know healthcare is different...but has any healthcare provider effectively demonstrated it is better in a way that appeals to the buyer? Very few.
It's easy to point the finger at- it's also pretty unproductive. If you want to break away from this, you have to figure out a way to differentiate.
be well Joe
🤣🤣🤣 - PT providers can’t raise prices. The middlemen take 30-40% for doing nothing.
Tell me what a physical therapy practice should differentiate on if they can’t get paid? Should Honda start making computers?
I did tell you but apparently you are so busy complaining about reality you aren't paying attention.
Payment follows differentiation not the other way around.
You have a a choice. Yell into the void, complain and lament the unfairness of it all...or do what I suggested.
Blaming reality is never a productive strategy.
I work with private practices. They have no leverage. Concentra is a large corp that provide terrible care. They have enough leverage to get a few more dollars from the middleman. I’m just amazed what consumers think about healthcare providers. They have no idea that a private practitioner has to live paycheck to paycheck and can hardly pay their bills. Anyone that’s in the healthcare space knows that there’s a massive corporate roll up. When you have to pay for the C suite, they extract that money from somewhere. It’s patient care. And no, economies of scale don’t make up for it.
Welcome back NFG.
Do you have some evidence or research supporting your claim that Concntra provides "terrible care"?
I understand your frustration re individual providers' lack of leverage. As I noted responding to your last comment, differentiation is the best tool you have to compete. If care is "terrible", show your employer clients the data. Show how you do a better job.
Also, I don't understand your comment regarding economies of scale. What are you trying to say?
be well Joe
Thanks for the note NewFiGuy.
Couple thoughts.
Some PT providers can and do raise prices; Concentra is pretty darn good at leveraging its network to get higher margins. Some of the large groups are also successful at this.
Some small practices have allied with local businesses and built very strong ties that negate any potential pricing power large networks have.
As to middlemen doing nothing, perhaps from your perspective that may appear to be the case. From the payer side the networks credential, contract with, schedule patients for, and handle communications and billing with the hands-on provider. That is a big chunk of the "value" payers see.
Lastly, its all about differentiation and looking ahead. 29 years ago I worked for UnitedHealthcare...suffice it to say I did not look forward to spending decades in that environment, so I made the leap into a sole proprietorship.
I get the small operations are at a disadvantage - they don't have bargaining power. This is a classic mature industry problem - mass = negotiating power on the other side of the table; leading to consolidation, and more bargaining power on the your side, and on it goes.
If you don't want to compete in that arena, I completely understand. Differentiate.
be well Joe
Well, Joe, yes I am in reality and the reality is that the legalized organized crime of health insurance has screwed American consumers, but you’re on their side I get it. You enjoy your day while other suffer and die. I don’t have to complain about it but I will advocate. I was part of the $2.7 billion lawsuit win against Blue Cross and that’s following the $2.5 billion lawsuit that Blue Cross lost. But hey, you guys are the good guys Joe.
NFG
Well that was a totally uncalled for personal attack. I responded to your request and questions and you accuse me of enjoying life making others suffer.
This conversation is over.
Be well Joe