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.

Employees must call the NHADA injury management facilitator, Marta Silakka, immediately after an injury occurs so that she can help the employee choose the best network provider based on the injury. Employers’ and employees’ knowledge of Managed Care and appropriate reporting requirements will ensure that they follow the appropriate protocol after an injury occurs and get off on the right foot immediately. NHADA members who are prepared to take injured workers back to work in advance of an injury will have the best outcomes after an injury occurs. 

NHADA’s claims staff can help members prepare for temporary alternate duty. We can also provide members with posters and tri-folds as needed and provide members with training on how best to educate and inform employees of the managed care and workers’ compensation process.

When Completing the Employers First Report of Injury (Form 8WC), How Should NHADA-WCT Members Fill Out Box #47?

Box #47 reads “Managed Care Program Y or N. If yes, name provider.” The answer is yes, and the name of the provider is Windham Managed Care. Windham Managed Care is NHADA’s current managed care program, and we utilize their network of providers.

The NHADA WCT Managed Care Program is successful because our members pay attention to following the appropriate protocols. Workplace injuries must be handled differently than personal health conditions. The employee’s primary care physician is there to treat non-work-related conditions. Our managed care network physicians understand the importance of prompt treatment and prompt referrals to specialty providers to maximize healing and resumption of activities in and out of work.

Emergency rooms must be reserved for life-threatening injuries. Most injuries can be treated at urgent care centers such as ConvenientMD, and if necessary, they will refer to the emergency room or a higher level of specialty. 

Remember, a call to our injury management facilitator, Marta Silakka, immediately after an injury occurs at (800) 852-3372 is the best way to begin the workers’ comp. process.