Instead of juggling all of the various parties within theworkers' compensation world — physicians, hospitals, nurse casemanagers, pharmacies, physical therapists, insurance carriers and claims adjusters —employers would be far better off working with a third-party administrator, according to ESIS'whitepaper, “WhyEmployers Should Consider Integrated Medical Programs to ManageWorkers Compensation Costs.”

“By connecting all programs, people and sources of datatogether, a wealth of real-time information can be accessed,aggregated and analyzed,” writes Veronica D. Cressman, ESIS' seniorvice president, medical programs. “Employers and their TPA partnersare able to detect unusually lengthy claim durations, evidence offraudulent and inaccurate healthcare provider billing, and otherinflated costs, arming them to take actions toquickly resolve these issues.”

However, if an employer works with multiple vendors, theinformation needed to efficiently identify wasteful medicalprocedures, skyrocketing drug expenses and unusually long claimdurations is buried in multiple data systems and processes,“impeding data analysis for actionable purposes.”

Cressman details three areas where the use of a TPA can make asignificant difference: bill review, case management and dataintegration in medical programs.

The use of TPAs can greatly enhance bill review, she writes.Medical bills often contain medical coding errors and can containunrelated or incorrect treatment records resulting in wastefulcosts and inaccuracies. TPAs can provide robust systems that cancompare provider bills to verify all charges fall within statemandated fee schedule guidelines, detect bill duplication andcoding errors to make sure all charges being billed are trulyrelated to an injured employees work related injury andtreatment.

“A well rounded program which incorporates a stringent approachto bill review and connects nurse case management and data reviewis necessary to help control these and other claim costs, with theadded benefit of allowing the claim adjuster to stay focused on theinjured workers recovery and ultimate closure of the case,”Cressman writes.

Case management can also be incredibly cumbersome if notintegrated, she writes. Typical questions that nurse case managersface, such as why a seemingly minor claim absorbed $500 in pharmacycosts, or why an employee repeatedly visited an emergency roominstead of making an appointment with a doctor, are difficult toresolve when a nurse has to work with multiple vendors' siloed datasystems.

“By integrating the various parties and programs together suchas the catastrophe nurse coordinating with the durable medicalequipment program, or the pharmacy benefit management program beingintegrated within the triage process — it allows for better overallcontrol of the claim,” Cressman writes. “Inquiries are much easierto perform, and responses to concerns are more immediatelyavailable. By taking this approach, the nurse is able to be farmore effective with regard to the overall outcome of the injuredemployee.”

Another benefit to using a TPA: data integration in medicalprograms is far superior, she writes. If an employer works withmultiple vendors for their various medical programs, quicklypulling meaningful stats surrounding areas such as occupation andinjury types, lost work days, tenure, cost drivers and theirassociated financial impact proves to be much more cumbersome andleaves potential for inaccuracy.

“Employers lose their ability to easily access more robust data,which also limits their ability to be responsive to jurisdictionaldemands, as many states are now requiring electronic datainterchange reporting as well as supplemental ad-hoc data onvarious aspects of insured and self-insured programs,” Cressmanwrites.

A streamlined process under the more integrated TPA approachallows for more assured compliance with jurisdictional reportingrequirements, she writes. A unified claims management process alsoenables more real-time adjustments to improve processes.

“Having an integrated program with a focused approach tyingtogether all aspects of medical programs including bill review,case management and data within the entire claims managementprocess, employers today can achieve stronger results allowing themto keep the focus on innovation and ultimately impact their thebottom line,” Cressman concludes.