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Not according to Tom Shivers, executive vice president at Healthcare Solutions, the Duluth, Ga.-based health services provider of integrated solutions to the property and casualty markets.

Although PPO networks have been used in workers' compensation for more than 30 years, payers have to be careful who they select as their service partner because the 'one-size-fit- all' approach no longer works," says Shivers.

"Healthcare Solutions started as a single-state provider, delivering the deepest penetration and savings results to customers," says David A. George, CEO of Healthcare Solutions. "Because the company held direct contracts with providers, we learned early the importance of developing positive relationships with the provider community as well as with customers."

Based on customer requests, Healthcare Solutions eventually expanded its PPO offering into additional states in the mid-Atlantic region.

"Customers provided the roadmap for the company's expansion strategy," George explains. "But the company's leadership made a conscious decision not to expand into a state until it was clear that the offering would be best-in-class."

"The company's growth strategy is still predicated on customer needs, performance and the continued ability to provide the highest level of customer service that our customers deserve," Shivers adds.

Today, Healthcare Solutions has evolved from its single-state provider beginnings in 1989 to its current offering of PPO solutions in 22 states.

According to Shivers, no company has the best product in every state, so it's important to find the top regional providers and develop a network that delivers the best outcomes based on each organization's claims distribution. In certain jurisdictions--where there's not a clear winner based on the disruption reports--it's important to consider other factors when making a purchasing decision, all of which can have a significant financial and operational impact to the purchaser.

During the procurement process, Healthcare Solutions' Shivers suggests considering the following:

DATA INTEGRITY

Every PPO offering includes some incorrect data, as providers change address and telephone numbers, change the type of health care coverage accepted, and open or close practices. Because of these frequent changes, it's important to assess how the PPO manages data. Healthcare Solutions provides complimentary panel production for customers, including 100 percent data verification. Prior to panels being disseminated to the customer, a provider relations specialist calls every provider on the panel to verify that the contact information is correct, and that the provider is still accepting new workers' compensation claims. There should never be a charge for data clean-up or provider verification. It is the PPO's responsibility to provide customers the most pristine data possible and fees associated with this process are inappropriate, Shivers says.

OUT-OF-NETWORK MANAGEMENT

It is important to know how your PPO partner will recruit providers into the network. While every PPO offers a nomination process that enables customer to request additions to the network, a more proactive approach should be used. Reports should be used to identify out-of-network providers who are utilized by injured workers, and this information should be used to proactively recruit providers into the network. PPO providers who wait for a nomination process to occur are missing out on an opportunity to provide additional savings to customers.

PROVIDER MANAGEMENT

Payers should ask how the PPO partner interacts with the provider community and an in-house provider relations department that is well staffed should be available to answer any questions, especially any disputes, appeals or fee reviews. By providing prompt and courteous provider relations, disputes can typically be quickly resolved. Provider education programs, such as provider newsletters or offering seminars for continuing education credits, helps establish positive relationships with providers and improves results for all stakeholders.

CUSTOMER SERVICE

A PPO partner should be just that--a partner. In addition to proactively managing the network on the customer's behalf, ensuring the most pristine data possible and returning high savings and penetration rates, every customer should be treated as a valued customer, no matter their size. An account executive should be assigned as a contact to address customer needs at any time. The PPO should be able to provide data feeds or custom and ad hoc reports within in a specific timeframe and according to a specified format. Flexibility is important to accommodate customer needs. Onsite stewardship meetings should provide the opportunity to talk about performance and identify new opportunities.

When selecting a PPO partner, savings and penetration rates are important, but before choosing a provider buyers should consider service as an additional success factor.

"The most valuable service we provide to our customers is our market-leading savings and penetration results," George says. "But we take greater satisfaction in our customer retention rate of 99 percent, which is based on our ability to deliver on projected results and provide each customer with an appropriately high level of service."

For more information, visit healthcaresolutions.com, or call 866-810-4332.

(The above piece is part of our continuing Insights series designed to highlight key products and services to our readers. This paid-for Insights was written and edited by Risk & Insurance® on behalf of our marketing partner. Additional Insights can be found on our Web site at www.riskandinsurance.com/.)

October 20, 2010

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