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Illinois’ Work Comp PPO: What’s the Real Impact?

Last Updated on Monday, 16 April 2012 20:56

Employers and insurers decry the recent reform instituting PPOs in Illinois as ‘California Lite’. Plaintiff attorneys claim it will lead to undertreatment and negative consequences for claimants.

What’s the real impact?

The right answer is it’s a bit early to say. The PPOs go into effect September 1; at least they CAN go into effect then; there’s a lot to be done by employers, network developers, and regulators before an employer can activate a PPO, so it may well be several more months before we start seeing widespread adoption.

First, the State Department of Insurance has to certify Preferred Provider Programs – there’s too much text to quote here – search for “Sec. 8.1a. Preferred provider programs” – relevant section starts on page 88 line 23.

When an employer does get a PPO certified and implemented, there’s a couple key points to remember.

First, when an employee reports an injury the employer has to tell him/her of the PPP and the employee’s need to choose a physician from the PPP.

Second, employees can opt out of the PPP – here’s the relevant text:

“Subsequent to the report of an injury by an employee, the employee may choose in writing at any time to decline the preferred provider program, [emphasis added] in which case that would constitute one of the two choices of medical providers to which the employee is entitled under subsection (a)(2) or (a)(3)”

Essentially this allows the injured worker to choose their initial treating doc, who controls their referrals to specialists, ancillary providers, and facilities. My take on the network direction provision is it is pretty weak, and – realistically – will help with those claimants engaged in doctor shopping. However, payers’ ability to control which physicians and other providers treat their injured worker, while certainly strengthened, is not greatly enhanced.

While some seem to have concluded that the initial opt-out decision is one choice, and the subsequent selection of a provider is the second, I’m not sure that’s the case. The regulatory process will certainly clarify the issue, and if the other analyses are correct, the single opt-out choice will help employers – and in most cases, facilitate return to work and reduce unnecessary medical expense.

That said, note that an injured worker’s initial opt out includes the treating doc, and anyone that treating doc refers the worker to. Physical therapy, imaging, surgery, hospitals, you name it. That’s a lot of ‘opt-out’. My sense is Illinois providers who want to maintain their current lucrative flow of work comp patients will get very good at complying with the (future) regulations to keep referrals within that initial treatment stream.

What does this mean for you?

The net is this – the regulatory process will greatly affect the actual impact of the reform law. We don’t yet know what the specifics will be, but any employer would be well-served to identify PPPs that:

– a) contract with a relatively few physicians with demonstrated expertise in workers comp and focus on return to work;

– b) don’t include every doc in the yellow pages (I’d run from any PPP that markets itself based on how many physicians it has); and

– c) include ancillary providers to keep care in the PPP.

Of course, discounts are important, but make sure the treating docs – the ones who order the scripts, arrange for surgery, prescribe PT, and facilitate RTW – are treated well. Look for deeper discounts on the ancillary/secondary providers – the ones that do what the original doc tells them to.


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Claims Eval