Regulator reveals costs of network and out-of-network claims

More injured workers are using networks to file claims – so how do the costs compare?

Insurance News

By Allie Sanchez

A recent report released by the Texas Department of Insurance (TDI) has revealed that claims coursed through managed care networks performed better and cost less in general than out-of-network claims. 

Among the top performers evaluated in the TDI 2016 Workers’ Compensation Network Report Card was WellComp Managed Care. In the annual report card, which compares the performance of certified networks with each other as well as with non-network claims, Well Comp bested other networks by specifically providing lower average medical costs, lower average medical costs for lost time claims, lower average professional costs, and lower average pharmacy costs.  

TDI data also reflects an increase in claims coursed through networks, as they currently represent almost half of workers’ compensation claims in the state, up from 20% in 2010.

The regulator further observed that network claims costs have been on a steady decline, in contrast to the rise in out-of-network costs. Also, for the first time since the adoption of health care networks in the Texas workers’ compensation system, the average medical cost per claim at six months and 18 months was lower for injured employees treated within a network compared with those who sought treatment outside a network.

D.C. Campbell, director of the TDI research and evaluation group, which produces the report, credits the improved network results to early action taken on claims.

“One of the strategies we’ve noticed is that networks provide higher levels of medical care earlier on,” Campbell noted. 

Steve Nichols, workers’ compensation manager for the Insurance Council of Texas, believes that the networks’ use of “cream of the crop doctors” who provide “higher quality care overall” also played a role. 

“By creating strong partnerships with our clients – both employers and claims administrators – we keep everyone focused on the goals of getting injured workers back to work as quickly as possible and managing costs responsibly,” Doug Markham, WellComp president, explained.  

Networks did not only outperform non-networks in average medical costs, however. The TDI report also noted that networks provide relatively better costs for physical medicine modalities, diagnostic testing, enhanced access to care, overall health outcomes, and return to work rates. 

TDI also found that injured workers treated in a network used professional and pharmacy services more, but did not use hospital services as much.

Related stories:
Payers’ workers comp drug spend declines: survey
Labor statistics reveal decline in workplace injuries

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