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Workers' Compensation and Managed Care

The increased presence of managed care is also evident in workers’ compensation programs where employers may contract with only one plan and employees are often assigned a physician.

Q. How does managed care within a workers’ compensation program differ from managed care in general?

A. In most managed care plans, members have the ability to select their physicians from a panel of plan providers. Additionally, more and more plans are offering point-of-service options which gives plan members unlimited physician choices for a higher fee. In the case of workers’ compensation managed care plans, the employer generally contracts with only one plan and sick or injured employees are often assigned a particular physician. Most managed care plans do not include appeals procedures, even though conflicts often occur when injured employees are returned to work before it is medically appropriate.

Q. Why is the ability to select a physician so important?

A. In workers’ compensation managed care plans, physicians have financial incentives to get workers back to work as quickly as possible and to lower the worker’s disability rating and award. The physician’s loyalties will be to the employer, and lowering employer costs may take precedence over treating the worker’s injury or illness.

Q. What if the plan does not include appropriate specialists?

A. Because workers’ compensation claims often involve injuries or diseases that require treatment by physicians trained in occupational illness, the make-up of the provider panel is extremely important.

Q. What type of protections are needed in workers’ compensation managed care plans?

A. Injured workers should have a choice of health plans, or at least a choice of providers within the plan. The plan should include physicians trained in occupational medicine and financial incentives that encourage high-quality care. The plan should include fair appeal procedures with reasonable time frames.