This week will discuss TRICARE and managed care workers compensation programs.

This week will discuss TRICARE and managed care workers compensation programs. Be sure to answer questions for both of these topics in your initial response to the Discussion Board.

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TRICARE:

What are three health care options of TRICARE?

What is the role of a TRICARE PCM (Primary Care Manager)?

Workers Compensation:

Review the definition of managed care in Chapter 3, and also read page 619 before responding to the following:

List at least 3 benefits from incorporating managed care into workers’ compensation programs.

Can you think of any disadvantages of having managed care incorporated into workers’ compensation programs?

Should patients be able to choose their own doctor for workers’ compensation injury care?

Chapter 3 Definition of Managed Care

A managed care organization (MCO) is responsible for the health of a group of enrollees and can be a health plan, hospital, physician group, or health system. Unlike traditional fee-for-service plans, which reimburse providers for individual health care services rendered, managed care is financed according to a method called capitation, where providers accept pre-established payments for providing health care services to enrollees over a period of time (usually one year).

and page 619

Out-of-State Treatment

Billing regulations vary from state to state. Contact the workers’ compensation board (or workers’ compensation commission) in the state where the injury occurred for billing instructions if an injured worker presents for treatment of a work-related injury that occurred in another state.

WORKERS’ COMPENSATION AND MANAGED CARE

Both employees and employers have benefited from incorporating managed care into workers’ compensation programs, thereby improving the quality of medical benefits and services provided. For employers, managed care protects human resources and reduces workers’ compensation costs. For employees, the benefits include:

• More comprehensive coverage, because states continue to eliminate exemptions under current law (e.g., small businesses and temporary workers)

• Expanded health care coverage if the injury or illness is work-related and the treatment/service is reasonable and necessary

• Provision of appropriate medical treatment to facilitate healing and promote prompt return to work (lack of treatment can result in increased permanent disability, greater wage replacement benefits, and higher total claim costs)

• Internal grievance and dispute resolution procedures involving the care and treatment provided by the workers’ compensation program, along with an appeals process to the state workers’ compensation agency

• Coordination of medical treatment and services with other services designed to get workers back to work (research by the Florida Division of Workers’ Compensation suggests that managed care may reduce the time it takes an injured worker to return to work)

• No out-of-pocket costs for coverage or provision of medical services and treatment; cost/time limits do not apply when an injury or illness occurs