issue 004, 2016 q1

Network improvements: Going the extra mile to help injured employees get to the right doctors

BY GEORGE FURLONG SVP, Managed Care Program Outcomes Analysis, Sedgwick

Whether you need to make dinner reservations at a new restaurant or an appointment for a first-time visit with a doctor, an accurate telephone number and location are essential. If an injured employee is unable to contact or find the physician for their workplace injury, it can be more than an inconvenience.

This is a real issue in the workers’ compensation and group health industries where 30% or more of the data in provider networks is incorrect.1 This includes information such as phone numbers, addresses and whether or not the providers are taking new patients. Every provider database in the industry, whether it is for group health or workers’ compensation, builds its list of providers from multiple networks. Part of the problem with the American healthcare system is that the applications used to maintain the information are on several different platforms that do not interface or correspond.

Network information inaccuracy is an industry-wide issue that has received attention from the federal and state governments as it relates to access to care, quality of care and the ability to identify doctors. “States are aware of the tension between accuracy and comprehensiveness when providing information to consumers. They understand that there are constraints on networks and carriers that rely on providers for the information and they are struggling to find a balance to make all stakeholders responsible. The details required for the directories are becoming increasingly complex – languages spoken, whether or not the provider is taking new clients, current office hours – all of that requires responsible and accurate reporting. As the states look for specific policies to further incentivize provider participation in the directories, carriers are looking for ways to streamline the information and make sure they are not duplicating their efforts,”  explains Robert A. Holden, Senior Vice President at Stateside Associates, a state and local government affairs firm that develops strategies to help industries and associations manage and improve a wide range of issues.

If the doctors do not provide updated information to the many networks they subscribe to or the networks do not take responsibility for updating their data, the employer and the injured employee can suffer. There is nothing worse than for an injured employee to show up at the address they’ve been given for a doctor’s office and find out that the doctor has moved. If an employee is given a telephone number for a specialist who is no longer in business or no longer accepting workers’ compensation patients, the employee has to call and ask the claims examiner or case manager to identify a different provider. This can cause treatment delays, unnecessary time away from work, increased claim durations and higher chances for litigation. The more bumps in the road like this, the more contentious – and costly – the claim can become. There has been no effective remedy in group health or workers’ compensation until now.


While challenges abound in preferred provider networks, Sedgwick has decided to take a stand and address this systemic problem for its customers and their injured employees by ensuring the provider information we share is accurate. In addition to using our provider benchmarking and search tool to find top-performing doctors for injured employees, we take the extra step to make sure we have the right information for each one of them in our database.

The Sedgwick team has proactively validated the demographic records for 60,000 providers and maintains it on an ongoing basis. We have a group of dedicated colleagues who continuously talk to the best-performing providers for workers’ compensation injuries to confirm that we have accurate information to give to injured employees. We have formally addressed the problem with this initiative, which includes continually identifying, updating and managing the data. It is part of providing appropriate care and ensuring injured employees have the best possible experience.

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This process improves efficiencies for our claims examiners and nurse case managers who are trying to take care of the injured employees, relieving them from individually validating and updating the provider information manually. Examiners and case managers still have the capability to update provider information if they find a bad record, but it is a team effort.

In the past, we would also send provider updates back to the networks. The networks frequently would add new records to their databases and not remove the old ones, or call the provider themselves and eventually update their database and three months later the data would be transmitted to the search tool leaving bad records in the system in the meantime. Due to the inconsistencies in their data management processes, we cannot rely on the networks to update the information. If the networks provide inaccurate records, we will continue to update them in our system.

In addition to updating the data, the verification is also tied into our provider benchmarking and search tool. We focus on identifying who the physicians are and assessing their performance and where they stack up in our quality benchmarking system. The process attaches them to their demographic records and validates those records to make sure that we have accurate locations, phone numbers, addresses and hours of operation, and that they are accepting workers’ compensation patients. These actions are the most important things we can do to ensure our customers’ injured employees get quality, appropriate care as quickly and seamlessly as possible.

issue 004, 2016 q1

Expert view

Q&A with Teresa Cheek, Managing Director, IT Enterprise Initiatives, Sedgwick