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Lowering Costs of Workers’ Comp Is Aim of Software

Lowering Costs of Workers’ Comp Is Aim of Software By JACQUELINE FOX Staff Reporter Woodland Hills-based Health Net Inc. and its subsidiary, Health Net Plus, have signed an exclusive deal with the makers of a software program created to help the HMO’s employer groups reduce workers’ compensation costs. Health Net is rolling out the Q-Worx billing management software program, a multi-tiered system designed to help bill reviewers determine if they are being charged fair market rates for workers’ comp bills, particularly those submitted from out-of-network, outpatient surgery centers. Unlike hospitals, outpatient surgery centers do not have to follow state medical fee schedules when setting rates, they are only required to offer fees that are “reasonable and fair.” Several state lawmakers, including Sen. Richard Alarcon, who represents the Valley, have introduced legislation that would establish a set of mandated fees for outpatient surgery centers, as well as pharmacies and home health service companies. But until such legislation clears, these medical care providers are free to set rates as they see fit, which is exacting a heavy toll on employers in California who are already paying among the highest premiums for workers’ comp insurance in the country. Q-Worx, developed by Portland-based Qmedtrix Systems Inc., enables bill reviewers to run a workers’ comp invoice from a non-contracted provider through a filtering system that compares the charges, for example, with those of outpatient centers nearby, as well as Health Net’s own pre-negotiated rates. This gives the reviewer a set of guidelines to follow to determine whether the bill amount is fair and reasonable. The software even provides medical updates on costs for prescriptions and treatments, as well as information on previous workers’ comp arbitration cases involving claims that may be similar to a bill in question. According to state statistics, non-network outpatient center costs to California employers represented about 5 percent of their incoming bills roughly five years ago. Today, the figure is closer to 35 percent. “Businesses are paying 20 to 40 percent higher premiums because of excessive costs being applied to workers’ comp case claims from ambulatory surgery centers because there are no state fee schedules in place and no uniform system for creating a fair and balanced set of costs,” said Tom Ash, president of Irvine-based Health Net Plus, Health Net’s managed care services unit. “Procedures that would normally cost about $800 in a physicians office are coming in from outpatient surgery centers at $8,000.”

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