Market opportunity (proposed intermediary)

The market opportunity lies in the fact that the process of finding qualified, appropriate, and willing independent medical evaluators is a time-consuming and tedious process for insurers and attorneys alike. This is exacerbated even more by the on-going contentious relationship between insurers and providers: There is little trust and much resentment on the part of both parties toward each other. Additional factors include being able to streamline processes and cutting costs without needing to drastically reduce physicians’ fees, which is the current method usually being employed.

 Proposed intermediary

The proposed intermediary is an improved and online version of the independent stand-alone intermediary, but more completely integrated with both clients and providers. Clients will continue to be insurers, attorneys, and possibly employers. Providers will continue to include high-quality, usually board-certified, physicians, as well as nurse-consultants, physical and occupational therapists, and other health care providers.

The value-added with this proposed intermediary still includes the specialized service of finding appropriate, qualified, and willing independent health care providers to perform IMEs, file reviews, medical-legal strategic consultation, and other services for clients, just like the bricks and mortar business. However, the value-added is the amount of time and administrative costs that will be saved, as well as the option of real-time reporting; critical mass will also result in lowered costs.

Benefits to participants

Especially for insurers, saving time directly translates into saving money. Claims adjusters, the individuals who work for the insurance company and are responsible for managing a workers’ comp or personal injury claim, are often responsible for 150 to 200 claims at any given time. Cutting the time it takes to find a qualified IME doctor, scheduling an exam within a short timeframe, and turning around the report in seven days, or even offering it in real time—in short, streamlining the processes—will cut down the time it takes to close a claim. This will result in savings on a variety of costs, including unnecessary medical expenses, workers’ compensation “salary,” and the payout at the end of the case—not to mention getting the worker back to work as safely and quickly as possible, either at the same job or on light duty. Similar costs are saved in other medical-legal situations.

From the provider’s perspective, such an intermediary provides unsolicited revenue to his/her business. Additionally, working with an intermediary assures that the paperwork is properly completed and the files are complete; that they are working with an organization they trust; that they don’t have to deal directly with the insurance carriers, thus allowing them to maintain a true independent status; and that their fees are not randomly discounted, as insurers are apt to do.

Existing intermediary models

A. Process without an intermediary

    DIAGRAM 1—NO INTERMEDIARY
  Aggregation model: many to many

The current process of ordering IME’s without using an intermediary is rather haphazard. Note:
 1). Insurance adjuster has claim, and needs to know status of care and 
      prognosis by an independent reviewer.
 2). Adjuster determines needed services.
 3). Adjuster starts networking process to find a independent evaluator 
      who is:

• is the appropriate specialty, preferably board certified
• has a good reputation in the field, so that the report will hold up in court
• has not treated this patient for this injury (or, preferably, ever)
• is willing to be deposed, if necessary
• will turn the report around in a timely manner
• close to patients' home

• collect all medicals and documentation and send to doctor (or other)
• fill out appropriate paperwork
• send out letter to patient to inform him/her of appointment
• call doctor after appointment to verify that patient showed; if no show, reschedule
• wait for report
• authorize payment for report

• verify receipt of medicals, and call adjuster if they haven’t been received or are incomplete
• organize medicals to that they can be logically reviewed
• review medicals and see patient
• transcribe report; edit as necessary
• send report with bill to adjuster
• call for payment

B. Process with an intermediary

    DIAGRAM 2—NO INTERMEDIARY
  model: many to one to many

The current process of ordering IME’s using an intermediary is considerably streamlined, but still takes a lot of manpower. Note (the intermediary function is in blue):
 1). Insurance adjuster has claim, and needs to know status of care and 
      prognosis by an independent reviewer.
 2). Adjuster determines needed services.
 3). Adjuster contacts intermediary, and orders needed services by filling
      out form, faxing it over, and calling intermediary to verify receipt.
      Medical records are forwarded to intermediary.
 4). Intermediary starts networking process to find a independent
      evaluator who is:

• is the appropriate specialty, preferably board certified
• has a good reputation in the field, so that the report will hold up in court
• has not treated this patient for this injury (or, preferably, ever)
• is willing to be deposed, if necessary
• will turn the report around in a timely manner
• close to patients’ home

• verify receipt of medicals, and call adjuster if they haven’t been received or are incomplete 
• organize medicals to that they can be logically reviewed
• sends organized medicals to doctor (or other)
• sends out letter to patient, adjuster and doctor to inform them of appointment
• call doctor after appointment to verify that patient showed; if no show, reschedule
• wait for report
• review report to ensure quality and that all questions are answered
• authorize payment for report to physician
• send report and bill to adjuster

• review medicals and see patient
• transcribe report; edit as necessary
• send report with bill to intermediary

C. Proposed intermediary model

    DIAGRAM 3 ---Electronical intermediary (an integrated model)
 
 

The proposed intermediary model is similar to the bricks and mortar model above, but uses available technology to further streamline the process. Note (electronic function in pink, manual intermediary function in blue):

 1). Insurance adjuster has claim, and needs to know status of care and
      prognosis by an independent reviewer.
 2). Adjuster determines needed services.
 3). Since intermediary is backward integrated into adjusters’ database,
      adjuster simply

• clicks on a button and appropriate data is sent to proper fields;
• fills out other information, such as requested services, physician specialty, urgency of report receipt, etc. Phone contact is always an option.
• electronically sends the file to intermediary; any medical files stored electronically are also sent electronically
• medical files not in electronic format are either scanned and forwarded to intermediary electronically, or sent to intermediary via common carrier
• intermediary electronically notifies adjuster of receipt of request
• status of claim may be checked online
• saves contact time; lowers transcription errors; saves input time at intermediary

4).  Established non-integrated clients access intermediary online by 
      filling out a secure online form that is then electronically forwarded 
      to intermediary’s database. Medical files are sent electronically, if 
      appropriate, or by common carrier to intermediary.

• saves contact time; lowers transcription errors; saves input time at intermediary

 5). Non-established clients may become “established” by filling out the
      required forms online, which is then followed up by an intermediary
      representative to verify information and determine any special 
      preferences.
 6). Intermediary

• coordinates collection of medicals
• organizes medicals to be forwarded electronically to physician

• pre-qualified as having a good reputation in the field, so that the report will hold up in court; is willing to be deposed, if appropriate or necessary; will turn the report around in a timely manner
• is the appropriate specialty, preferably board certified
• has not treated this patient for this injury (or, preferably, ever)
• close to patients’ home
• available within the requested timeframe
• saves research time at intermediary

8). Electronic system will send recommended evaluators to intermediary
      representative

• representative approves choice(s)
• if doctor has agreed to blocked time (e.g., Tuesday 9-12), electronic system will set appointment, and send letters or email of notification to patient, adjuster, and doctor to inform them of appointment; forward integration allows system to automatically update doctor’s schedule
• organized medicals are sent electronically to doctors’ office
• saves phone time between intermediary and doctors’ office, as well as notification time and cost
• if necessary, representative will call doctors’ office to set appointment
• if no doctor is found in database, representative networks to find an appropriate candidate, who is then added to database

9). After appointment, intermediary

• sends automated electronic request to doctor to verify that patient showed; if no show, authorize or set reschedule
• waits for report and reviews to ensure quality and that all questions are answered 
• electronically authorizes payment for report to physician 
• electronically send report and bill to adjuster

 10). Once doctor agrees to perform evaluation, his/her office must

• download medicals and schedule from electronic format
• review medicals and see patient
• transcribe report; edit as necessary
• send report with bill to intermediary electronically
• assured receipt of medicals; cuts payment cycle.

In this model, the intermediary is an electronic B2B that acts like a true intermediary: as a facilitator of business between two parties that need to find each other. The online (web) component acts as both a storefront and information about the company, a secure site to determine status of service requests, and direct access to services and the network of providers.

Other value-added considerations, in addition to those mentioned above, include:providing other services, such as 

• file reviews
• impairment and disability evaluations
• medical-legal strategic consultation
• return-to-work determination
• others

Because all patient data is entered into our database system, aggregate demographic data can be tracked, which can in turn be sold back to the insurance companies, including
 

• types of claims filed
• injuries sustained (by diagnostic code)
• job functions that are most prone to injury, and type of injury
• impairments associated with specific injuries

Transparency was not considered to be an option because of the high possibility that once the parties found each other, they would eliminate the intermediary. (Adjusters tend to keep using the same, favored physicians, who inevitably become known as “insurance docs,” which is not exactly a compliment in the medical community.) A B2B exchange was eliminated as an option because the revenue model could not be assured, because existing networks play into this type of model, but do not seem to be taking hold, and because quality assurance regarding reports and payment could not be assured. This also assumes that insurers have the time to find appropriately qualified evaluators, and that both parties prefer to “do it themselves” than be catered to.

V. Other notes

Transparency was not considered to be an option because of the high possibility that once the parties found each other, they would eliminate the intermediary --- pre-screening provides value-added. (adjusters tend to keep using the same, favored physicians, who inevitably become known as "insurance docs," which is not exactly a compliment in the medical community.) A B2B exchange was eliminated as an option because the revenue model could not be assured, because existing provider networks play into this type of model, but do not seem to taking hold, and because quality assurance regarding reports and payment could not be assured. An exchange model also assumes that insurers have the time to find appropriately qualified evaluators, and that both parties prefer to "do it themselves" than be catered to.

Due to socialized medicine, the insurance, helathcare and workers' compensation systems outside the US do not necessarily or easily lend themselves to this type of intermediary solution. Most international opportunities will be through US-based MNEs or transnational companies, most likely to address job-related injuries sustained by Aamerican expatriates, or through the United States Federal  government, which has employees all over the world (military, State Department, etc.).