希瑟Tomhave
项目经理，产品管理
阅读我们最近对希瑟Tomhave的采访, 考文垂德州卫生保健网络(HCN)项目经理将讨论德州卫生保健系统, TX HCN是如何工作的, 项目要求和使用考文垂TX HCN的好处.
Q. 你能给我们简单回顾一下德克萨斯州的工人赔偿制度吗
A. The State of Texas is unique in that the state does not require private employers to purchase workers’ compensation insurance for their employees. 决定不购买工人赔偿保险的雇主被称为“非订户”。.
根据德克萨斯州最近公布的估计, 德克萨斯州大约20%的私营部门劳动力受雇于非WC系统用户.
Managing the treatment for work-related injuries for non-subscribers falls outside the State’s Workers’ Compensation Rules and Regulations. 结果是, non-subscribers do not benefit from some of the legal protections offered to subscribers to the workers’ compensation system. 然而, 从提供者契约的角度来看, 因为非订户不符合国家的工作补偿规则和条例, they do have the option to access provider contracts through any alternative coverage plans they may have in place for their employees.
问:你能描述一下德州医疗保健网络(HCN)是什么以及它是如何运作的吗?
答:医疗保健网络(或HCN)亚博真人官方版APP适用于德克萨斯州工人赔偿系统的订户. 那些为员工制定了工伤补偿政策的公司.
2006年，德克萨斯州立法机关实施了众议院第7号法案. 该法案旨在改革德州工人的薪酬制度, 哪家公司的成本增长达到了两位数, 医疗利用率高，复工率低. HB7的关键举措是建立卫生保健网络.
卫生保健网络提供了降低医疗费用的框架, 确保受伤员工接受的护理在医学上是适当的, 提高复工率, 帮助受伤员工获得满意度和护理, 等.
从2011年开始, 德克萨斯州的另一项立法取消了雇主参加工人赔偿制度的选择, 但还没有加入HCN, 无法获得低于国家收费标准的供应商折扣. 今天，任何WC系统的用户都想要访问德克萨斯州的正式提供商网络, 必须通过认证的HCN.
问:卫生保健网络(HCN)认证过程是如何运作的?
答:德州保险部门管理医疗保健网络. 要获得国家的认证，需要一个具体而详细的申请过程. 一次认证, the HCN is available to contract with carriers as well as self-insured employers to provide health care services to injured employees in Texas. 雇主可以选择使用，但不要求使用认证的工人补偿网络. Recent estimates published by the State of Texas indicate that approximately 48% of subscribers to the workers’ compensation system today are enrolled in an HCN.
问:为什么雇主不决定加入HCN?
A:我们收到的反馈是，这个项目对一些雇主来说可能有点行政负担. 然而, 因为考文垂从一开始就为德克萨斯州的雇主提供HCN亚博真人官方版APP, 我们有一个精简和明确的执行程序. 考文垂学院协助航空公司及其雇主完成项目的行政管理工作, 这样他们就可以利用这个项目的好处, 哪些比最初的实现步骤和需求更重要.
问:你能解释一下这个项目的“管理部分”是什么意思吗?
A:一经认证, HCN必须与希望使用其HCN的承运人和/或自保雇主签订合同. 另外, HCN本身不执行的任何必需的HCN组件, must be managed through a third-party delegation agreement between the certified HCN and the vendor performing the service. That agreement includes oversight of the third-party delegate by the Certified HCN to ensure all components of an HCN are being managed according to the State’s Rules and Regulations.
除了所需的收缩件, 承运人和雇主必须向雇员提供HCN计划的通知. That Notice is required to go out to all employees when the program is implemented (or within 3-days of hire to new employees, 一旦程序就位). 工伤发生时，须再次通知员工. 此外，雇主必须在工作场所的公共区域张贴有关HCN的通知.
这些合同和通知要求共享有关HCN项目所需组件的具体细节.
问:TX HCN需要哪些组件?
答:HCN的基本组成部分包括接入提供商网络, 一个案例管理和质量保险计划, 利用审核, 网络管理服务, 投诉管理和报告程序.
国家按县对每个HCN进行认证, 确保居住在“网络服务区”或县内的受伤员工获得足够的护理. 当受伤发生时, 如果需要紧急护理, 员工可以去最近的紧急设施-无论该设施是否在HCN中, 或不.
然而, 一旦紧急情况得到解决或需要非紧急护理时, 受伤的员工必须从网络供应商的名单中选择一名治疗医生，以进一步管理他们的护理. The treating doctor would be responsible for referring the injured employees to any specialists (also within the network) when specialized care is required.
HCN Rules do allow injured employees not satisfied with their initial choice in treating doctors to make one change without the HCN’s approval. 任何后续更改必须通过HCN的网络管理服务批准. Those services may also include approving out-of-network treatment if a network provider cannot be found to provide the service and reviewing other potential provider scenarios like established HMO providers or specialists who would like to serve as the injured employees treating doctor.
受伤员工的治疗是通过雇主之间的合作来管理的, the treating provider and the HCN’s case management program to ensure the injured employee receives the most appropriate care for their injury, 让他们重返工作岗位, 健康和生命越快越好.
德克萨斯州要求对所有受伤员工的使用情况进行审查, 无论他们是否注册了HCN. 然而, HCN’s can establish different 利用审核 requirements than the State’s standard list – which can further manage the appropriateness of the care the injured employee is receiving. HCN’s also have specific reporting requirements that they must work in collaboration with the employer / carrier to meet.
If any participant in the HCN program becomes unsatisfied with the service they receive related to any of these components they are welcome to file a complaint. HCN必须有适当的流程来管理和记录收到的任何投诉.
Coventry has proven and established workflows in place to meet or assist the carrier and/or employer in fulfilling all of the required components. 一旦实施，承运人和雇主可以利用HCN计划的好处.
问:访问HCN的好处是什么?
答:最大的好处是能够获得低于国家收费计划的网络合同费率. The ability to ensure the injured employee has the access to care they need and that care is delivered by network providers with proven results is also key. Treatment within the HCN can be strictly managed by requiring out-of-network approval any time an injured employee needs to obtain care outside the HCN.
和, 当然, the injured employee’s care is managed through case management and 利用审核 components that ensure treatment is appropriate and effective. 所有工作人员将在安全、适当的情况下尽快让受伤员工重返工作岗位.
The State of Texas reviews the results of injuries managed through network and non-network settings every other year via their Network Report Card. Recent years clearly show injured employees enrolled in a network tend to be more satisfied with the care they receive, 更快地得到他们需要的照顾, 并且比在HCN之外处理索赔更快地恢复工作. Costs associated with care received via a network also tend to be lower; especially as the claim matures.
问:不同的付费用户对HCN有不同的需求和目标吗?
答:截至今天，27家HCN通过了德克萨斯州的认证, Coventry has some relationship (whether that be holding the certification ourselves or supporting the certification of one of our Network Partners with 16 of those HCN’s. Each network is established to serve a specific population of injured employees and meet the various goals of the specific HCN.
问:考文垂提供哪些类型的TX HCN课程?
答:考文垂提供了几种HCN选择，旨在满足德克萨斯州的法定要求, 管理医疗护理, 降低索赔成本, 并改善整体索赔结果. 最广泛使用的亚博真人官方版APP是考文垂工人补偿网络. 最初于2007年获得德克萨斯州认证, 考文垂工人补偿网络在该州所有254个县和10多个县获得认证,每年有000名受伤员工访问该网络.
问:考文垂HCN的不同之处是什么?
答:考文垂与我们的客户在国家备案方面有着数十年的专业经验, 与全国15个完全捆绑和网络认证的项目合规性和法规. 建立在多年的专业知识与米切尔，Genex和考文垂. Teams across Enlyte work together to fully support the Coventry Workers’ Comp Network and other Coventry HCN solutions.
Coventry provides the provider network expertise; committed to identifying and recruiting the best primary treating and specialty providers available. We collaborate with those providers to ensure they make referrals to other network providers when at all possible and adhere to all network treatment and return-to-work guidelines.
Genex provides case management and 利用审核 expertise; with the goal of improving outcomes, 确保适当的护理，并最终使受伤的员工在医疗条件允许的情况下尽快返回工作岗位.
米切尔 provides the bill review system that manages the pricing and cost containment solutions and ensures all reporting requirements are appropriately managed and met.
All three of these Enlyte organizations offer a full-service managed care solution to the workers’ compensation market. 通过这些成熟和成熟的团队, the Coventry Workers’ Comp Network and all other Coventry HCN solutions are administered with strict adherence to HCN rules and requirements. Enlyte团队之间的无缝集成无疑提高了HCN的整体成果和效益.
对于那些优先考虑员工补偿结果的人, Enlyte始终致力于在医疗保健网络亚博真人官方版APP(HCN)方面提供无与伦比的专业知识。. 安排一次咨询 今天与网络专家一起探索我们全面的网络产品套件, 确保精确地满足组织的需求.