p 5

Industry Trends: Moving toValue-based CareWe’ve established several clinical programs using evidenced-basedmedicine focused on achieving the best possible outcomes and aprompt return to work.

p 7

Return-to-Work ProgramHelps Recovery of InjuredWorkersThe goal of workers’ compensation is to provide injured workerswith prompt and effective medical treatment so they can recoverquickly and return to work.

p 10

Navigating ICD-10HCS and its clients have made all the necessary updates to internaland external information management systems and beganaccepting ICD-10 codes on October 1, 2015.

A newsletter for Horizon Casualty Services participating health care professionals and their office staff.

November 2015 HorizonCasualty.com

2

President’s Message......................................................................................................................3

From the Desk of Gerard Malanga, MD, HCS Medical Director...............................................4

HCS InitiativesEnsuring a Positive Experience for Patients – The Initial Treater Experience ..........................5

Industry Trends: Moving to Value-based Care............................................................................5

Use of Compound Medications in Workers’ Compensation Increased Significantly..............6

Keeping Patients In-Network Helps Maximize Results ..............................................................7

AdministrativeNavigating ICD-10.........................................................................................................................7

Timely, Accurate Reimbursement: Use Correct Coding ............................................................8

Timely, Accurate Reimbursement: Ensure Appropriate Medical Documentation ..................9

Return-to-Work Program Helps Recovery of Injured Workers ................................................10

The Keys to Filing a Successful Appeal.....................................................................................10

Teams Work Together for our Network and Client Insurers ....................................................11

Send Us Your Office Updates.....................................................................................................11

Table of Contents

Horizon Casualty Services, Inc.3 Penn Plaza East, PP-14W, Newark, NJ 07105

Editor: Dorothy DriscollManaging Editor: Jennifer RocheDirector: Daisy Chan Design and Layout: Michael Piersanti

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Across the United States, there is increasing awarenessthat good health is essential to optimizing the lives ofindividuals and their families. Moreover, a healthfulpopulation is integral to a strong, stable economy.Health fuels our nation’s strength and viability.

Injury or illness disrupts lives. Horizon Casualty Services(HCS) provides support systems to help people accesshealth care during challenging times. Whether peopleare injured on the job or in auto accidents, HCS and itsnetwork professionals play an important role in helpingpeople return to leading productive lives.

Within workers’ compensation, HCS can achieve itsgreatest impact because New Jersey law allows theinsurer or its selected agent to direct care to appropriatemedical network participants. This allows HCS topioneer and implement best practices.

HCS is especially well positioned to lead thesegroundbreaking initiatives. HCS is New Jersey’s workers’ compensation PPO market leader with a client base of 45 percent of all New Jersey workers’compensation written premiums. Our company hasstrong, longstanding relationships with networkprofessionals. We have provided medical managementservices to a large population of claimants in our 20-yearcompany history. We have extensive data analyticcapabilities that we leverage to achieve our objective –the best possible outcome for claimants at the lowestcost.

In 2013, HCS launched the first-ever workers’compensation Pain Management Medical Home(PMMH) Program in the country. The program consists ofphysicians, pain psychologists and physical therapistscollaborating to deliver conservative medical care inaccordance with evidence-based medical guidelines.Preliminary results are outstanding. When outcomes ofPMMH patients were compared with a cohort group ofsimilar demographics, initial results show savings of 50 percent in medical costs and 50 percent in wagereplacement costs. Moreover, the study showed thatPMMH was effective in avoiding spinal surgery in someinstances because conservative approaches to treatmentwere sufficient in resolving high levels of pain.

HCS is now piloting Surgical Episode of Care (SEOC)Programs with the objective of connecting spine,shoulder and knee surgeons with designated physicaltherapists to help ensure that surgery is appropriate,

effective and well coordinatedwith ancillary services.

Both programs are focused onpatient engagement to helpensure that patientsunderstand their medicalcondition, are familiar with theaffected anatomy, and takeownership for assisting in theirown recoveries throughadherence to exercise and related therapeuticprograms.

We work to ensure that all workers’ compensationclaimants are treated by in-network physicians and otherhealth care professionals in all aspects of their care,including in-network hospitals and ambulatory surgerycenters. Timely access to care and a conservativeapproach to medical treatment using evidence-basedmedical guidelines, which can help avoid unnecessarysurgery wherever possible, are other importantelements. Outcomes-Focused Network programs –PMMH and SEOC – represent an even higher level ofmedical care excellence.

HCS is more than just a workers’ compensation andpersonal injury protection PPO. We differentiate ourcompany by actively collaborating with our medicalnetwork, client insurance company executives, claimadjusters and nurses to refer claimants to physicians,health care facilities and other medical professionalswho are focused on achieving optimal results. It is by thisapproach that we achieve sustainable value.

We have a responsibility to help improve the health ofour claimants. HCS fulfills this obligation by establishingsupport systems that enable injured workers to receiveappropriate care and achieve the best possibleoutcomes. In the coming years, HCS will continue toimplement its value-based workers’ compensationhealth care strategy. Thank you for your keycontributions toward achieving this goal.

Ilene B. WachsPresidentHorizon Casualty Services, Inc.

President’s Message

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From the Desk of…

HCS Medical DirectorThere continues to be exciting advances with our Outcomes-Focused Network(OFN). The first program developed within OFN was Pain Management MedicalHome (PMMH) Program, which focuses on early intervention of injured workers whohave suffered a spinal injury (primarily neck and low-back pain episodes). Theprogram uses the most current, scientific evidence of treatment of these injuriesand coordinates with clinicians, including a pain management physician, a painpsychologist and a physical therapist, who focus on functional rehabilitationtreatments. The goal of this program is to maximize outcomes, including diminished pain and a prompt returnto work, while decreasing use of opioid medications, avoiding excessive imaging and invasive procedures suchas spinal injections, and eliminating passive modalities in physical therapy.

The initial results from this program are impressive. With virtually no patients on opioid medications, use ofinjection procedures consistent with what has been reported in the current medical literature and faster returnto work times, the program achieved significant claim cost reductions.

We also initiated Surgical Episode of Care (SEOC) Program for workers who require either spine, knee orshoulder surgery. This program coordinates care so that surgeries are performed at in-network ambulatorysurgery centers (ASCs) and post-operative care is provided by physical therapists who have close workingrelationships with the surgeon. Once again, treatment plans are guided by current, scientifically validatedguidelines with the goal of a timely return to work.

Finally, HCS’ initial treaters have been reminded of the well-established principles of avoiding early,unnecessary imaging and excessive treatment, and timely referral, when necessary, to the most appropriatespecialist. For spine injuries, this would be a referral to a PMMH specialist instead of a spine surgeon. Currentresearch has demonstrated that this can result in a significant reduction in surgeries and their associated costs,and an increase in patient satisfaction. See page 5 for more information.

By using highly qualified medical professionals who provide state of the art, evidenced-based and coordinatedtreatment, these programs can achieve optimal outcomes – resolution of symptoms, efficient return to workand high patient satisfaction in a cost-efficient manner.

Gerard Malanga, MD Medical DirectorHorizon Casualty Services, Inc.

Gerard Malanga, MD

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Ensuring a Positive Experience for Patients –The Initial Treater ExperienceOur Initial Treater Episode of Care Program helpsinjured claimants achieve a speedy recovery and aprompt return to work. HCS’ initial treaters mustprovide injured claimants with quick access to medical care, accurate diagnosis, appropriate careand positive reinforcement.

Most occupational medicine and urgent care facilities that participate in the HCS network provideextended hours and walk-in services for a wide variety of work-related injuries. Patients who havemusculoskeletal injuries that do not requireemergency care are treated in an outpatient settingby clinicians whose focus is to return the patient topre-injury functioning as soon as possible.

HCS has established care plans using evidenced-based medicine to treat patients in theearly stages of an injury. The care plan outlines theappropriate evaluation and treatment processincluding time frames, diagnostics, medications,procedures, physical therapy and education.

Initial treaters guide patients through the acute phaseof the injury using conservative treatments and short-term therapies, when necessary. When referringto specialists, initial treaters are required to obtainprecertification and refer to the appropriate level ofcare within the HCS network. Documentation andexamination reports are submitted to the claimant’scase manager within the timelines set forth by theclaimant’s insurer.

Another essential component of HCS’ Initial TreatersEpisode of Care is patient engagement. Initial treatersmust educate patients on their condition, treatmentplan and goals using positive reinforcement so thatpatients remain active and focused on their recovery.

At HCS, our experience shows that providing prompt,efficient and appropriate care during the acute phaseof an injury enhances the injured worker’s experienceand results in a faster recovery and return to work.

Industry Trends: Moving to Value-based CareHCS is paving the way for change in the workers’compensation managed care industry. Instead offocusing on controlling the volume of servicesrendered, we are pursuing a value-based approach.

In the past, the industry approach to treating injuredclaimants was often fragmented, resulting in the high volume of unnecessary medical services, out-of-network expenses, overutilization of opioidmedications and loss of work time.

At HCS, we established several clinical programsusing evidenced-based medicine focused onachieving the best possible outcomes and a prompt

return to work. Our clinical programs includemultidisciplinary teams of quality health careprofessionals who work together to improvetreatment efficiency and reduce overall medical costs. Highly specialized groups of in-networkphysicians and other health care professionals,ambulatory surgery centers and anesthesiologistscollaborate to provide patients with personalizedcare.

The preliminary results of our clinical programstatistics show a reduction in the use of opioidmedications, a faster return to work and lowercosts per claim.

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Recently published industry studies indicate that the cost of topical compound medications hasdramatically increased in recent years and is expected to continue to rise, despite researchfindings that question their effectiveness and safety when used to treat work-related injuries.1

Study experts recently concluded that:

• There is no evidence that certain topicalcompound medications are safe or effective.

• The costs associated with compoundmedications are unreasonable.

• Compound medications increase the risks ofadverse effects.

Compound medications, in the form of topicalointments and creams, are prescribed to managepain. Some physicians maintain that compoundmedications offer an alternative to using addictiveand sometimes dangerous opioid medications.

Another emerging trend involving topical creams isthe sale of compound kits, which are being marketeddirectly to physicians. These kits provide prescribingphysicians with pre-weighed active and inactiveingredients used for compounding medications intotopical or other dosage formulations.

The indications for compound kits vary depending on the ingredients contained in the kit, but mayinclude topical analgesia and muscle relaxant therapy. An example of a compounding kit includes Ketoprofen-Lidocaine HCI Cream 10-2% (Vopac™).With an average wholesale price per kit of $600 to$2,500, there is potentially a significant financialimpact to payers as manufacturers market thesespecialty compounds.2

HCS employs rigorous precertification requirementsfor compound medicines as a means to protect theinjured worker and contain the skyrocketing costsassociated with compound medications. Prescribersare expected to use their best judgment when using apharmaceutical product outside of the approvedlabeling.

Use of Compound Medications in Workers’Compensation Increased Significantly

1 Walls AP, Johnson, S, Nguyen M, et al. Compounding isConfounding Workers’ Compensation. CompPharma. 2014. Available at CompPharma.com.

2 Workers’ Compensation Drug Trends Report 2015. Helios. 2015. Available at http://www.helioscomp.com/insights/2015-drug-trends-report.

VopacTM is a trademark of Sircle Laboratories, LLC.This article contains references to brand name prescriptionmedicines that are trademarks or registered marks ofpharmaceutical manufacturers that are not affiliated with Horizon Blue Cross Blue Shield of New Jersey, the Blue Cross andBlue Shield Association or Prime Therapeutics.

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Navigating ICD-10HCS and its clients have made all the necessaryupdates to internal and external informationmanagement systems and began accepting ICD-10 codes on October 1, 2015.

Physicians and other health care professionals mayencounter situations where they need to reportservices that occurred on dates when ICD-9 codeswere in effect and other times when ICD-10 codeswere in effect. Since ICD-9 codes and ICD-10 codescannot be reported on the same claim form, servicesmust be reported separately. When submittingmedical bills to HCS and its clients, please check theappropriate box for the code set used.

ICD-10 procedure codes provide expanded codelengths and will enable the addition of new codesthat better reflect current and emerging medicaltechnologies. Additionally, ICD-10 allows for greaterprecision in coding, billing and reimbursement,making complete and thorough medicaldocumentation essential to appropriatereimbursement for services.

Keeping Patients In Network Helps Maximize ResultsWhen referring patients for treatment of a work-related injury, services must be rendered in anin-network freestanding ambulatory surgery center orhospital-based, same-day surgery center, as stated inthe HCS Physician and Health Care ProfessionalOffice Manual. Network professionals and facilitiesare required to follow these policies, whether medicalcare is coordinated by HCS case managers or casemanagers based at our clients’ offices.

Additionally, when treating personal injury protection(PIP) claimants covered by HCS clients, your office isrequired to recommend the use of networkphysicians, facilities and other network professionalsbecause of their expertise in the treatment of

musculoskeletal injuries. Claimants who have PIPcoverage should also be made aware that they canmaximize their PIP benefits using HCS networkparticipants. Under New Jersey PIP regulations,patients have the right to seek medical care of theirchoosing. However, it is important to inform them oftheir options and how the HCS network might be anoverall benefit to them.

To obtain a list of HCS-participating freestandingambulatory surgery centers and hospitals, includingcontact information you can use to scheduleambulatory procedures, visit HorizonCasualty.comand select HCS Network Directory.

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Timely, Accurate Reimbursement: Use Correct CodingTo avoid medical bill system edits and receiveprompt, accurate reimbursement, you must followcorrect coding guidelines that are consistent with theAmerican Medical Association and those publishedby the Centers for Medicare & Medicaid Services’National Correct Coding Initiatives (NCCI). Medicalservices must be billed using the code that bestdescribes the services rendered. Clear, complete andconcise medical documentation must be used tosupport billing.

Our clients use sophisticated processing systems tovalidate the accuracy and appropriateness of thecodes reported prior to approving reimbursement.When a billed code fails to meet the system’sprocessing validation criteria or the code is notsupported by the medical documentation submitted,a bill processing edit occurs.

When billing for an office visit for the evaluation and management (E&M) of a new or established patient,select the E&M code that best identifies the level of service. The level of service criteria is determined byfactoring the skill level, effort, time and risk used to prevent or diagnose the illness or injury, along with thecomplexity of medical decision making and the face-to-face time spent with the patient.

Typically, the patient’s initial E&M visit requires a higher level of service than a follow-up visit. Therefore, thesame codes should not be used to bill for these visits. If the code used to report the initial E&M visit is thesame code used to report the E&M follow-up visit, a medical bill processing edit occurs.

Other coding guidelines used by HCS clients include NCCI Procedure-to-Procedure (PTP) edits. NCCI PTPedits identify services that are global to other procedures rendered to the same patient on the same date ofservice and should not be reported together. Services that are billed with inappropriate procedure codecombinations result in reimbursement denials.

For example, procedure code 20600, arthrocentesis, aspiration and/or injection, is billed with anesthesia code64450. Because this type of anesthesia provided by the surgeon is not separately payable, CPT® code 64450 isbundled into CPT code 20600.

Exception: Some procedure code combinations may be reported together if an appropriate NCCI-associatedmodifier is used and the documentation supports it.

For more information about correct coding and NCCI edits, visitcms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html.CPT® is a registered mark of the American Medical Association.

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Medical documentation is a key element of theappropriate management of an injured claimant.HCS and its client insurers use medical records toreview and monitor the claimants’ medical progressand verify the accuracy of the medical services billed.

Medical records facilitate:

• The ability of the physician and other health careprofessionals to manage the patient’s care

• Communication among physicians involved inthe patient’s care

• Accuracy and timeliness of medical bill review and reimbursement

• Appropriate utilization review and quality-of-care evaluations

• Collection of data for research and education

Insurers have an obligation to their claimants toensure that the services provided are consistent withtheir coverage and that the reimbursement formedical services rendered is accurate. It is imperativethat physicians and other health care professionalsprovide clear and complete medical documentationto validate:

• The site of service

• The medical necessity and appropriateness ofthe diagnostic and/or therapeutic servicesprovided

• The services rendered were accurately reported

General Principles of Medical RecordDocumentationThe following guidelines apply to all types of medicaland surgical services in all settings. For evaluation andmanagement (E&M) services, the nature and amountof physician work and documentation varies by typeof service, place of service and the patient’s status, sothese guidelines may be modified to account forthose variable circumstances in providing E&Mservices.

• The medical records should be complete andlegible.

• The documentation of each patient encountershould include the:

– Reason for the encounter and relevanthistory, physical examination findings andprior diagnostic test results;

– Assessment, clinical impression or diagnosis;

– Medical plan of care; and

– Date and legible identity of the observer.

• If not documented, the rationale for orderingdiagnostic and other ancillary services should beeasily inferred.

• Past and present diagnosis should be accessibleto the treating and/or consulting physician.

• Appropriate health risk factors should beidentified.

• The patient’s progress, response to and changesin treatment and revision of diagnosis should bedocumented.

• The diagnosis and treatment codes reported onthe health insurance claim form or billingstatement should be supported by thedocumentation in the medical record.

To maintain an accurate medical record, servicesshould be documented during the encounter or assoon as possible thereafter. If a service is not properlydocumented on the medical record, reimbursementmay be denied.

Timely, Accurate Reimbursement: Ensure Appropriate Medical Documentation

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Return-to-Work Program Helps Recovery ofInjured WorkersThe goal of workers’ compensation is to provideinjured workers with prompt and effective medicaltreatment so they can recover quickly and return towork. Some employers, including the State of New Jersey, offer their workers’ compensationclaimants the opportunity to return to work while they continue to recover from their injury. Our casemanagers and medical professionals work togetherwith the employer to tailor the return-to-work processto meet the needs of the injured worker and theemployer.

Some studies suggest that injured workers whoparticipate in a transitional return-to-work programrecover faster. Companies that provide return-to-workopportunities were able to lower their overall workers’compensation costs.

To determine the claimant’s eligibility to join a return-to-work program and/or to continue benefitpayments, most employers require their workers’compensation claimants to provide them with a

work-status note following each medical visit. Thework-status note describes the health careprofessional’s recommendation regarding thepatient’s ability to return to work.

The work-status note must include the following:

• Patient’s full name

• Date of service

• Work status with restrictions, if any

• Projected return-to-work date

• Date of next office visit

An effective return-to-work program benefits bothemployers and workers; employers’ productivity andworkers’ earnings remain stable.

HCS network professionals are required to comply with the employers’ requirements and the HCS policies contained in the HCS Physicians and Other Health Care Professionals Office Manual.

The Keys to Filing a Successful AppealHCS wants to ensure that reimbursements tophysicians, other health care professionals andfacilities are accurate. If you have a concern about areimbursement, you can submit a medical paymentappeal. The appeal must be submitted in writing andinclude the following documentation:

• A letter explaining what you are appealingand why

• A copy of the original bill

• A copy of the Explanation of Payment (EOP)

• Supporting medical documentation

Appeals can be faxed to 1-973-622-7265 ormailed to:

Horizon Casualty Services, Inc. Appeals Department PO Box 10175 Newark, NJ 07101-3175HCS responds to all appeals within 15 business daysof receipt.

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Teams Work Together for our Network andClient InsurersOur Network Relations Representatives, incollaboration with our Client Services AccountLiaisons, handle administrative work betweenphysicians, other health care professionals, facilitiesand client insurers.

Network Relations Representatives are responsiblefor:

• Conducting new provider orientations

• Resolving administrative complaints promptly

• Developing network communications

• Supporting HCS provider initiatives

Account Liaisons provide support services to clientsrelated to HCS operations by:

• Coordinating medical bill reconsiderations

• Monitoring electronic data interchangetransactions

• Assisting with business process improvements

• Ensuring that service level agreements are met

Maintaining a well-coordinated business operationenables HCS, its clients and HCS network participantsto maximize administrative efficiencies and meet ourbusiness objectives.

Send Us Your Office UpdatesHas your office moved? Has another physician joined your practice? If any practice information changes,let us know so referrals can be made and reimbursements reach you in a timely manner. Practiceinformation includes:

• Phone/fax number

• Address, including new locations or the closure of existing locations

• Physician(s) joining or leaving the practice

• Tax Identification Number (TIN)

• Practice name or ownership

• Other changes affecting your practice

Please mail information changes listed on practice letterhead to:

Horizon Casualty Services Attn: Network Services PO Box 10175 Newark NJ 07101-3175Thank you in advance for your assistance.

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Learn more at HorizonCasualty.com

Services and products may be provided by Horizon Casualty Services, Inc., P.O. Box 10175, Newark, NJ 07101-3175,a subsidiary of Horizon Blue Cross Blue Shield of New Jersey. Horizon Casualty Services and Horizon Blue Cross Blue Shieldof New Jersey are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross® and Blue Shield® names and symbols are registered marks of the Blue Cross and Blue Shield Association.The Horizon® name and symbols are registered marks of Horizon Blue Cross Blue Shield of New Jersey. © 2015 Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey 07105.