Workers’ compensation payers are seeking new solutions that provide access to the best diagnostic providers and accurate test results. Based on its 17 years of experience in diagnostic radiology and electrodiagostics, One Call Medical has identified the top seven criteria that can be used to assess the quality quotient of a provider network.

Checkpoint #1: Provider Credentialing.
Quality begins and ends with the qualifications and experience of the providers who perform the test. As a result, the first indicator of a quality network is the process by which providers are evaluated and admitted into a diagnostic network. 

Some networks say they assess provider qualifications, but in truth, they do little more than process a signed provider request to join. Proper provider credentialing is rigorous and labor-intensive and can therefore be quite time-consuming and expensive.

One Call Medical, the largest provider of diagnostic testing to the workers’ compensation industry, is fundamentally committed to quality. As such, it has built quality into the very foundation of its provider credentialing process, employing a large team of 10 full-time employees to conduct, manage, and continually improve the credentialing process.

All OCM network providers go through a rigorous credentialing process, which meets or exceeds standards set by the National Committee for Quality Assurance (NCQA), a not-for-profit organization dedicated to improving health care and the recognized symbol for medical quality.

OCM also uses the American Medical Association (AMA) and National Practitioner Data Bank (NPDB) to verify professional credentials, licensure, and memberships. Every three years, its providers are re-credentialed to ensure ongoing adherence to quality guidelines.

By December 2012, radiology providers must be accredited by the American College of Radiology (ACR) in order to receive payment from Medicare. In this regard, One Call Medical is ahead of the game. It credentials 100% of its providers, and its quality standards meet or exceed national quality guidelines. 

Checkpoint #2: Volume Matters.
The volume of diagnostic tests performed by a single network is not only an indicator of that organization’s business success, but also of the quality of the services provided.

Statistics show that when procedures are performed often, the quality of those services go up over time. This was the thesis behind the bestselling book, “Outliers,” by Malcolm Gladwell, and the concept is borne out with statistics. For example, hospitals performing the highest number of specific medical procedures have the best outcomes for those procedures. In short, experience breeds excellence.

The One Call Medical network schedules  more than 400,000 diagnostic tests annually. No other diagnostic network in workers’ compensation comes close to handling this volume. Consequently, OCM providers get better and better at what they do.

In addition to consistent enhancement in the quality of the tests performed, high volume also improves the efficiency of the processes around the tests. Regular and consistent interactions with providers results in integrated workflows that are repeatable and reliable. As a result, appointment times are faster; turnaround time on medical reports is quicker for all stakeholders; information for both the provider and the patient is streamlined and clear, eliminating confusion or misunderstandings; and even billing is easier. These process improvements are possible only with a strong partnership built from high volume and consistent performance against commitments to each other.

Checkpoint #3: Using Evidence-based Outcomes for Complex Electrodiagnostic Tests.
In workers’ compensation, electrodiagnostic tests—such as Electromyography (EMG) and Nerve Conduction Studies (NCS)—provide a roadmap to locate and evaluate the type and severity of nerve injuries.

With no barrier to entry in this field, payers often receive test results from providers who have no proven training or expertise in performing these tests and as a result, tests may be inaccurate.

A study presented at last year’s annual American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) meeting confirmed this theory. The study reviewed 140 EMG/NCS reports to assess the medical usefulness of reports performed by providers who had not undergone a pre-qualification process. Out of these reports, 68 percent were considered not medically useful. In a number of cases, surgeries had to be cancelled and repeat studies were requested by other physicians. 

Inaccurate diagnostic information can lead to inappropriate treatment plans and undetected co-morbidities. As a result, employee injuries may not be effectively addressed or they may actually worsen, driving up the cost and length of those claims.

One Call Medical is the only company with a network of qualified EMG and NCS providers (neurologists and physiatrists), selected and credentialed using AANEM quality guidelines and an evidence-based approach that continually monitors quality.

“Of the networks I participate in, only One Call Medical performs a credentialing process to verify qualifications and review sample reports to ensure quality,” said Dr. John Robinton, Medical Director at One Call Medical. “Passing this credentialing process is a prerequisite to being admitted into the One Call Medical network. Other provider networks only require a provider request to perform EMGs and a signature.”

OCM’s Medical Director oversees the Clinical Services team, which reviews all provider reports and ensures continual adherence to quality guidelines and proprietary report standards. In this way, OCM detects deficiencies and takes corrective action to improve outcomes.

As a result, payers receive the most accurate diagnostic information to guide potentially chronic cases. OCM also offers a Quality Review service for tests performed outside its network, so payers can find out if tests were performed appropriately and provide medically useful information.

Checklist #4: Access to Radiology Subspecialists.
A key issue affecting the quality of diagnostic scans is the accurate interpretation of images. With select cases, specialized expertise is required to precisely assess the patient’s injury and medical condition. 

In diagnostic radiology, sub-specialists are radiologists who have specialized training and experience in interpreting specific types of scans. For example, injuries of the back and spine may require an ACR board-certified neuroradiologist.

According to ACR, 69% of radiologists sub-specialize at least to a small extent. However, only 31% spend at least 70% of their clinical work time in a single subspecialty. The largest subspecialties are interventional radiology, breast imaging, neuroradiology, and body/cross-sectional imaging.

In what type of situation might a second opinion or second read of a diagnostic scan be a good idea? Situations might include:

• A major claims-related decision needs to be made.
• There is an unresolved question of medical necessity.
• Two physicians may disagree over what the scan suggests. For example, one doctor may believe that surgery is indicated and another disagrees.
• The diagnosis is indeterminate.
• The patient is not improving under the current course of treatment.

These decisions need to be made on a case-by-case basis. One Call Medical has gathered leading radiology sub-specialists to interpret potentially chronic or problematic cases, which may require a more precise diagnostic interpretation to ensure an accurate treatment plan.

Checkpoint #5: Minimizing Repeat Scans.
The recent AHIP report cited studies that showed that a range of 20% - 50% of diagnostic imaging for a variety of conditions failed to provide information to improve patient diagnosis and treatment. This metric implies that a high number of scans provide inconclusive information or have film quality issues, and as such, need to be re-done. However, it must be noted that the scans in this study encompassed imaging used in a full array of disease and injury treatment. Workers’ compensation represents a small segment of total scans performed, and these tests are primarily for injuries, not illnesses. 

Due to its standards of excellence, OCM has received  a complaint rate of significantly less than  1%  in regards to its images.  Upon further investigation, only a small fraction  of the 1% actually have quality issues.

Checkpoint #6: Medical Oversight.
A diagnostic network should have a medical advisory board of physicians that guide the network toward excellence. For example, One Call Medical’s Radiology Advisory Board includes some of the most well-known and respected radiologists in the United States. They are all fully board certified radiologists, who help to guide OCM on best practices in regards to quality provider credentialing. 

Checkpoint #7: Patient Satisfaction.
Another indicator of quality is the value patients perceive in the timeliness, convenience, and service provided in the diagnostic referral process.

When injured workers are contacted,  an OCM Care Coordinator helps them to identify a quality imaging facility located in close proximity to their home or work. Care Coordinators also enhance patient service by facilitating prompt scheduling of exams, an open dialogue between provider and patient, and a greater understanding of the imaging procedure that will be performed.

"I was very happy with the MRI scheduled through One Call Medical. I was able to schedule an MRI the next day. I was told that it could take three to five business days to get the results, but my physician and I received the results the very next day,” said Leann Goetz, a patient who lives in Elizabeth, Colorado.

The Quality Quotient
In summary, quality in a provider network has to be built in—or hard wired-into the system, not added on as an afterthought.

It’s analogous to the manufacturing of an automobile where quality assurance must be incorporated into every step of the design and assembly. Quality management processes like Six Sigma drive down error rates and boost the quality of the final product.

That has been OCM’s approach to quality from the beginning of its network 16 years ago, and remains at the core of our commitment to our customers, claims professionals , nurse case managers, referring physicians, and injured workers.

For more information on how to ensure the “quality quotient” in your diagnostic network, please contact:

Bill Colacurcio
Phone: 973-316-3718
Email: bill_colacurcio@onecallmedical.com