One of the most frequently asked questions here at KESA is whether we have or participate in a managed care system. When we answer no, the next question that is always asked is “Why?”.

At KESA we feel we have incorporated the best attributes of a managed care system without the many shortcomings. First and foremost, all treatment is reviewed for reasonableness and necessity. We have in-house staff members who are experts in the coding used by medical providers. They review each medical bill and make sure it is coded and billed properly.

KESA uses Comprehensive Consulting for the more complicated and subjective decisions. Comprehensive Consulting is staffed with several registered nurses and also utilizes the expertise of Dr. Daniel Wolens, an occupational specialist. Occupational specialists are experts on the parameters established by The Office of Workers’ Claims. Dr. Wolens also has a network of specialty physicians he can call on for advice.

The Office of Workers’ Claims established the following criteria for referrals to utilization review:

1. Upon a medical provider’s request for preauthorization of a medical treatment or procedure.
2. Upon notification of a surgical procedure or resident placement.
3. When total medical costs cumulatively exceed $3,000.00.
4. When total lost work days cumulatively exceed 30 days.

KESA uses these as minimum guidelines only. We refer any treatment that is somewhat questionable.

Over and over again we have found this avenue more effective than a full managed care system. Not only does it mean that we do not have to secure a panel of physicians of every specialty, which is time consuming and expensive, but it also alleviates much of the politics of a managed care system. All systems want the same physicians and the most sought-after physicians can use their clout to push through their initiatives. They simply threaten to quit or leave the system if their bill or proposed surgery is questioned.

We also realize that many of our customers have already established relationships with physicians in their area and we do not want to harm these relationships. Many times these physicians do much more than workers’ compensation work so we want our members to have the flexibility to choose the physicians they would like their employees to see. This is not always possible in a managed care system.

Lastly, we feel the managed care systems try to take control of the claims by deciding what is compensable. We have heard many stories where the employer sent notice of an injury to the managed care system and never heard any response. At KESA, we handle the claims with our customer’s involvement by welcoming their input and keeping them active in all decisions.

Therefore, while KESA does not participate in a managed care system, we do actively manage all of the claims and the care given to injured employees. Our claimants receive the best possible care and our members receive the most efficient service possible.