Medical Management Services

SeaBright's innovative, multifaceted medical management services and top-notch provider networks have helped reduce claims costs through their aggregate benefits. Services include:

Chief Medical Officer: Our on-staff chief medical officer develops and oversees our managed care strategies and maintains active relationships with our health care providers, continually monitoring their outcomes to identify the best performers. As needed, he and his medical team also contribute medical expertise to individual claims, consulting with treating physicians, claim examiners, and/or employers regarding the care of injured workers. The active involvement and oversight provided by our in-house medical team help ensure that our medical management services meet or exceed our policy holders' performance goals.

SeaBright Provider Networks:

• National PPO Network: We provide access to quality medical care at discounted rates for workers who use providers in our national PPO network.
• BrightCure® Medical Provider Network (MPN): In California and Texas, policyholders have access to our BrightCure medical provider network (MPN) at discounted rates. In California, we hand-select doctors and facilities based on their ability to meet strict performance standards and metrics.
• Preferential Access Network (PAN): For complex claims involving specialized medical care, injured workers receive preferential treatment that helps return them to health and productivity more quickly. Orthopedists, neurologists, surgeons, and other PAN specialists commit to providing appointments within three to five working days, surgeries within 10 days, and IME/med-legal examinations within 30 days.

Physician-Guided Care: SeaBright pioneered the practice of physician-guided care for workers' compensation claims. Through our Physician-Guided Care (PGC) program, we assign a physician to any claim that could potentially involve six weeks or more of lost work time, as determined by predictive modeling. PGC physicians have full authority to oversee the claim during its entire lifecycle, including the medical treatment received by injured workers. The program also makes physicians available, as needed, for oversight of less complex claims, and assigns pharmacists or physicians to review all narcotics prescriptions.

Field Case Management Nurses: On select cases, we employ field case management nurses to help monitor and guide an injured worker's medical treatment. Supported by local physicians, field nurses help ensure that injured workers recover completely and return to work as quickly as possible through effective treatment.

Utilization Reviews: To eliminate unnecessary treatments and reduce medical costs, we use physicians, rather than nurses or laypeople, to conduct utilization reviews (URs). Physicians get involved early on to evaluate the medical treatment plan and work with the treating physician to match the right treatment to the injury. All UR data is tied electronically to our bill review system to lower claims costs by preventing payment of disallowed services.

Medical Bill Reviews: Trained staff review every medical bill to guard against over-billing and unnecessary charges.

Pharmacy Benefit Program: To lower prescription costs and avoid out-of-pocket expenses, injured workers can obtain injury-related medications at discounted prices from a network of over 64,000 pharmacies nationwide. Affiliate pharmacies also review prescriptions prior to their being filled and cross-check patient information to identify any potential adverse effects. In addition, health care providers receive SeaBright's experience-based formulary of effective drugs for various worker-related injuries, with an emphasis on lower-cost generic equivalents as appropriate. Beyond this, staff pharmacists provide an extra level of expertise by reviewing narcotics requests, guiding treating physicians in weaning recovering workers of chronic narcotics use, and serving as an ongoing resource for our claims examiners.

Medical Savings Report: Each policyholder can get a summary report documenting the claim costs saved through our medical bill reviews and PPO network discounts.

Our Performance Record

BrightCure MPN Network (California)1

• The average benefits paid per claim is 51 percent lower than the average paid for claims involving other medical providers.
• The rate of attorney involvement in claims is less than half the average rate of those involving other medical providers.

Physician-Guided Care Program2

• The amount of time that injured workers were off work was reduced by 11 percent when a PGC physician was involved.
• The cost of medical treatment for injured workers with similar injuries was reduced by 8 percent, a 14.6 percent improvement over the industry trend of 6.6 percent.

Utilization Reviews (UR)3
Our URs result in very few appeals, even though we approve fewer than the industry average:

• Only 3.3 percent of URs that we changed or denied are appealed; and
• Only 0.82 percent of these appeals are overturned.

• 2010: Policyholders saved $16.50 for every $1 clients spent on URs.
• 2011 (through October 2011): Policyholders saved $18.40 for every $1 spent on URs.

Medical Bill Reviews3

• Only 1.89 percent of our review results are ever questioned by medical providers.
• For the first 10 months of 2011, policyholders saved 66 percent as a result of bill reviews.
• For the first 10 months of 2011, policyholders' return on investment averaged $30.21 for every dollar spent on bill reviews.
• In addition to the cost savings, we are often faster than the state-mandated turnaround times for medical bill reviews.

1 Based on research for California conducted by Axiomedics Research, Inc, an independent company.
2 Based on SeaBright actuarials between July 1, 2010 and May 31, 2011.
3 Research conducted for 2010 and the first 10 months of 2011 by Paladin Medical Management Services, a subsidiary of SeaBright Holdings Inc. The research compared Paladin's utilization and bill review results for SeaBright Insurance Company to those produced by SeaBright's previous medical management service provider, one of the largest in the United States.
4 Ibid.