The wrong doctor treating the employee for a workers compensation injury is one of the biggest mistakes an employer can make. It is a very fast way to incur higher than necessary medical expenses and higher than necessary indemnity cost. The proper selection of the medical provider is crucial to the overall outcome and cost of the workers compensation claim.
While most employers are blissfully unaware of the importance of the medical provider selection, it is a fact very well known by the plaintiff’s bar association. When the concept of workers compensation was being adopted by the states nearly a hundred years ago, the employer always provided the medical provider. Over the years in approximately half of the states, the plaintiff’s bar has wrestled control of the medical provider selection away from employers and put it in the hands of the employee (who normally allows the attorney to make the medical provider selection). (WCxKit)
Why is the selection of the medical provider is important to the plaintiff’s bar association? The answer is simple: money. The television attorney holding a fistful of money while soliciting the injured employee got most of that money by controlling the selection of the medical provider.
The plaintiff attorney representing the employee works for a percentage of the indemnity benefits paid to the employee. The more indemnity benefits paid to the employee, the more money the employee’s attorney makes. Hence it is in the best interest of the employee’s attorney to keep the employee off work as long as possible and for the employee to get the highest possible disability rating (regardless of whether or not it is accurate).
The large majority of medical providers are honest in the assessment of the employee’s ability to return to work light duty or full duty and are honest in the assessment of the employee’s permanent partial disability rating. Some of the doctors in this large majority are more liberal and some are more conservative, but even within those parameters they remain honest.
Unfortunately, there is a small minority of doctors, concentrating primarily in the chiropractic field and the orthopedic field, that sold off souls to the plaintiff’s bar. Whether it is by collusion with the plaintiff attorney or a silent agreement, the plaintiff attorney sends as many of his clients as possible to the “doctor” who in return keeps the employee off of work as long as possible. The employee remains off work until the employee wants to go back to work, or the doctor can no longer justify keeping him off work. The doctor then consults the disability rating guide used in that state, and gives the employee the highest possible disability rating out of the possible range of disability ratings.
This is a win-win situation for the attorney and the doctor. The doctor increases the attorney’s income, and the attorney increases the doctor’s income. The employer loses. The higher the amount paid to the employee in temporary total disability and permanent partial disability, the higher the eventual workers comp insurance premium will be for the employer.
What should the self-insured employer or insurance company do? The employer cannot conspire with a doctor to put the employee back to work before he is physically able to return to work and will not conspire with a doctor to falsify the disability rating. The answer is to consult with the workers compensation defense attorneys in the area where the employer is located. The defense counsels who have had extensive experience dealing with the various doctors in the areas can advise who are conservative, moderate or liberal in disability ratings. They can tell you which doctors get the employees back to work timely. They can also warn of doctors who work solely for the plaintiff’s bar.
We would recommend consulting with defense counsel and learn the precise requirements of the state. In some states, the employer only has to post one medical provider, while in other states the employer must post a list of medical providers (also referred to as a panel in some states). The list of medical providers should include both general practice doctors for the minor injuries, the orthopedic specialists, the emergency care facility and/or hospital and, any other specialties required by the state.
Not only should the employer ask defense counsel what the posting requirements are for the particular state but should also ask the names of conservative, reputable doctors. Employers need doctors who will provide the employee with all necessary medical care, but will also work to get the employee back to work on modified duty or full duty as soon as practical. Also doctors who will give the employee a fair, objective disability rating, if one is needed, are ideal.
Occasionally there will be a plaintiff attorney who will ignore the employer’s posted list of doctors and send the employee to a favorite doctor. The claims adjuster should immediately object and advise the attorney that any medical care the employee receives at the non-approved doctor will be at the employee’s own expense, plus if the employee does not attend the medical appointments with the employer selected doctor, the indemnity benefits will be suspended. WCxKit
In the states where the employee has the right to select the medical provider, we suggest for the employer to post the “recommended” (not required) doctors suggested by defense counsel. While this will not stop the plaintiff attorneys from sending the injured employee to their favorite doctor, it will eliminate some of the claims that end up in the hands of plaintiff attorneys as the employee will be receiving the medical care they need timely.
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.com.
Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact
Workers’ Compensation Costs Can Be Reduced by Implementing Operational Best Practices: Learn How With This New Guidebook.
A company that wants to implement a new workers compensation program or revamp an existing system will find this book helpful. Maybe your company has recently expanded and you realize the need to train a workers compensation manager or regional coordinators how to hold down compensation costs. Whatever your need, here is the answer:
Workers Compensation Management Program: Reduce Workers’ Comp Costs 20%-50%.
Used by more than 150 firms across the country, this is THE book to help every employer develop a more effective workers compensation program to reduce workers compensation costs. It is based on field research and decades of experience in workers compensation from all aspects of the business. Best practices are described in detail for each person in the injury process.
This easy-to-read manual has been updated for 2012. It now includes:
An index for quick topic look-up so you can view a term or a procedure and see all relevant references.
NEW – Workers Compensation Basics
Purpose of Workers Compensation
Who Pays for Workers Compensation?
Parties Involved in Workers Compensation
Benefits for the Employer
Independent Contractors
Benefits for the Employee
Injuries Covered
Types of Workers Compensation
How Losses are Categorized
How Losses are Reported
Calculating Your Premium
How Mod Effects Your Premium
Good/Bad Mod Example
Five Ways to Reduce Your Mod
NEW – Fundamentals of Cost Containment
Reasons Workers Compensation Costs are High
Who is in Charge?
Work Ability Form Properties
Who is Responsible for Managing Workers Compensation Claims?
Who is Responsible for Managing Workers Compensation Process?
Hidden (Indirect) Costs of Workers Compensation
Additional Costs
Calculating WC Costs
External Obstacles to Cost Control
Internal Obstacles to Cost Control
NEW – Working with Your Adjusters or TPA
Account Handling Instructions
MD Participation
NEW- Reporting a Claim
Critical Issues
Essential Intake Considerations
Nurse Triage
NEW- Directing Medical Care
Occupational Health Clinics
Remote Health Services
Directing Medical Care in California
NEW- Return to Work
What to Include in a Transitional Duty Policy
Non-Profit, Volunteer or Charitable Positions
Employees Who Never Return to Work
Coordinating WC with Federal and State Leave Statutes
NEW – Other Indemnity Cost Containment Services
Telephonic Disability Intervention
NEW – Medical Cost Containment
URAC Certification
Mental Health RNs
Chronic Pain Programs
An Aging Workforce
At Home Recovery Services
Medical Fee Schedules
Fee Schedule Coding
ICD-9 and CPT Codes
NEW- Physical Therapy and Physical Rehabilitation
Differences between Physical Rehabilitation Programs
Pharmacy Benefits Management Program
Authorized Drug Formulary
Toxicology Screening
NEW – Fighting Fraud and Abuse
Medical Terminology Used to Identify Malingering
Reviewing Investigation Reports and Videos
Avoid good Day/Bad Day Syndrome
NEW – Claims Resolution and Settlements
Conditional Payment and Final Demand
Pharmacy Component of MSA
California Settlement Process
A 183-page guide covering how to assess your workers compensation program, design program materials, roll out a program to the organization, and monitor and manage the program once implemented.
Written by a national expert on workers compensation cost containment with over 25 years experience helping companies reduce their losses 20% to 50%.
T. Ronca, a workers’ compensation defense attorney from Long Island, NY, said the
book is an invaluable desk reference. “It is one of the tools that should never be out of reach for a risk manager. Direct employer involvement with claims in the first weeks is the difference between success and failure. This manual will guide the conscientious employer through the pitfalls,” Ronca said.
What’s more, the book can be delivered with your company logo on the cover and a full-color ad for your company on the back cover.
Take it out to the field. Text tabs are available to put on each chapter and it is ready to go as your company training manual. All you will have to do is customize the Training Agenda that is in Part I of the book.
Included in the manual are topics such as: Return to work and transitional duty, claim reporting, employee communications, controlling fraud and abuse, directing medical care, medical cost containment solutions, post injury response procedures, reporting procedures, working with your carrier and third party administrator. There is information about physical therapy, pharmacy benefits management programs, training supervisors and gaining management commitment. It also contains concepts of claim settlement and resolution as well as safety and loss control. New areas are identified above.
There are 5 sample worksheets in the manual to help organize an efficient workers’ compensation program. These include: timetable for implementation, the injury coordinator job description, and several sample roll-out letters. We recently received a terrific phone call from a third-party administration firm saying how the manual provided an organized way to train clients at loss prevention and has helped their clients put "layers of better WC management" in place. Everyone benefited.
One large distribution firm wrote to us to say the chapter on safety and loss control led to a company-wide safety change that only cost a few hundred dollars but prevented a specific type of injury that had been draining its budget, says Rebecca Shafer, Esq., President of Amaxx Risk Solution, Inc. who authors the book. Shafer is a national expert on workers’ compensation cost containment with more than 25 years of industry experience helping many companies reduce their losses 20-50%.
When you order your copy of Manage your Workers’ Compensation Program from Advisen at
http://corner.advisen.com/wcbooks, the 183-page guidebook shows how to assess your program, design program materials, roll-out a program to the organization, and monitor and manage the program once implemented.
The workbook is also available with a customized front and back cover for bulk purchases. Discounted rates apply to bulk orders.
One company said, "After reading the manual, we took a look at past workers comp practices and saw that every department did things differently. Manage Your Workers’' Compensation Program 2012 gave us the guidance we needed to standardize our workers’ compensation programs across the country. It was like a pre-prepared lesson plan," according to the risk manager.
A regional hospital in North Dakota wrote that, "Our small company expanded rapidly and we actually didn’t have any official workers’ compensation program in place. This manual gave us step-by-step procedures from the first meetings with management to monitoring the final program. Buying and reading the book was almost like hiring another employee – one who was an expert in workers’ compensation."
Who Uses the Workers’ Compensation Book?
Risk Managers and Workers’ Comp Managers find it useful learning about the cost containment niche and use it for themselves and to bringing new team members up to speed very quickly. The book becomes a “lesson plan” tool.
Safety Directors use the book to train supervisors in workers’ compensation claims management. They learn more about their area of responsibility — post loss cost containment — adding to their overall knowledge. They also learn what to do after an injury and what steps are supposed to take place during the first 24 hours.
Brokers use it for prospects, as well as, to learn about specific aspects of cost containment, passing their knowledge on to their clients. For example, when discussing how to develop a return-to-work program and a client asks about, “off-site return-to-work programs,” the broker quickly finds the relevant section in the book, reviews it and passes the answer on to the client, along with a copy of the cost containment book with the broker’s logo.
Adjusters use the book to gain a better understanding of the employer’s perspective. Adjusters also want to learn more about cost containment to add to their overall workers’ compensation knowledge in order to grow their careers and stay abreast of new services.
Account Producers give the book to prospects during formal presentations to illustrate their company is on top of the workers’ compensation industry. The book makes an excellent client gift.
Vendors such as doctors, physical therapy networks, occupational clinics and medical management firms learn how their service might fit into the workers’ compensation marketplace, what is important to employers, and what they look for in medical services to enable the vendors to enter the workers’ compensation marketplace.
The manual is a cost-cutting tool to learn more about systematic and operational techniques for reducing workers compensation costs.
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.
Posted in
Claim Audits & File Review,
Communication with Employees,
Coordinating Medical Care,
Federal Workers Compensation,
Fraud and Abuse,
Insurance Issues, Rates, Premiums,
Lowering Premiums & Experience Mod,
Management Commitment,
Medical Cost Containment & Managed Care,
Medicare Set Asides (MSAs),
Professional Development Issues,
Return to Work and Transitional Duty,
Risk Management,
Safety and Loss Control,
Settling WC Claims,
TPA and Claims Administration,
WC 101,
WC in Other Countries (International) |
It is time to address a topic about causal relation in a workers comp case. This case involves a teacher and school aid in a library, where the desktop computer is being replaced by a laptop. Soon after the switch, both employees begin to complain about neck pain since the height of the monitor on the laptop could not be adjusted from person to person, and extended use was causing some neck pain. The insured wondered if the change to a laptop was causing the neck problems and if these would be considered as workers compensation cases. We discuss the investigation of causal relation here.
- What does the treating doctor say in the medical records?
The most important aspects of this case will be the causal relation statements the physician makes. If the two employees are of the same height and build, why are they complaining of pain, more importantly how is the laptop situated, and how is that causing neck pain? Prolonged sitting in a non-comfortable ergonomic position can lead to strains of the neck, but at a normal desk this should not cause neck pain. Is the laptop screen at eye level or situated down inside the actual top of the desk, where the employees are looking down at the screen? Or is the laptop mounted on top of something where the neck is in a constant extended position? Are other employees complaining of pain or having a hard time viewing the screen of the laptop? WCxKit
It is important to remember in this situation that if an employee comes to an employer and complains of pain and wants to pursue a workers comp claim with supporting medical documentation stating a work injury is present, then it is the employer’s duty to call the claim in to the carrier. The adjuster will make the determination, if the claim is compensable. Certainly more than one employee complaining about the same issue can lead to a more convincing case, but it does not mean it will be automatically accepted. Take pictures of the desk and of these people sitting at the desk as they normally would and send those on to the adjuster as well, so the adjusters can see the setup of the work station and pass that information on to the physician. Being able to actually see the worker sitting as they normally would will help them arrive to the proper decision on the case.
- Does either employee have a history of neck pain from another source?
One of the first questions the adjuster will ask is if either employee has a history of neck pain or prior surgery. This could predispose them to having pain if the neck is positioned in certain ways. Again it does not mean that the laptop setup itself is responsible for the pain. It could be pre-existing post-surgical pain that is the culprit. Prior auto accidents involving whiplash complaints can also contribute to neck pain in the future. Also the employees’ activities outside the workplace are unknown. Maybe one or both of them are engaged in activities that fatigue the neck, and this laptop exacerbated that non-occupational pain. A question about whether the injury could have another cause is part of a normal investigation in just about every workers compensation claim.
- Is the workstation adjustable or not?
If these employees are of different height, can the chair or workstation be adjusted to properly fit them? And if so, are they still complaining about pain? If nothing is adjustable, are other employees of similar builds complaining about the position of the laptop screen? Why or why not? Again, if no other employees are complaining about any problem with the laptop, then go back to these two employees. What is the relationship to each other? Do these two often hang out at the school? Are they in common positions and have similar duties? How long are they actually sitting at this computer and how often are they required to be moving up and around during the day? All of these questions are part of a normal investigation the adjuster will do, and as the employer, try and gather as much of this information as possible to help the adjuster make the proper determination on the claim.
At the same time the claim is investigated by the adjuster, the incidents should be reported to the safety director who should review the workstation design. Consider having an ergonomic consultant review the set up. Ask your TPA or insurance carrier what resources are available for ergonomic consulting. Consider what other equipment could be provided to make the work station more comfortable.
- Has the adjuster performed an IME or peer review yet?
Usually background searches have been completed for prior injuries, and the next thing is to gather all of the medical evidence and set an IME with a qualified physician or occupational medicine doctor to address the causal relation. Is there any objective evidence of degenerative arthritic conditions in the neck that can contribute to this pain? Was an MRI performed, and if so are there any objective results, and, if so, how can they relate to the ergonomics of the workstation? This should all be part of the normal investigation on the claim, and all of these questions should be included in the cover letter to the IME doctor, so that doctor can specifically address these questions with the correct answers, using objective medical evidence to back up the opinion.
- What is the decision–is this compensable or not?
This is the million-dollar question. There are cases like this where these are accepted injuries under workers comp and similar cases where coverage is denied for similar complaints. The lesson here is that no two cases are the same. Maybe one of these employees has no pre-existing condition, and the other one has a prior surgery. This could play a role in which case is compensable and which one is not. It will be up to the adjuster on the file to make a decision on the compensability. Even if the employer disagrees with the decision, there is little to do to swing the case the other way. Let the adjuster do a thorough investigation and stand by the decision. If the worker disagrees with the decision, there are ways to appeal the decision and research to pursue that on their own. That is the choice of the worker. WCxKit
Summary
Ergonomic claims such as this one are going to happen at some point. The key thing to remember as the employer is to do a thorough investigation. Gather as much information as possible, even if it appears to not matter in the final outcome. The adjuster always prefers too much information rather than not enough. Take pictures, and assist the adjuster in any request they have. They will make the proper decision on the claim, since that is an adjuster’s job day in and day out. If, however, you disagree with the decision, make sure to talk this out with the adjuster and the claim supervisor.
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.
Employers are continually searching for ways to reduce workers compensation costs. Triage, where a nurse immediately assesses the employee's medical condition and in some cases arranges for the medical care, is growing rapidly as one of the most effective ways employers can control workers comp cost. In triage, the nurse is involved at the very beginning of the claim. The triage nurse evaluates what medical care is needed through a phone call with the injured employee at the time of injury, provides a list of approved in-network doctors or medical clinics, then passes the claim to a nurse case manager who follows through with the medical provider, the employee, and the employer to ensure the needs of each are met. Companies using nurse triage consistently have very high "penetration rates" meaning that a very high percentage of employees utilize in-network providers; penetration rates for companies using nurse triage are frequently higher than 90%, many approaching 100%.
Triage in workers compensation is a concept that has been borrowed from hospital emergency rooms where the triage nurse is responsible for immediate assessment of the individual's injury and organizing the treatment based on the seriousness of the injury. In workers compensation, the triage nurse immediately evaluates the nature and type of the employee’s injury and directs the employee to the proper level of medical care whether it is first-aid, a walk-in clinic, or an urgent care facility. Sometimes the employee is given home-care instructions. (WCxKit)
The proper use of triage eliminates lag time and indecision. The injured employee, the employee’s supervisor or a co-worker (in an emergency situation) can report the occurrence of the injury to the triage nurse by phone. Most triage organizations provide a toll-free “hot-line” number for workers compensation claims to be reported and are staffed 24/7. The triage nurses that answer the calls are trained to obtain all necessary information in order to perform a comprehensive evaluation of the medical needs of the injured employee. The triage nurse will use treatment protocols and algorithms to identify the proper course of treatment. The employee is then directed to the nearest appropriate level medical facility. These nurses are specially trained and have had a minimum of 10 years of clinical experience.
The triage nurse does not stop after directing the employee to the medical facility. The triage nurse can then contact the medical facility to inform them the patient will arrive soon. Or, this can be done by the employer's workers compensation coordinator. The triage nurse provides the medical facility with the information on the employee’s injury along with the employee’s name, address, phone number, date of birth, social security number, employer's name, address, phone number, and contact information. The triage nurse will also provide the medical provider with billing information and adjuster contact information. Reports of daily activity is sent to the carrier/TPA and the employer, if requested.
Nurse triage makes sure the employee gets to the correct LEVEL of care, but the nurse case manager takes over to "manage" care. Note: When triage is too closely integrated into managing care, it looses focus on preventing unnecessary claims and guiding injuries to the right level of care.
Note: The triage system is more likely to refer more often when the triage provider gains economically from opening a claim. Even "features" that seem convenient like 800 numbers and aps that make it easy for employees to find networks clinics themselves result in employees bypassing triage and going straight to the clinics.
After the employee has had time to be treated, the case managment nurse will contact the medical facility the same day and determine the nature of the medical treatment. Sometimes, this can be done by a senior nurse reviewer or the employer's medical director. A senior nurse reviewer is a nurse who reviews and follows ALL claims from beginning to end; they monitor all claims within an insureds book of claims. A nurse case manager will inquire to see if there are any prescriptions that need to be filled, if there is any diagnostic testing (MRI, CT scan, EMG, etc.) that needs to be done, and if there is a need for durable medical equipment. The case management nurse will then advise the workers compensation adjuster of the prescriptions, diagnostic testing, and durable medical equipment that is needed. Once the adjuster approves the requested prescriptions, testing or equipment, the case management nurse will assist in arranging for it.
The case management nurse will also ask the medical facility for the return-to-work restrictions placed on the employee by the medical provider. If the employee can return to work with restrictions, the case management nurse obtains all the information on the work restrictions and contacts the employer to see if the employer can accommodate the return-to-work restrictions. IF the employer has a return to work coordinator, the return to work coordinator can make contacts related to transitional duty capabilities.
The recommendations of the medical facility for future medical care and the date the employee will be returning to the medical provider will be obtained by the case management nurse. If the employee needs diagnostic testing prior to the return appointment being scheduled, the case management nurse can follow up with the medical facility providing the diagnostic testing and provide the test results to the medical provider.
The case management nurse (NCM) will facilitate and expedite the communication between the medical provider, the employer, and the workers comp adjuster. NCM also has the responsibility of keeping everyone informed about the medical status of the employee. The NCM will be in regular contact with the employee, the employer, the medical provider(s), and the workers comp adjuster. All information about the medical treatment, medical progress and return-to-work options are shared with all parties.
The length of time the triage nurse will continue to work on the new workers claim is determined by the arrangement between the employer and the triage company but generally the triage nurse will hand the case to the case management nurse once the initial care is evaluated. The case management nurse will normally continue on the case until the employee returns to work full time however there may be a need for a nurse case manager depending on the severity of the injury or the employee's inability to return to work even in a modified duty capacity. (WCxKit)
Integrating the triage nurse into the initial medical treatment allows the employer or insurer to set the tone and level of medical care and ensure the employee gets the appropriate level of care immediately. Then the nurse case manager helps to coordinate employee's return to work before the employee has the opportunity to adjust to the idea of not working. By providing medical management at the beginning of the workers comp claim, the triage process improves the return-to-work program results, reduces days lost from work, lowers the cost of indemnity payments, and lowers the cost of medical care. Normally, nurse triage can reduce the number of lost time claims by up to 40%.
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.com.
Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
Most states allow an injured worker to seek care with whatever physician the employee prefers. There are some rules to follow, but as long as the doctor cooperates there usually is not a problem.
But when there is a problem, it is a big problem. When the adjuster is working with a doctor that does not want to cooperate and respond to certain questions, that is a major issue. This issue will affect the injured worker by affecting care and time off of work. It can cause the claim to go to litigation, etc. So something as simple as going to the doctor for an injury can morph into a really big deal. Here are some warning signs that a claim could be heading down the bumpy road. (WCxKit)
1. The physician places the worker off of work with no restrictions and no explanation
This one item frustrates adjusters more than any other. If a person comes in with a hand laceration, and the doctor places them off of work for 4 weeks, how is that legitimate? The worker has another hand that is perfectly fine. Even if the workplace is a dirty environment it does not mean it is risky to be at work with a hand laceration to one hand.
Physicians familiar with workers comp know better. They know if they place a worker totally off of work and do not address restrictions, the adjuster will call. In the world of workers comp, if a worker is on total off work status that means the employee either just had surgery or sustained a major injury.
There are 2 roadblocks to return to work: (1) the employer does not cooperate with creating light duty work for the injured workers, and (2) the doctor totally disables the employee for no good reason. But it depends, if this injury is acute and very severe, then certainly some time off of work is warranted for rest. But the doctor has to explain why. There is nothing the adjuster hates more than to see a back injury, and the worker is totally disabled, but in physical therapy. So the worker is good enough to go to therapy, but not good enough to go do some light desk work for the employer?
Physicians have to explain the diagnosis and work restrictions, and they have to have good objective evidence to support the decisions. The adjuster has the right to demand that the doctor answer specific questions, and if the doctor disregards that, then it can affect the benefits being paid out on the file. So warning sign #1 if there is an off work slip with no real explanation as to why.
2. Makes a return appointment in 3-4 week intervals
A doctor that is monitoring a condition on a comp claim knows the worker’s main goal is to get back to work. So they closely monitor the situation. They schedule to see the injured party at least once every week, if not sooner depending on the injury. A warning sign for a complacent doc is a return visit in 4-6 weeks. That is a long period of time to go without being evaluated. If it is a surgical claim, and this worker is post-surgery, and starting rehab, then this may be ok. But for early on in a comp claim, anything over 7-10 days I would raise an eyebrow. He will drag out the claim costing the employer more money.
3. Everyone at work knows the physician or has treated there
If the injured worker goes to Dr. Smith, and everyone knows Dr. Smith at the shop, and everyone treats with Dr. Smith both for personal medical issues and for workers comp injuries, I would be concerned. Maybe Dr. Smith prescribes a lot of Vicodin for simple injuries. Maybe Dr. Smith disables them from working for a longer time than anyplace else. It could be anything, but if this particular clinic is a place where 85% of your workplaces treat, something is awry. It may not be “illegal” activity, but there is some trend that this doctor does that nobody else in town will do. And that is always cause for concern in an insurance claim.
4. The doctor prescribes narcotics for minor strain injuries
This is perhaps the most popular trend these days. I have observed countless claimants going to the doc for a simple strain and walk out of the clinic with a 30-day RX for Vicodin. That is never a good sign. I am not a physician. I did not go to med school. If Vicodin is needed for 3-5 days, that is warranted. But for an initial visit, for a simple strain, that is not really all that severe, a 30 day supply is unnecessary. RX stands for "prescription."
The cost of the RX is determined by quantity and type of drug. If you look at the work slip and the doctor prescribed Vicodin and Percocet, Valium, and Motrin, that is not acceptable. Not only did this doc over-prescribe by giving the worker 2 similar narcotic drugs (Vicodin, Percocet) but also prescribed Valium, which may or may not even be needed for this particular case. Probably the only RX a simple strain needs is the Motrin. All the other RX’s are warning signs that this doctor is happy to prescribe anything at will, and these medicines are not cheap, and some are not even necessary.
5. Recommend physical therapy (at his clinic) for everything
I recall a while back there was a large occupational clinic that would give anyone that walked in a script for physical therapy (PT). You can have sprained your hand, and you were going to go for 4 weeks of PT. Back injuries, finger lacerations, elbow pain, the answer was PT. They were using PT as a stall tactic, not the way it should be used by reputable doctors. Finally enough people must have stepped up and said “This is ridiculous! You mean to tell me every person that walks in needs PT?”
But this shows a crucial point. Some physicians are also financially tied in to therapy facilities as well as to other testing facilities. So not only do they make money off office visits for evaluating the patient, but they make even more money billing for 12-16 PT visits. Then they will probably see the patient again at the clinic for another evaluation. And maybe more PT is needed. And, before you know it, the cycle begins. In most states this is illegal and unethical. Excessive PT is an indicator that something fishy is going on, and you can use your tools, such as an IME, to deem if more PT is really reasonable and necessary treatment in your given claim. Employers can eliminate the risk of using the wrong PT facilities by using the services of a Physical Therapy Management Company instead of simply working with the least expensive PT network. Physical therapy can be extremely effective in facilitating recovery and return to work when used appropriately. I know, I've been there, done that.
6. Hesitant to refer out to a specialist
This is a warning sign because the physician wants to keep seeing the patient and wants to keep billing the carrier/TPA. As soon as the patient goes to an ortho or other specialist, that patient no longer treats at this clinic. So, the doc has incentive to keep that patient around for a longer period of time. Repeat business is what makes money, and if the patients are continually coming back, that is more money in someone's pocket. So if it has been a few months and the injured party is no better, it is way beyond time to be evaluated by a specialist. And if the treating doctor is not bringing this up, you may need to force the issue.
7. No dictation and very few hand-written notes
The adjuster will always want to see the doctor’s actual notes or transcribed dictation. This is where the adjuster can see exactly what the patient said, what the doctor saw on examination, and what the doctor’s plans are for resolving this medical condition.
If the adjuster requests the notes, and they consist of 1-2 sentences of barely visible hand written scribbles, this is not good. Not only is it worthless to the adjuster, it is worthless in general. There is no info about the patient, about the exam, or about the treatment plan. These doctors are out there. An example of their medical note could consist of the items below.
“Jack feels the same. Continue therapy for 4 weeks and return afterwards.”
As crazy as that seems, that sometimes is it. And the bill was probably $100-$150 for that “exam.” So beware of the doctor that does not dictate or does not have properly typed notes. It does not mean the doctor is necessarily bad, it just means that if the worker continues to treat with this physician, it is going to be a struggle to get information and clarification the longer the claim goes on. Those issues are very important, and if you struggle getting that much needed information, the rest of the claim will be a struggle as well.
Summary
There are good doctors, and bad doctors. There are doctors that care about their patients, and doctors that could care less. There are doctors that write up fantastic notes, and some that jot down a sentence or 2. Physicians are just like everyone else. They all have a unique style. They have good days and bad days. Some have successful practices, and some do not. (WCxKit)
But the bottom line is if a doctor is going to treat the injured worker, in a workers comp situation, then they have to abide by the rules. And if they choose not to do so, it is going to complicate the claim one way or another. Use the above warning signs to evaluate current claims for rough roads ahead.
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.com.
Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com
Never heard of a "med-legal" conference? Neither had I. I learned when I did a chair side visit to a major third party administrator in Windsor, CT. I asked the adjuster who was hosting me, "What is the next step in the indemnity claim?" – my standard question when an adjuster walks me through a client's claims, when I seek to learn how the adjusters in that office approach claims. The adjuster said that the "med-legal" conference was coming up soon. Huh? The WHAT kind of conference? Ah, med legal… I had never heard of it and neither had the employer's risk management team. Tell me more.
Medical care for an injured employee can be complicated. When the injured employee is represented by an attorney, the plaintiff’s attorney often tries to make the injury appear more serious than it is. Defense attorneys who have handled many similar claims often have a fairly good understanding of the medical terminology and what is meant by various medical reports and are not fooled by the plaintiff attorney overstating the nature and extent of the injury.
However, there are situations where the injury to the employee is unique, and the seriousness and/or complexity of the injury is not fully understood by either the workers comp claims adjuster or by the defense attorney. It is in situations of this nature that a conference between the defense attorney and the doctor is needed. These medical-legal conferences are normally held during the discovery phase of a workers comp claim in litigation, but can be held at any time and are often held in person at the doctor's office attended by the claimant's doctor and the employer's attorney. (WCxKit)
Med-legal conferences can occur by telephone, but more often the defense attorney will reserve an appointment with the medical provider to review and discuss the medical treatment an injured employee is incurring. The med-legal conference allows the defense attorney to better understand the injured employee’s medical care. The defense attorney will have the opportunity to ask questions about the medical reports and will hence be able to decipher and understand the medical reports better.
The med-legal conference puts the nature of the injury, the extent of the injury and the future medical treatment needed into plain English that the defense attorney will be able to understand and convey, if necessary, at a Board hearing or in a full-blown trial. This makes the negotiation of any settlement on the workers comp claim more accurate and feasible.
The med-legal conference also will assist the defense attorney to understand the chronological sequence of the injury, the medical treatment and the recovery. The defense attorney will also better understand the reasonableness of the previously provided care and of the proposed future medical care.
To better understand the use of a med-legal conference, consider the following real claim.
The employee was removing a motor from a dump truck. The employee fastened a chain around it and lifted it with a fork of the forklift (no safety program at this employer!). When the forklift moved, the motor dangling on a chain, swung around and struck the employee in the top of the back, breaking the right clavicle with a compound fracture.
After four months of treatment, the medical provider placed the employee at MMI. The workers comp adjuster paid the PPD rating and thought the claim was done. Two months later the claimant calls the doctor and is in severe pain. The doctor does an x-ray and the clavicle, which had been healed in the prior x-ray before the employee was placed at MMI had developed a non-union along the fracture lines. The plaintiff attorney filed for a “worsening of condition” with a request for additional medical treatment, additional temporary total disability and was pursuing a higher PPD rating.
The defense attorney met with the doctor following the resumption of medical care to discuss the cause of the non-union and how it could have developed after the employee was released from care. The doctor explained that within a reasonable degree of medical certainty the failure of the previous union of the bones had to be caused by the employee suffering an aggravation at his new employer. The doctor explained there was diagnostic evidence of an aggravation. The aggravation breaks the chain of causation resulting in the employer at the time of the initial injury no longer being responsible for the claimant’s medical condition.
To prepare for the med-legal, the employer's medical director can have a conversation about the injury with the defense attorney (their defense attorney). The better understanding the defense attorney has, the more effective the discussion with the claimant's doctor will be. Get the Injury 101- version of the injury from your own doctor, then be prepared to gather advanced information from the claimant's doctor.
Attorney Theodore Ronca suggests for the employer's attorney ask the claimant's doctor, "What is your timeframe for return to work?"
The cost of a med-legal conference is the cost of the doctor’s time and the cost of the defense attorney’s time. The med-legal conference will often answer the questions the defense attorney has in regards to the medical treatment and the status of the injured employee, eliminating the need for a formal deposition and the associated cost.
It is often worthwhile to pay for the time the doctor and the defense lawyer spend reviewing the medical care, the causes of medical issues and the proper resolution of the medical issues. Med-legal conferences should be used any time the medical issues are complex and the understanding of the employee’s medical condition is not clear.
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.
The cost of prescribed drugs, especially narcotic pain medications, is rising in the world of workers' compensation. This cost increase is due to the fact that a drug company is like any other company: When the demand for your product is high, supply lessens, and costs have to increase. And, these medications are not exactly cheap to manufacture. In fact I saw a news report that some cancer fighting drugs are in short supply due to overwhelming demand.
Think about going to your personal physician for a knee strain you had over the weekend playing football with your family. You probably went to your doctor, and you probably left with a prescription for Motrin buddied up with a short-term prescription for a narcotic pain reliever — even if a cold pack or hot pack and rest would have taken care of the problem. This is the world in which we live. In the past, these pain medications were for extremely acute trauma, such as a car accident or bone fracture. But more and more, medications such as Vicodin, Percocet, Oxycodone, etc are being prescribed for the slightly-above-average diagnosis of lumbar or shoulder strain. (WCxKit)
Below we discuss five ways you can try to control these associated drug costs when it comes to your workers compensation claims. By no means is this an exact science, but it is certainly one you should look into for help controlling your bottom line.
1. Come up with your game plan.
Whether you have five claims a year, or five claims per week, medication cost will be a significant expense of the claim. Many carrier/TPAs are partnering with a Pharmacy Benefit Manager (PBM) to review prescription history and also to provide a reduced cost for medications. These outside vendors attract carrier/TPAs by offering them a discount cost for medications, in exchange for their guaranteed business.
Adjusters set claimants up with a drug card from these vendors, and they are widely accepted at many pharmacies nationwide. Furthermore, the PBM will review the injury and the claimant’s individual medication history. They can recommend medications based on the injury type and location. This is an attempt to stop every John Doe back pain sufferer from walking out of his doctor’s office with an RX for Percocet, when he really does not meet the criteria for needing that strong of a medication to begin with. Most strains can resolve by taking a stronger dose of Motrin, an anti-inflammatory medication similar to Advil or Ibuprofen. The PBM will also monitor duration of medication use and quantity limits. Why pay for 90 pills when John Doe should only need 30? Medication costs are associated with dosage as well, so it doesn’t make sense to pay for 90 pills unless they are needed.
2. Start being aggressive at the first prescribed RX.
When a new claim is filed and the adjuster sets the drug card up to be mailed out to the employee, it may already be too late. This is when proper communication is handy. If you have a worse-than-average claim, you can phone your adjuster with the info, and they can get the PBM info right to the claimant.
This way they are not getting medication from an occupational clinic or hospital, where the costs are typically the highest. Right off the bat they can use the PBM card, and that reduces cost right from the beginning. This also helps manage future spending on RXs, since they already have the card and should be using it for any medication the claimant is prescribed. Sure, not using the card for your first medication fill is no big deal if you only have one or two claims per year, but if you have one or two claims per week, over the course of a year this can lead to a dramatic savings in medication cost. Every little bit of savings will help in the long run, and it is important not to overlook the small savings that you can implement right away.
3. Can you do bulk home delivery?
For those injuries lasting longer than a month, it is worth it to look into home delivery of medications. This increases the discount, because you buy more of the medication at one time, and you do not have to pay the pharmacy overhead for a short-term 30 day fill. Injured workers will appreciate having one less errand to run, especially those who do not have easy transportation readily at hand. At the same point, the PBM will monitor dosage and quantity. Why should you continue to get a medication if it is not helping? Or, if the injured worker is not taking the medication at all? These are leakage costs, and expensive ones at that. The adjuster will ultimately decide if a claim is worthy of needing home delivery, and the delivery will not last forever. If a person has a bad fracture and will need a long-term supply of Motrin, this is a perfect scenario.
Adjusters do frown on home delivery of narcotic pain meds. This gives the claimant a large supply of potentially strong medication, which carries the risk of addiction. Home delivery meds are generally milder. Again, even though these drugs may not cost the most, any sort of savings is better than no savings at all.
4. Are you using prescription utilization review?
PBM companies use a panel of clinical pharmacists to examine prescription data and injury type to make sure appropriate medication is dispensed. This helps control unnecessary costs due to prescribing incorrect medication. Also, PBM utilization review will help to control fraud by monitoring the date and location of refills. Red flags indicating abuse include early refills, a doctor shopping around to get new prescriptions, or a patient changing pharmacies to get refills. Clinical pharmacists also are useful at catching new medication trends, proper quantities of medications, and future costs/needs for ongoing medications.
By using prospective utilization review, done before the product is used, to avoid the cost, consider prior authorization program. By having an MD on the TPA's staff review the file, many of the medication concerns are addressed proactively. The utilization review company you use, should be URAC certified to ensure quality, credentials and training. A good TPA might even have a chronic pain program to discuss pain issues with an interdisciplinary team of experts.
5. Use a Pharmacy Benefit Manager or vendor to help with repeat offenders and duplicate prescription medications.
This use of an outside PBM is effective for many reasons, including catching a doctor prescribing both a short-term and long-term narcotic pain medication, duplicate or similar prescriptions being unnecessarily prescribed, and implementing the use of generics whenever possible. The PBM will also participate in state-wide reporting, which will catch if a claimant has other narcotic pain medication fills before the date of injury. This can show the worker may have a history of requesting certain narcotics — a red flag for abuse.
Surveillance companies usually have a service that can do a background check of pharmacies, to see if your claimant has had fills of certain medications aside from the meds needed for your specific injury. This fights fraud, and can expose someone that may have a prescription drug problem. An easy way to get strong medication is to file a comp claim, and any weapons you have to fight fraudulent claims are worth it.(WCxKit)
In summary, a third-party PBM is a useful tool not only for cost-savings but also for catching the many forms of prescription abuse out there. Doctors get lazy when it comes to prescribing medications. Sometimes the answer to every injury is a prescription of Vicodin, Percocet, or some other narcotic when none are needed. Not only are these medications expensive, but they can carry long-term health problems including addiction, which only increase the overall cost of the claim. Using a PBM is another way of being proactive when it comes to handling your claims, and your carrier/TPA will have more information on what you can do to implement a PBM program for use on all of your claims that require prescription medication.
Ask your TPA what programs they offer.
Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.com.
Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact
Two-thousand-eleven has been an interesting year in the workers compensation industry. New software has helped many administrators take better control of their costs, studies on safety have led to an increase in preventative measures and legal changes have led to unusual and sometimes controversial administration in some states.
Here at Roundup we asked one of our favorite experts, Curtis Smith, executive vice president of Medcor, Inc., a national on-site health services company, what he thought the top WC issues were for 2011. What follows are his conclusions:
Conflicts of Interest Inherent in the Industry
The very organizations employers depend on to help manage and reduce costs depend on claims for their core revenue – and this can lead to potential conflicts of interest, according to Smith. He offers these examples: contingent commissions for brokers and consultants, TPAs (third-party administrators) and MCOs (managed care organizations) who select network providers and share revenue from provider discounts. Smith also cautions against pharmacy chains that put pharmacies on-site in large worksites for convenience also employ the practitioners who write the prescriptions.
Prescription Drug Abuse
Thousands of people incur illness and injury each year from abuse of prescription medications, especially pain medications. Addictions and overdoses are increasing, as are deaths, Smith wrote. Addictions often arise from treatment after a work-related injuries but the medical community is not policing or restricting doctors who write these prescriptions. What’s more, TPAs are not excluding these unrestricted doctors from networks of approved providers for fear of litigation.
Prescription Drug Costs
The same medication can cost 10 times as much in workers compensation cases as it does in general health applications. Medications’ fee schedules have been negotiated down and controlled in group healthcare far more than in workers comp situations. Consequently, drug companies and others are moving into the comp space to take advantage of increased profitability, Smith said.
Increased Litigation in the Industry
The fundamental premise behind the workers compensation system is falling apart in many states (e.g. California and New York) where an increasing percentage of claims are contested and litigated. Huge settlements out of proportion to true economic need are forcing employers to be defensive and deny claims; denying and resisting legitimate claims forces employees to seek counsel and litigate. The comp system is turning into a battleground of plaintiff and defense attorneys working the system.
Injury Triage
Smith said he would be remiss if he did not mention injury triage. “This truly is an effective way to reduce unnecessary claims and costs, to identify serious cases, and to provide early intervention for all cases,” he wrote. Financial and health outcomes are improved with the use of triage. “It’s also innovative – wining several U.S. patents — are there any other WC methods that have been patented in the last 10 years? Or ever?” he asks. Thousands of companies are using triage and many competitors have joined the market, providing a variety of service and pricing models. Yet, many employers (even most) still don’t use it and the claims-driven industry still resists it.
Even those who offer injury triage often do so begrudgingly to satisfy their employer-clients, to block another triage provider from taking claims away, or to acquire business – but they are slow to introduce triage to an existing book of businesses, or, once introduced, often let implementation and utilization languish so claims can continue to flow.
In conclusion, look to hear more about these important topics in 2012. Though they may not be resolved in short order, they are certainly going to be on the minds of those of us in the industry in years to come.
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.
Often overlooked in the on-going battle to control workers compensation cost is the cost of prescriptions. Pharmacy Benefits Managers (PBM) offer the self-insured employer, insurer or third party administrator a way to manage and control the cost of drugs. While PBM provide a cost savings by obtaining a discount on the cost of drugs, the good PBM goes a lot further.
The PBM that will provide the best results is the one that keeps track of not only the cost savings provided, but also the utilization of prescriptions, especially narcotics. The better PBMs will alert the medical provider and adjuster when there is over-utilization of drugs. (WCxKit)
The PBM you select should have a national network covering most of the 70,000+ drug stores in the United States. The PBM should have a working relationship with the three major drug store chains which include CVS, Walgreens and Rite-Aid, as well as the local independent drug stores.
The effectiveness of the PBM can be judged by three different criteria which are the rate of use by the employees, the ease of use for the adjuster, and their technology interface ability.
The penetration rate is a measure of how extensively the employees use the pharmacy program. The PBM will often mail the employee a pharmacy benefit card with a cover letter on the pharmacy benefit card use. Most employees will opt to use the PBM card rather than out of pocket and then having to seek reimbursement. The adjuster should have the ability to suspend the use of pharmacy benefit card when the claim is denied or concluded.
The PBM should coordinate the prescription with the employee, the pharmacy and the medical provider without involvement of the adjuster. The easier the process is to use, the less the involvement of the adjuster. The better PBM will make the process totally seamless resulting in no involvement for the adjuster, while the adjuster can be assured the cost of the prescriptions and the utilization of the prescriptions is being properly controlled.
The PBM should provide the user of the service with the ability to review on-line all transactions and to obtain all necessary management reports. The technology interface should allow you to quickly know and understand the prescription drug usage of any employee. This will allow you to identify both the high cost employees and the doctors who prescribe the medications.
There are numerous ways the PBM can control cost. Some of the techniques used by PBMs include: (WCxKit)
-The use of generic drugs wherever substitution for patent drugs is permitted.
-A comprehensive, standard formulary specific to workers compensation injuries.
-A pre-negotiated price for each drug in the formulary.
-The ability to provide home delivery for employees who are unable to pick-up the prescribed drugs.
-Mail order services for maintenance drugs.
-The ability to approve or deny the “off-label” use of a drug.
-The ability to prevent consumption of drugs faster than manufacturer recommendations.
-The prevention of multiple, overlapping prescriptions from multiple doctors.
-The prevention of multiple pharmacies filling the same prescription.
-The prevention of filling non-injury related prescriptions.
The use of a PBM is a great way to reduce the cost of prescriptions and to lower their cost impact on your workers compensation program. To learn more about PBMs and how you can utilize their services to reduce your workers compensation cost, read the chapter on Implementing a Pharmacy Benefits Management Program in our new 2012 edition of Manage Your Workers Compensation Program, Reduce Costs 20-50%. To obtain your copy, please contact us.
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.com.
Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact
Info@ReduceYourWorkersComp.com.
Back again with the final part of the series on medical provider red flags. This could be 50 red flags, but these are some of the most common. This is to provide continued awareness that not all medical clinics are on your side. The caveat again is that this is not the norm. This article is just meant to raise awareness. Because these issues, while uncommon, really do happen. That is about as politically correct as I can make it. Here are the physician red flags you should be watching for. This article is summarized from an interview with an adjuster I met recently.
1. The medical records are “template” style, or barely exist at all. Out of all of the red flag issues we discuss, this one does not indicate a shady doctor. It could just be that the doctor is very poor at note taking. But the two go hand in hand. Great doctors do great analysis, and back up opinions with objective medical facts. They arrive at this point by walking through the medical records, and creating a great conclusive medical report. Doctors that get by by pairing up subjective history from a patient’s mouth are another story. (WCxKit)
2. Missing dates of service, or no date labels on the medical notes. I suppose if the “template”style medical record, is paired with one that is similar to a fill-in the-blank system (Patient came in with complaints of _______ which they attribute to work causing them _____ pain out of 10, with 10 being the worst pain imaginable) and pair it up without a date of service, I guess you could use that medical record for every date of service you ever have. If anyone is watching, a physician will not get far by doing this. But, if nobody is paying attention, thousands of dollars could be paid and for who knows what. Make sure the notes are clearly labeled, dated, and legible. If not, you need to contact the physician’s office right away.
3. Different handwriting or inks on same dates of service. Granted again, that may be the nurse or the medical assistant jotting some notes down before the doctor jots the notes down, but if you get the feeling that something is not adding up, then call them. Their patient may be contacting them and coaching them what to put in the record, which we all know is not OK.
4. The medical provider office will not send medical records or state that they do not keep a medical “record”. I cannot think of one legit company that does not keep a note or record of some sort, for whatever reason. Even the most trivial of companies store records of some sort. So using that as a comparison, the medical record is very important. And for a clinic to say they do not keep a record is unbelievable. As a matter of fact, you should not pay any bill ever without a medical record attached to it. How do you know what is being paid and for what? If a doctor’s office ever tells you that they do not keep a record on a patient, my advice is to alert your counsel and have them step in right away.
5. The medical notes showed continued high levels of pain. I have never broken my arm, but I anticipate that it hurts quite a bit. Enough to be uncomfortable anyway. So if it is 2 months later and you still have “10 out of 10” pain, that is just not correct. If the pain is so unbearable, and you have treated with this doctor for 2 months, why go back there? And how is the worker driving to these appointments? And how can the worker go to the bank and cash your check, all with “10 out of 10” pain that has not lessened? The doctor should be stating in the medical notes that the objective indicators for pain do not match the subjective complaints of “10 out of 10” pain. If the physician is not doing anything about it, or the person is no better, then you have to find out what is going on medically and get that person to a specialist or set up an IME to address these ongoing complaints.
6. Consistent improper billing practices. Your Carrier/TPA usually cannot process a payment off of an invoice. Usually the bill has to be printed on an HCFA-1500 form so the Carrier/TPA can process it. This is standard. A lot of offices that handle any type of insurance work know this. So if they keep trying to submit their bills improperly, something is going on. Why are they doing this? Have any others had this sort of problem with this provider? Coding errors, print errors, ICD-9 code errors, etc. should be correct and correlate to the claim. A few errors are to be expected. But if it is constantly going on and on and on, you have to dig a little deeper.
7. Conflicting medical reports or conflicting subjective complaints that are not addressed. Let us say you are the adjuster and you are reviewing a stack of medical records on your claimant. One day your claimant states they are in very bad pain, 8 out of 10. It is hard to bend, and walk. The next day they show up for therapy and they tell the therapist they are doing great, and they think treatment is really helping them. 2 days later they go back to the doctor and say they feel the same, about 7-8/10 pain. Then the same day they have therapy and tell the therapist they feel great, and are looking back to getting back to work. I believe in the fact that people have good days and bad days. But if you are hurt, and in legit pain, your symptoms should not yo-yo up and down like that. Therapy can flare pain up a bit, but over the course of a few weeks the pain should be gradually lessened. If you start to notice yo-yo pain complaints and pain out of proportion to the injury, think about getting your IME in order because the claimant is trying to extend their time out of work.
8. Consistent excessive referrals or quick referrals to physical therapy where it may not be needed. I know of a very popular occupational clinic. A very large one. And I have handled a ton of claims where the clinic is the treating provider. And over the course of a year or 2, I wager to say that everyone that walks through their doors with a comp case had a referral to go to the same physical therapy facility after the first or second visit. These were strains, sprains, lacerations, contusions, etc. Every injury you could think of and they were all sent for therapy. We had to call and talk to the doctor to find out the rationale. This took a lot of time, but after a while they go the point and started to go by the medical norm for a referral for physical therapy. This is meant to be a very loose example, but a lot of times personal doctors or practices also own therapy companies or diagnostic laboratories, or they have partial ownership in them, so they get to make money twice; once when you go to see them, and again when you go to their therapy facility. So trust your instinct. If you think a referral is questionable, call and talk to the doctor. Make that doctor defend their decision and ask them questions. After all they have a service to provide to you, and you have rights too in these work comp scenarios. Depending on your jurisdiction anyway. NOTE: Make sure your company is aligned with a high-quality independent physical therapy network, perhaps even a national network, and put that in the account handling instructions, then monitor compliance and make sure the adjuster is helping monitor compliance.
Summary
Again this is not every doctor, at every clinic, attempting to get extra. These questionable doctors are few and far between. But they are out there, and your adjuster and counsel know of some of them. Physicians will say that they can only treat what the patient is telling them, and if the patient states they are in pain, then no matter what doctors are going to do what they can to help them. So part of this problem is on the doctor, and part is on the claimant or patient. However, all of it can be questioned by you in a workers comp scenario. Keep names of doctors and group practices that you had trouble with in the past. If something does not seem right call and talk to the doctor about it and share your concerns. Remember the doctors or practices that caused you problems–chances are you will cross paths with them again. Continue to stay proactive, and trust those instincts.
Your responsibility as an employer is to establish procedures, select vendors, and make sure you are actively involved in who treats your employees and the results they get from treatment, assuming this is allowed in your state. Working with a good TPA is important; ask them how they control these issues and learn what they are doing to prevent over treatment.
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.com.
Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
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