It’s easy to become trapped in assumptions. One such assumption is that predictive modeling is exclusively achieved by scouring data using advanced mathematical computations. While that is the generally accepted method, and a valid one, it need not be the only method. Extraordinary outcomes and substantial savings can also result from simpler initiatives.
While more commonly used in other industries, predictive modeling is gathering interest in workers compensation. Predictive modeling is a process used to create a statistical model of future behavior. It is the area of data mining and business intelligence concerned with forecasting probable outcomes or trends.Multiple methods of testing assumptions and uncertainty are involved while looking for patterns in the data. Statistical modeling uses advanced mathematics to find correlations, look for consistent causation, develop a theory — apply it, validate it, adjust the theory and continually retest it. (WCxKit)
Answers are sought for basic questions using predictive modeling. If X is true, then what is the probability Y will occur? Or when Y occurs, what are the factors that could have predicted it?
A familiar example of how predictive modeling is used is auto insurance companies taking into account potential driving safety predictors in the data such as age, gender, and driving record. The predictions are not guesses. Instead, indicators are found using huge amounts of data and are based on the idea that consistent historic behavior found in costly claims is a predictor of future claims with similar conditions. Auto insurance premium costs are rated by this actuarial intelligence applied to the data.
Similarly, when predictive modeling is applied to workers compensation, the objective is to identify claims likely to be complex and costly based on historical data. The goal is also to identify those claims early so damage control can be implemented such as focused claim and medical management or early settlement. Regression analysis and other advanced methods of statistical mathematics are applied to the data to find key indicator data in those claims.
Nevertheless, advanced statistical modeling is not for everyone. Studying the data in this way requires huge amounts of data to achieve statistically significant results. Experts must be contracted and financial investments made. Such efforts are well founded, encouraged and ultimately lead to refined intelligence in workers comp. Still, there are lesser, yet valid, achievements to be made.
Notably, most payer organizations have an untapped predictive resource: internal wisdom. Claims adjusters, nurse case managers, and medical directors all know their claimant population and instinctively know what claims are likely to be problematic. Moreover, many organizations utilize the three-point contact methodology where vital data are collected about the claim that can be predictive. All this information should be collected in data form and structured procedurally to strengthen claim management functions.
Another way to find predictors in data is to leverage workers comp medical research as a guide. Edward Bernacki, MD and his team at Johns Hopkins published a study in the Journal of Occupational and Environmental Medicine in January of this year describing Cost Intensive Physicians. (Bernacki, et.al. “Impact of Cost Intensive Physicians on Workers Compensation” JOEM. Vol. 52. No. 1. January, 2010) Using five years’ closed claim data from the Louisiana Workers Compensation Corporation, they studied claims that began with reserves less than $15,000, but migrated to reserves of +/-$50,000. Of those claims, 3.8% of physicians involved were responsible for 72% of the costs. Their information about cost intensive physicians can be applied to identify predictors.
Cost intensive physicians, as labeled in the study, were those who had higher medical costs, longer medical treatment duration, longer claim durations, and higher indemnity costs. Therefore, one can conclude that identifying, avoiding or managing the cost intensive physicians is one way to contain costs. Look for those features associated with specific physicians in the data along with other characteristics highlighted in the study.
The Bernacki study also named certain injury types and procedures high cost predictors. Those injury types or diagnoses that do not have clearly defined treatment pathways are often problematic. Whereas a fractured tibia has a predictable treatment path, injuries of joints and back strains do not, leaving a wide berth of treatment options and opportunities for abuse. Monitor the data proactively to isolate injury types and procedures identified in the study and manage them aggressively.
Another study, “Long-term Outcomes of Lumbar Fusion Among Workers Compensation Subjects: An Historical Cohort Study”, found at
http://www.ncbi.nlm.nih.gov/pubmed/20736894. This study concluded, “Lumbar fusion for the diagnoses of disc degeneration, disc herniation, and/or radiculopathy in a workers comp setting is associated with significant increase in disability, opiate use, prolonged work loss, and poor RTW status.” Clearly, these conditions, when spinal fusion is the selected option, are predictors of complexity and cost. (WC
xKit)
Identifying and naming predictors using the knowledge from professionals and from research is a simple, yet valid approach to cost control through predictive methods. Call it “predictive modeling-light.” Monitor the data concurrently and continually to identify claims containing combinations of data that portend risk and focus on those. While the process is not sophisticated or complex, it will structure claims and medical management procedures, making them more proactive, effective, and replicable.
Author Karen Wolfe, BSN, MA, MBA, President/CEO, MedMetrics®, LLC. Karen is founder and president of MedMetrics® LLC, an Internet-based Workers Compensation medical analytics company. She applies her medical knowledge to gathering, understanding and applying Workers Compensation data to the operational process. MedMetrics imports, integrates, and analyzes its clients’ medical billing and claims level data. MedMetrics uses several tools such as Predictive Intelligence Profiling and Medical Provider Performance Assessment to gather and analyze data. Contact: Phone: 541-390-1680;
Karenwolfe@medmetrics.org; www.medmetrics.org.
©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
One of the most important parts of medical management of a workers compensation claim is the precertification process within utilization review. Precertification is the process of have certain medical procedures or medical treatments preapproved by the workers comp insurer before the procedure or treatment is started.
The purpose of precertification is to determine the medical necessity of the medical procedure or medical treatment. Precertification protects the employee from unnecessary medical procedures and it gives the insurer the opportunity to verify the medical procedures requested by the treating physician to meet the accepted medical guidelines for the injury. (The accepted medical guidelines normally used are the criteria for medical procedures or medical treatment established by the American Medical Association). (WCxKit)
A precertification review is not done for each routine visit the injured employee has with the treating physician. When the treating physician determines a medical procedure or medical treatment is needed, one not routinely included in an office visit, a request for precertification is needed.
13 Examples of When to Request Precertification:
1. Non-emergency hospital admittance
2. Non-emergency surgical procedures
3. Non-emergency outpatient hospital care
4. Physical therapy and occupational therapy
5. Speech, cognitive, rehabilitation and other restorative therapy
6. Diagnostic testing – MRI, CT scan, myelography, EMG, EEG, etc.
7. Durable medical equipment
8. Home health care
9. Psychological testing
10.Chronic pain management
11.Work hardening programs
12.Acupuncture
13.Experimental procedures
Utilization review precertification is normally done by a medical reviewer employed by the insured, a registered nurse (RN) a contracted vendor. The RN makes a medical necessity approval determination after reviewing the medical history of the injured employee. The RN reviews the medical documentation including diagnostic testing, clinical evaluation reports, physical therapy records, the results of any specialized testing in regards to the requested medical procedures.
If the RN determines the medical procedure is appropriate, the treating physician is notified of the approval. If the RN determines the medical procedure is not supported by the medical records, the denial of the procedure is referred to a doctor employed by the insurer or contracted vendor. The insurer's doctor reviews all the medical information to determine if the requested procedure or treatment is medically necessary and if it is the best option for the employee. If the insurer's doctor concurs with the RN that the medical procedure should be denied, the treating physician is notified of the reasons the proposed treatment is denied. If the insurer's doctor disagrees with the RN and concurs with the treating physician, the treating physician is notified the medical procedure is approved.
When a medical procedure is denied, precertification gives the insurer's doctor and the treating physician an opportunity to discuss the best options for the treatment of the injured employee. The injured employee benefits by receiving an improved treatment plan. Precertification will provide early identification of treatment issues. It allows the medical reviewer to communicate with the workers comp adjuster what the medical issues are and to explain what is/are the employee's best medical option(s). (WCxKit)
An example of the benefits of precertification is the treatment options for low back pain. The admission of employees to the hospital for non-surgical treatment of low back pain was common thirty years ago. Treating physicians would run out of treating options and admit people to the hospital primarily for bed rest. With precertification showing a lack of medical necessity for the hospital admission, this practice is unheard of today.
In addition to providing the injured employee with the best medical option(s) for recovery, precertification has other benefits including lower cost for the employer and promotion of an atmosphere of the best interest of the injured employee.
Precertification determines the medical necessity of medical procedures and medical treatment before the cost is incurred. Precertification is a win-win scenario. It insures the employee is receiving the best medical care for their injury and prevents unnecessary medical care that delays the employee's recovery. Precertification lowers the overall cost of medical care by eliminating unnecessary medical expense.
Jane Steele, RN, MS, CCM, Nurse Case Manager from Genex Services, points out that one downside to precertification review is that things take forever to get things done…. unless you have a nurse cse mgr who can jump thru the necessary hoops in the system and speed things along.
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.
Contact: RShafer@ReduceYourWorkersComp.com or 860-553-6604.
Copyright © 2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
The cost of drugs is the fastest growing component of medical care cost and often one of the most neglected areas of workers compensation cost control. It is estimated that workers compensation pays $5 billion in drug cost each year. While there are numerous pharmacy benefit managers (PBM) in the work comp arena, they are often either totally ignored or only partially utilized by the insurers, self-insureds and third party administrators (TPA). Other areas of medical cost control like fee bill schedules, medical provider networks, medical management and utilization review get more attention than PBM, but proper utilization of PBM can result in substantial savings in the cost of work comp.
What PBM Can Do?
Unfortunately, many claim adjusters think of PBM only as a way of saving money by getting a discount on the cost of prescriptions. With some PBM that
is all they do. However, if the insurer (or the self-insured employer who is paying attention to the factors in the cost of their work comp coverage) shops around among the PBM providers, they should be able to locate a PBM that has a national presence and a focus on proactive utilization control. Key service points and cost control solutions to consider for a PBM include:
1. The flexibility to coordinate the medical prescription benefit in the most efficient manner between the employee, the pharmacy and the medical provider with minimal involvement of the adjuster
2. The ability to comply with all the workers' compensation rules and regulations of each state, which can vary tremendously from state to state, and to stay current/up to date
3. The technology to process the prescription in real time – without delay when presented by the employee to the pharmacy – with the appropriate pricing (WCxKit)
4. A national network covering most of the 70,000+ pharmacies in the United States. This will provide convenience and hassle-free access for the employees regardless where they live (also to prevent non-compliance with the required use of the PBM). The PBM network should definitely include the three major chains – Walgreens, CVS Pharmacies and Rite-Aid
5. A comprehensive standard formulary that can be customized and injury-specific and/or patient-specific to manage utilization (even customized down to the ICD-9 codes)
6. A pre-negotiated price (network discount) for each drug (a 25% discount off a price that is 50% higher than it should be is not a cost savings)
7. The ability to provide home delivery by the Postal Service, Fed Ex or UPS at minimal extra cost
8. The willingness to provide 24 hours a day, 7 days a week customer support service
9. The ability to identify generic substitution opportunities
10.The identification of newer drugs that provide greater benefit
11.The ability to process – approve or deny – the off-label use of a drug
12.Utilization review — before the prescription is filled - to prevent of overuse of narcotics – consumption faster than manufacturer recommendations or faster than the medical provider's prescription amount
13.The prevention of multi-physician (“doctor shopping”) prescriptions from being processed for the same drugs or duplicate use drugs
14.The prevention of multi-pharmacy involvement in filling the same prescription (for example – the employee takes the paper prescription to one pharmacy to be filled, then called the medical provider, claims to have lost the prescription and has the prescription called into another pharmacy)
15.The technology to recognize when inappropriate or non-compensable medication is being dispensed (for example – a non-injury related medication is being presented to the pharmacy) and the ability to stop it from being filled
16.The ability to be electronically integrated with the insurers', TPAs or self-insured's bill review system to eliminate the manual processing of individual prescription payments
17.The ability to provide ancillary services like durable medical equipment (nice to have, but not absolutely essential)
18.The ability to provide reports on cost savings, utilization and trending
19.The ability to provide correct pricing for any drugs dispensed from the doctor's office which often are over billed
20. Accreditation by the Utilization Review Accreditation Committee reflects the PBM promotes quality and efficiency of health care delivery
A Growing Problem:
The use of PBM does result in a reduction in the abuse of pain medications. However, some employees who become pain medication junkies have found a way to circumvent the PBM. A growing problem is the medical providers who will perform office injections for the employee. The medical provider gets paid for multiple office visits and the pain medication junkie keeps on abusing the pain medication. (WCxKit)
Summary:
The appropriate management of medications by the PBM can lower the overall cost of medical care and shorten the return to work time. The employee benefits from the PBM by receiving the necessary medications locally (or home delivery) while the employer benefits from the employee receiving the appropriate medications in a timely manner. The insurer or self-insured benefit from the medical savings the PBM provides.
Author Rebecca Shafer, President, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. Info@ReduceYourWorkersComp.com .
©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
Employers need every edge in reducing their costs of workers compensation, given our stagnant economy. Medical billing and coding is perhaps an overlooked area of cost control. One tiny error can lead to a very big problem in a medical bill — i.e., kicking the bill back for re-processing thus delaying payment.
An employer can do one of two things: rely on an outside source,– billing departments of doctors, nurses, therapists, hospitals, etc.– to produce correct, timely medical invoicing with accurate coding and risk paying more, paying for the wrong procedure, or waiting longer for a work comp claim to close. However, an employer still need to provide oversight, will be one of many other clients, must be sure the staff understands workers comp issues – in other words, you’ll be bird-dogging. (WCxKit)
Another and better way is to have your own in-house staff whose job is to review and analyze all medical bills submitted by health care providers before they are approved for payment. Either hire or train a person to vet all medical bills. Training a current employee has the advantage having someone already familiar with the company’s workers comp procedures and works only for the employer.
Whether you hire or train, there is a high demand for workers who are medical billers and coder, a field described as “recession proof.” Look for a person with a:
Certification of Completion in Medical Billing and Coding
Someone with this certification comes ready to start work with these skills:
1. Knowledge of the universal alphanumeric medical coding system.
This is a system used in all areas of health care so there is little discrepancy or room for errors. Doctors and nurses uses these codes to know more about the patient's medical history and current afflictions, while insurance agencies use these codes to determine how much to pay their clients on their insurance claims.
2. Training in basic medical terminology to understand medical terms in the fields of biology, anatomy, physiology and pharmaceuticals.
3. Training in the latest billing technologies, every-changing in today’s healthcare climate.
4. Good organizational skills for implementing and maintaining filing systems.
5. Detailed oriented and very accurate. Remember, just one tiny error can delay a bill “forever” so to speak.
6. Basic computer skills in word processing and spreadsheets for record keeping. (WCxKit)
7. Good communications skills for dealing with healthcare personnel.
If you decide to train from within there are affordable and flexible one- or two-year MBA programs, many offered on line allowing an employee to continue in a current position.
Worker Comp Kit Blog thanks and welcomes
Jenna Devoss who helps run and maintain
MedicalBillingandCoding.org, for her insightful contributions. MedicalBillingandCoding.org is a reliable source for medical billing and coding training programs, careers and future job outlooks.
©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
Recently, I have been touring operations of various vendors such as an MSA compliance company, nurse triage company, claim intake company and several investigation firms. This is very helpful in understanding the intricacies of these services, enabling me to explain to readers the pros and cons of these services. There's really no substitute to seeing something with my own eyes versus reading sales brochures about it.
One issue I am researching for an article is whether there is an advantage to private labeling workers compensation related services. Do companies prefer private labeled products, do they prefer to make the transaction transparent or don't they care. Or, as is likely the case for many, they do not know some of the services they use may not be owned by their TPA or carrier because the service brochures bear the names of their TPA or insurance company.
Is your company more likely to use services such as nurse triage or nurse case management if they are private-labeled (meaning the vendor has agreed to allow a 3rd party to use their own branding designation) or is there more value in having the servicing provider's identity and qualifications clearly visible? Some carriers prefer to private-label all their products and have all brochures with the same brand, others prefer total transparency. What do YOU prefer?
Please help me explore this issue, by responding to a simple one-question poll. Link Below.
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.
Contact: RShafer@ReduceYourWorkersComp.com or 860-553-6604.
©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
The skill level of the Nurse Case Manager (NCM) on your workers' compensation claims can have a major impact on the overall cost of your claims. In fact, I get more calls about "nurse case management" than about any other problem!
A NCM can be a valuable resource in getting the employee back to work promptly and insuring the employee makes the best recovery possible. Having the best NCM can save your company a ton of money, but the question becomes how do you get the best NCM on your work comp claims?! (WCxKit)
The approach taken by many risk managers, or the claims coordinator for the employer, in selection of the NCM is the old tried and true method history and experience. After the NCM has handled numerous claims for your company, you begin to recognize whether or not the NCM is doing a good job of medical management. This is an expensive way to learn who the good NCMs are. You have spent major dollars on numerous claims before you know for sure you have a great NCM or a lousy NCM. Some companies have "senior nurse reviewers" who have more expertise and experience than others.
Unfortunately some NCMs are reactive to medical developments and take a passive approach to the employee's overall recovery. These NCM can be, and should be, avoided. Like adjusters, the good and great NCMs have definite characteristics that set them apart from the rest. Recognizing the good NCM can be done before you have to spend major dollars on many claims. Some of the characteristics of a great NCM are:
1. Great interpersonal skills and organizational skills.
2. Having clinical expertise and experience with complex medical care issues.
3. A proactive approach to obtaining the most appropriate medical care for the employee while controlling the cost of the medical care.
4. A keen understanding of the financial aspects of medical care.
5. An ability to exercise independent judgment.
6. An ability to manage multiple priorities and activities in an unstructured environment.
7. A willingness to assist the employee to understand the medical treatment goals and expected outcomes of the treatment.
8. An ability to assess the employee's medical status by understanding the injury history, the medical treatment, the plan for future medical treatment and the overall recovery process, then combining this information to develop a case management plan and a return to work plan.
9. An ability to facilitate timely health care services with the minimal of lag time – maintaining continuity throughout the employee's recovery process.
10. An ability to act as a liaison between the employee, the employer, the medical provider and the workers' compensation adjuster.
11. A willingness to act as the employee's advocate with the employer, the medical provider and the insurer when necessary to achieve the quickest recovery for the employee.
12. An ability to work with the medical provider(s) to create the best treatment plan that will allow for the employee's timely return to work.
13. An ability to negotiate with both the employer and the medical provider to facilitate the employee's return to work on modified duty while accommodating the employee's limitation during the recovery process.
14. An ability to educate the employee to prevent a recurrence of the injury after the employee has returned to work full time.
15. A willingness to provide timely updates on the employee's progress to both the workers' compensation adjuster and the employer.
If you think you received a lot of push-back from the insurance carrier or the third party administrator (TPA) when you asked to select the adjuster for your insurance program, it was minor compare to the resistant you will get from the manager of the nurse case mangers for the insurer, TPA or outside vendor of medical case management services when you ask to select your NCM. The manager for the NCM unit will reassure you that all of his NCMs are professionals and they all have all the attributes listed above. While it is doubtful every NCM in the NCM unit will have all of these attributes, and even if they do, some NCMs will always do a better job than others – just like some adjusters are better than others, and some risk managers are better than others.
If you have already spent the money on many claims to learn which NCMs available to you are the best, then insist on excluding all but the top two or three NCMs. The insurer, TPA or independent vendor of medical case management will not want to lose your business and will accommodate your request (maybe begrudgingly). (WCxKit)
If your program is new to the insurer, TPA or outside vendor of case management services, ask the NCM unit manager for the names of current clients that you can contact for references. While you are checking the references, ask for the names of the top NCMs in the NCM unit. After you have identified the top two or three performers in the NCM unit, ask for only these top two or three performers to be assigned to your claims. Or, ask for Senior Nurse Reviewers. Again, the NCM manager will accommodate your request, maybe begrudgingly, but you will be happy with the money you save on your workers' compensation claims.
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. Contact: RShafer@ReduceYourWorkersComp.com
©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
An independent medical examination (IME) should be completed when an employee's recovery from an injury takes longer than normal, or when the employee is released from medical care, but receives a higher than expected disability rating by the treating physician. The IME documents the employee's medical condition. An IME also provides the insurance company or employer with an independent verification as to whether the employee's medical condition is or is not related to an on-the-job injury.
While most treating physicians are honest and reputable doctors, some treating physicians rely on referrals from plaintiff attorneys for the bulk of their business. These doctors have a tendency to overstate the employee's disability and permanency level. They know the attorneys who provide them with patients use their medical evaluations to obtain the highest possible settlement for their clients. Therefore, the independent medical examination documenting the medical status of the employee is essential to the fair settlement of the workers comp claim. (WCxKit)
If the employee has more than one aspect of his/her health in question, more than one IME is necessary. For instance, to evaluate properly the employees workers comp claim, it may be necessary to have IMEs done by an orthopedic surgeon, a neurologist and a physical rehabilitation specialist. Most states limit the number of IMEs to one, two or three in each area of medicine. While a few states allow the insurer as many IMEs as they want, the cost of an IME can quickly add to the overall claim cost. Therefore, use IMEs when needed, but do not abuse the process.
An IME should be performed by a doctor who specializes in the field of medicine routinely treating the type of injury the employee has incurred. The IME doctor should not have been previously involved in the employee's medical care either for the injury in question or for any other medical care. An IME does not create a doctor-patient relationship.
The purpose of an IME in a workers compensation claim is to determine the cause of injury and the extent of the disability from the injury. If the treating physician has not placed the employee at maximum medical improvement (MMI), the IME can be utilized to determine what further treatment the employee needs.
By obtaining an IME, the insurer is better able to make fair decisions on how to handle the claim. The IME provides the workers comp adjuster with the necessary information to discontinue medical treatment, to continue medical treatment, to change medical treatment, and to determine the appropriate permanent partial disability benefit or permanent total disability benefit.
In most states the workers comp adjuster selects the IME doctor. In a few states the adjuster must petition the Workers Compensation Board to have the employee seen by an IME doctor. In some states the workers comp board selects the IME doctor. Whether the doctor is adjuster selected or workers comp board selected, it is imperative the doctor be a specialist in the field of medicine that involves the injury. The proper selection of the doctor results in high quality exams both accurate and medically sound.
To insure the IME is accurate, the adjuster or the nurse case manager assigned to the claim, provides the IME doctor with all the employee's medical records and diagnostic tests results (x-rays, CT scans, MRI reports, EMG studies, etc.). The information needs to be provided to the IME doctor well in advance of the employee's appointment to allow the doctor time to review properly the medical history of the employee. Also, the adjuster or nurse case manager also provides the IME doctor with a detailed job description obtained from the employer – the IME doctor should not have to rely on the employee's description of his/her work (which could overstate the physical demands of the job).
The IME doctor in addition to being provided the medical records, diagnostic test and job description, is informed of the reason the adjuster is requesting the examination — whether it is to establish what further medical care is needed, the level of permanent disability or other concern. By understanding why they are performing the IME, the doctor can then focus on answering the question(s) or concerns of the adjuster and/or the employer.
When the employee is represented by an attorney, the IME is normally set by agreement between the parties. If the employee's attorney is uncooperative about having an IME it is usually a sign the employee's attorney questions or doubt's the veracity of the claim or the extent of the injury. When the employee or the employee’s attorney refuses an IME, an immediate petition to compel the IME is filed with the workers comp board.
During the IME the doctor conducts an interview of the employee, performs the appropriate medical examination, observe the employee's general appearance, the employee's gait, how the employee stands, whether or not the employee has any difficulty climbing onto the examination table, whether or not the employee shows any signs of distress and the employee's weight. The doctor evaluates the employee's subjective symptoms and determines if they are consistent with the manifestations of the injury claimed. The IME doctor looks for any signs of exaggeration or deception by the employee and will include in the IME report if the employee is intentionally exaggerating his/her symptoms or if s/he feels the employee is malingering.
Also during the IME the doctor performs various test to verify the symptoms alleged by the employee conform to the normal symptoms for the injury claimed. The doctor questions the employee about his/her ailment(s), the treatment the employee has had for the injury, whether or not the employee had a prior injury or an injury subsequent to the workers comp injury and discusses any underlying pathologies to the injury. The IME doctor determines if the employee smokes, drinks, uses illicit drugs or has other health or lifestyle issues that will impact the employee's ability to recover from the injury or the employee's level of permanent disability. (WCxKit)
The independent medical examination should be used by the insurer or the employer to document the medical status of the employee at that moment in time. The information obtained from the IME is used either to provide the employee with the full medical care needed, or to determine the employee's level of disability, or both
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. Contact: RShafer@ReduceYourWorkersComp.com.
©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
The goal of the Nurse Case Manager (NCM) is to assist the injured employee and facilitate the employee's return to work through identification of the medical services needed, the arrangement for those services to be provided, to advocate for the employee's medical needs through communication with all medical providers, and to educate the employee on the employee's role in the recovery process.
The NCM can be employed by the workers compensation insurance carrier, the self-insured employer, the third party administrator or by the medical provider, such as an orthopedist. For the purpose of this blog, we will review the role of the NCM from the perspective of the workers comp insurance carrier.
The title of Nurse Case Manager is the most frequently used name for the role, but like workers comp adjusters are sometimes referred to as claim examiners, there are other names for the NCM. In some insurance companies the role is referred to as the “workers compensation case manager” or “injury management facilitator” or “field case manager” (FCM) if most of the work is done away from the office, or “telephonic case manager” (TCM) if the work is done in the office by using the telephone. (WCxKit)
Note: These are NOT the same as NURSE TRIAGE which is when a claim is reported directly to an RN for suggestions about initial medical treatment.
The NCM is a trained nurse, either a Registered Nurse (RN) or a Licensed Practical Nurse (LPN) before entering the NCM field. Most workers compensation insurance carriers hire experienced NCMs from other areas of the medical field, for instance from a health maintenance organization. The insurance carrier can teach the NCM the basics of workers compensation to which the NCM will add her knowledge of medical management.
It is normal for the NCM of an insurance carrier to have experience in occupational health, medical management, discharge planning and home health care. The role of the NCM is to combine these disciplines to facilitate the employee's return to work in the minimum amount of time without reducing the quality of the medical care. The NCM is a skilled communicator as she is constantly in contact and working with the employees and the medical provider.
The NCM can be brought into the workers comp claim at any point in the life of the claim. Normally, it is the adjuster who determines whether or not a NCM will be utilized on a workers comp claim, but the employer can and should request a NCM if they feel the employee would benefit from the utilization of a NCM.
Different insurance carriers utilize the NCM in different ways. Some insurance carriers rely heavily on a TCM who contacts all parties by telephone, fax or letter. To function as a TCM, the nurse must have excellent telephone skills and interpersonal skills, along with a very in-depth clinical background knowledge. The caseload assigned to a TCM is larger than the caseload assigned to an FCM as the TCM does not have the travel time.
Other insurance carriers prefer to use a FCM. The FCM is often referred to as on-site nurse, as the work is done in person by appointments with the employee, the employer, the medical providers and other vendors. The FCM must have strong interpersonal skills and be able to establish a good rapport with all the parties involved in the medical care. The caseload is lighter than the TCM due to t travel time to appointments.
Many workers compensation insurers use both a TCM and FCM. The TCM is utilized to handle the simpler or less severe workers comp claims. The FCM is utilized on the severe or complex workers comp claims where the on-site case management will be the most beneficial.
The NCM, whether a TCM or FCM, works in conjunction with the claims adjuster. The NCM makes a separate three-point contact (employee, employer, medical provider) from the three-point contact made by the adjuster, as the NCM has a different perspective than the adjuster has in the management of the workers comp claim.
When the NCM makes three-point contact, it is for the purpose of introducing himself/herself and obtaining an understanding of the nature and severity of the claim. The initial contacts assist the NCM in establishing rapport and creating a working relationship with the employee, employer and medical provider(s). It is most beneficial to the employee to know a medical professional will be there to assist them throughout the workers comp process.
The initial interviews also assists the NCM with the initial assessment, coordination, planning and evaluation of the injury and the necessary medical treatment. In conjunction with the medical provider(s) the NCM will formulate a treatment plan. The NCM is then able to determine what barriers exist that would prevent the employee from returning to work. The NCM educates the employee on the benefits of returning to work quickly and facilitates with the employer the accommodations necessary to meet the medical concerns of the physician.
It often takes several contacts with the three parties (employee, employer, medical provider) to coordinate the employee's timely and successful return to work. The more complex or severe the injury, the more times the NCM must be in contact with these three parties. The NCM continues to evaluate the employee's progress and monitors the treatment until the employee is released to return to work. (WCxKit)
The benefits provided by the NCM are many. The return on investment is such that many insurance carriers have shifted from the adjuster bringing the NCM into the claim when needed to an approach of early intervention. Each new workers comp claim is reviewed by a NCM. This allows the NCM to direct and control the medical care from the beginning, preventing many workers comp claims from getting on a treatment track that delays the employee's recovery and return to work.
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.
Contact: RShafer@ReduceYourWorkersComp.com or 860-553-6604
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.
©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
Body shop workers in Great Britain are being encouraged to do more to protect themselves when paint spraying, as new research suggests some are putting themselves at risk of developing asthma.
A report by the Health and Safety Executive (HSE) into the use of two-pack paints containing isocyanates has identified that, while practices have improved greatly in recent years, there are still a number of areas of concern. (WCxKit)
HSE estimates that vehicle spray painters are 80 times more likely to develop occupational asthma than the average worker in the UK because they fail to take the correct precautions.
Visits to 30 motor vehicle repair body shops and telephone surveys with 500 body shops found some sprayers and managers remain unaware of the link between breathing in isocyanates contained within the invisible spray mist and developing occupational asthma.
Almost one in five body shop managers surveyed by telephone did not know their booth clearance times. This, combined with the finding that many sprayers are still unaware of the dangers of invisible spray mist puts workers at risk of re-entering booths too soon, making them more vulnerable to breathing in isocyanates.
Encouragingly, the study found the vast majority of sprayers (85%) do wear air-fed breathing apparatus. However, many continue to put their health at risk by lifting their visors to check the finish before the paint is dry, potentially exposing them to the isocyanate-containing mist.
Louise Rice from HSE, noted, "We're encouraged to see that body shop managers and sprayers are generally much more aware of the risks of isocyanates and what they need to do to protect themselves, but it is worrying that the message is still not getting through to all of them.
"Occupational asthma destroys careers and lives. We appreciate that sprayers work to tight deadlines and time pressures, but they should not be gambling with their health. We will use this research to ensure we're working with industry in the most effective way to help reduce the risk to workers." (WCxKit)
The research also considered how factors such as size of business, working hours and bonus systems, health surveillance, personal protective equipment and training impact on health and safety practices in isocyanate paint use.
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 their workers compensation costs. Her clients include airlines, healthcare, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. Contact: RShafer@ReduceYourWorkersComp.com or 860-553-6604.
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©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com
Effective July 1, 2010 the Connecticut Workers Compensation Commission established new guidelines to enhance communication between payors and medical providers in the workers compensation context. The goal of these guidelines is to improve the coordination of medical services to benefit both the employee by restoring their health as quickly as possible and the employer by returning a valuable employee to work without the need to defend a costly personal injury civil suit. In the introduction to these new guidelines the Commission explains that the major impediment to the delivery of prompt medical services is the lack of communication between the payors and providers. This lack of communication requires a voluminous number of largely unnecessary hearings wasting time and resources of the Commission as well as claimants and respondents. As such, these new guidelines target the “breakdown in communication” between health care providers and respondents with the goal of establishing a cooperative system to enable injured workers to promptly obtain necessary medical services.
In terms of payor responsibilities in these guidelines, the unmistakable goal is consistency in how claims are handled. Regarding accepted claims where all parties acknowledge an injury occurred in the course of employment, the new guidelines first mandate that voluntary agreements be issued on all accepted lost-time cases. Second, in accepted cases no “pre-approval” can be required by payors for basic medical services such as routine office visits and physical therapy for the accepted body part. Third, in these cases the guidelines advise that all forms of communication between health care providers and payors; telephone calls, facsimiles, e-mails, etc. should be returned in two business days. This rule is intended to include payors’ requests for medical records. While this rule will frankly be difficult to enforce, it is referenced on numerous occasions throughout the new guidelines.
Keeping in mind that prompt communication is required; the guidelines remind payors and their representatives that they are only permitted to communicate directly with treating physicians in writing with notification to all parties. Claimants and their counsel are conversely prohibited from speaking with a Respondent’s examining physician. Finally, in the event that a Commissioner’s Exam occurs, neither party can communicate with the examining physician except through the Commissioner who ordered the exam itself.
Regarding extensions of treatment requested by claimants, in accepted cases, the guidelines require that payors decide to approve or deny further diagnostics and/or treatment plans and communicate that decision to both the claimant and the authorized physician within five business days from the date of the claimant’s request. Due to the cost of such studies and/or treatments, written authorization is required for the following: EMG, CT scan/MRI, Bone Scan, Epidural steroid injection, Additional physical therapy and/or chiropractic treatment beyond the Commission’s Medical Protocols, surgery, diagnostic arthroscopy, pain management, physical rehabilitation, referrals for second opinions and functional capacity evaluations.
Should a payor deny any of the above treatment/diagnostic studies, or contest a claim in general, a Form 43 should be filed and the payor should consider the need to refer to peer or utilization review or schedule a Respondent’s Medical Exam with a provider in a similar medical specialty. The “Respondent’s Medical Exam” (previously referred to as an Independent Medical Exam) if pursued, must be scheduled within twelve calendar days of the payor’s receipt of the claimant’s medical reports. The RME must then be held within sixty calendar days after it is scheduled. In terms of the medical provider responsibilities when an “RME” occurs, the examination report must be issued within twenty-one days of the exam. Again, while difficult to enforce, the objective behind these guidelines is simply to expedite the communication between payors and providers.
In regards to contested claims, it is imperative that payors serve a Form 43 on the Commissioner and the claimant within twenty-eight days of receipt of the written notice of the claim. However, even in contested cases the guidelines encourage payors to authorize evaluations or even indemnity benefits without prejudice pending pursuit of an RME.
In the event that a hearing is necessary to decide a Form 43, the guidelines require that the payor’s representative at the hearing have authority to potentially resolve the noticed issue. Conn. Admin. Reg. § 31-279-5. Further, if the same issue remains unresolved and the matter proceeds to a preformal hearing, an adjustor must be available by telephone to assist in resolution. If no authority is provided by the time a matter reaches the preformal stage, the guidelines permit sanctions/penalties at the presiding Commissioner’s discretion.
As medical providers have a pivotal role in the handling of workers compensation claims the guidelines set forth an array of responsibilities on their end as well. In accepted cases, medical providers should not seek pre-approval for rendering routine medical services unless it has been more than one year since the claimant’s prior treatment. After rendering treatment in these cases, providers must furnish reports to the payor and the claimant within thirty days of the treatment’s completion. Connecticut General Statutes § 31-294f (b). The requisite content of these reports is specified in the guidelines and includes the following: the injury history and causal relationship to work (if applicable), the claimant’s current complaints and the physical findings of the exam, the diagnosis and treatment plan, and the claimant’s present work capacity and restrictions if any. If the treating physician desires to refer a claimant to a specialist and/or for a second opinion, the request must be made in writing to the payor and include a medical basis for the same. Finally, medical providers are instructed to maintain a summary sheet in each respective claimant’s file including: employer identification, claim number, adjuster name and contact information, the medical care plan applicable and its requirements.
In terms of medical providers’ responsibilities with contested claims, the guidelines advise that payors may contest claims on the basis that they are untimely, non-compensable, not the cause of injury due to a subsequent intervening event, or because the treatment requested is not considered reasonable and/or necessary (i.e. palliative). When the claim itself or specific treatment for a claim is denied the provider may need to justify treatment recommended or be willing to testify at a hearing regarding their findings. In terms of payment for treatment in contested cases, if the claimant is covered by a group health insurance policy, the insurer must pay for the claimant’s treatment. C.G.S. § 31-299a. In the absence of group health, the guidelines emphasize that attorneys are prohibited from paying for treatment but that a provider has the right to request a Commission hearing to discuss any bills outstanding.
As the additional obligations placed on medical providers in these guidelines may be met with some resistance, the penalties found in the pre-existing General Statutes Administrative Regulations can be exercised on those physicians who do not comply. Specifically, physicians who fail to comply with the guidelines established by the Commission can be removed from the approved list of physicians to provide treatment in workers compensation cases. C.G.S. § 31-280 (b)(10); Conn. Admin. Reg. § 31-279-9 (g).
Finally, though at first glance they appear minimal, the guidelines do establish obligations on injured workers as well. In accepted cases claimants must immediately notify their employer of the injury and attend all scheduled appointments to obtain written updates on work status. If further treatment beyond initial exams is required, claimants can select a medical provider from the employer’s approved workers compensation network or within the state of Connecticut if none exists. If at any point a payor desires to pursue an RME, or in the event that the Commissioner orders an examination, the claimant must attend and bring any relevant radiographic studies. The guidelines further recommend that claimants review all medical reports to ensure their accuracy.
In contested cases claimants are instructed to contact their employer to attempt to resolve the issue absent a hearing and provide any further information requested. In the event resolution is not possible, the claimant should request a hearing if he or she elects to pursue a claim. Group health insurance, Medicare, Medicaid and Veteran’s benefits are available to pay for treatment when claims are contested but the guidelines advise that claimants should keep a detailed record of any out of pocket expenses incurred.
While these guidelines appear quite broad, the Commission’s goal in enacting them is quite simple; to expedite the claims process and avoid the need for unnecessary hearings. Although the obligations imposed on payors and medical providers in particular appear extensive, no new penalties were established for those who do not comply. Accordingly, only time will tell if the guidelines can accomplish their intended purpose.
Authors: Collette S. Griffin, Esq., Howd & Ludorf, LLC, Hartford, CT represents employers, self-insureds and insurance carriers in workers compensation matters. Contact Info: 860-249-1361;
www.hl-law.com
©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com
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