Address 3 Areas of Concern For Chiropractic Care in Work Comp

Chiropractic care has been a mainstay in workers’ compensation systems for some time.  While there are many benefits to this form of care, members of the claims management team should use caution when managing claims involving a chiropractor.

 

 

Are Chiropractors Real Doctors?

 

Chiropractic care is an alternative form of mainstream medicine used to treat a variety of disorders impacting the musculoskeletal system.  By using the spinal cord as a reference point, chiropractors use various manipulations in order to treat not only neck and back pain, but also other conditions that have their origins in the central nervous system.

 

The requirements to become a chiropractor vary in every state.  In some instances, a chiropractor receives more medical based training than the average medical doctor (MD).  The main difference in training is chiropractors concentrate their focus of study in physiology and body mechanics.

 

 

 

Areas of Concern for the Work Comp Professional

 

Chiropractors should be treated with the same professionalism as any other health care professional.  Like anyone else who provides medical care and treatment, a majority of chiropractors are professionals in every sense of the word.

 

Claims handlers do need to educate themselves on how chiropractors operate.  Unlike most medical doctors who work in or associate with larger groups, many chiropractors operate in a solo practitioner setting.  They also offer additional services such as massage and aromatherapy.  When managing claims involving chiropractors, claims professional should employ the following techniques to ensure the injured worker is receiving quality medical care and treatment:

 

  • Review of Billing Practices: Every claims professional should review all medical bills submitted for payment with integrity.  When an employee sustains a work injury and is seen and examined by a chiropractor, it is important to review it under the same standards one would from a medical doctor specializing in orthopedic and neurological care.  This will include identifying billing codes that are consistent with an initial examination.

 

  • History of Chiropractic Care: It is important for every member of the claims management team to obtain a complete set of medical records for a claimant.  This can be difficult when a person has received previous chiropractic care.  Any billing statement from an injured worker’s initial visit should indicate if they are an existing patient, have received chiropractic care in the past or are new to this form of treatment.

 

  • Reviewing Treatment History: While chiropractors use medical terminology in their records, it does differ from what you would typically find in reports generated from a traditional medical doctor.  It is important to note the frequency of care and how long it is recommended.  One should also take note of “flare-ups” listed in medical records and determine if they coincide with the employee’s recollection.  It is also important to scrutinize any medical care with applicable state medical treatment parameters.

 

 

Managing Claim Costs

 

Members of the claims management team will need to take additional steps to address out of control treatment with a chiropractor.  There are steps that can be taken to address this form of medical mismanagement.

 

  • Independent Medical Examination: The IME is the easiest, but sometimes most expensive cost containment method in claims involving chiropractic care.  Given the restrictions most states place on such exams, it is a decision that cannot be taken lightly.

 

  • Record-Only Medical Review: This is also known as a “paper review.”  From a cost perspective, this is an excellent method to obtain an expert opinion regarding the reasonableness and necessity of care.  They can also address whether the chiropractic care is consistent with medical treatment parameters.  A paper review is also less expensive when compared to a full-blown IME.

 

 

Conclusions

 

Members of the claims management team and other interested stakeholders need to understand the benefits and dangers of chiropractic care.  Part of this includes methods and techniques to analyze the care received and making sure it is consistent with workers’ compensation guidelines.  It should also be care to treat the effects of a work injury and make the employee whole.

 

 

Author Michael Stack, Principal, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center. .

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

 

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

8 Ways to Prepare For The Next Healthcare Reform

The great healthcare debate in Washington, D.C., left many in our industry wondering what the ultimate impact would be on the workers’ comp system.  While the proposed republican bill has failed to pass, employers and payers can still take steps to ensure they are in the best position for the status quo – or whatever future legislation may be proposed.

 

Here are some areas to consider.

 

Employee Safety & Health

 

  1. Wellness programs. If your company does not have one, this is a good time to consider the idea. Healthier employees are less likely to sustain workplace injuries or illnesses and more likely to recover quickly when they do. If your company has a program, look at its effectiveness. How do you measure its success? What is the participation rate? What kind of feedback have you received about it? Even if your wellness program is doing well, it may be time to try some new features or change it up a bit to encourage increased buy-in. If possible, connect wellness initiatives with nurse case management.

 

  1. Focus on older workers. If you’ve thought about taking steps to increase safety and health among aging workers, now is a good time to do so. Improve the lighting, implement efforts to ensure hallways are free of obstacles, and look into assistive devices to reduce bodily strain.

 

 

Fraud Concerns

 

  1. Step up investigations. You want to make sure you’re not hit with claims that are not work related; so when an injury does occur, make sure you don’t skip steps to uncover what really happened. Talk to witnesses, review any video footage, look at the timeline of events.

 

  1. Scrutinize bills. To the extent possible, make sure your providers, attorneys, and others are not trying to cushion their potential income losses at your expense. If anything on a bill raises a question — ask about it. Any reputable vendor should be able to easily explain changes in billing.

 

 

Claims Management Processes

 

  1. Use workflow automation to better manage your loss trends and reduce claims leakage. You might consider data warehousing to integrate legacy systems and multiple data sources to identify fraud and cost shifting, and to better manage performance.

 

  1. Intervene early. Don’t let potentially high risk claims deteriorate. Work with your insurer or third party administrator to identify claims that could go south. Leverage clinical and specialty resources early in the claim cycle.

 

  1. Use quality providers. Make sure you’re working with high quality partners, to help expedite claims and get your injured employees back to function and work. Medical providers should be outcomes-based with good track records of delivering the best care. They should also have a comprehensive understanding of occupational health. If not, look for new providers or educate those in your network.

 

  1. Check the paperwork. Make sure your policies and procedures relating to employee health and safety are up to date and easily available to employees. If you have a drug-free workplace policy, for example, make sure it includes any recent related changes in your jurisdiction. Any relevant portion of the employee manual should also be reviewed and changed where needed.

 

 

Conclusion

 

At the moment it seems healthcare is going to remain unchanged.  However, whether or not there are future changes proposed, it behooves stakeholders to be prepared.

 

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

Author Michael Stack, Principal, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center. .

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

4 Areas To Manage Workers’ Comp Medical Costs

Medical treatment has comprised the bulk of workers’ comp claim costs in recent years, and the trend seems to have no end in sight. Where indemnity used to be the main expense, medical now represents 60% or more.

 

There are a variety of tools to help manage medical costs; medical bill review, utilization review, provider networks, nurse case management, nurse triage, Medicare Set-asides, and the list goes on. While any of these tools can be effective, they might actually be costing you more than they are saving. You need to look at your return on investment and make sure the medical management services you are using are truly helping your organization save money on medical.

 

 

  1. The Doctors: Costs vs. Outcomes

 

Low-cost medical networks were all the rage in the workers’ comp system for a while. But in recent years, there’s been more and more evidence to show that going cheap on medical providers may come back to bite you.

 

The latest indication comes from a study in which a 63-year-old woman with low back pain was sent for MRIs at 10 facilities in the New York area to see what, if any differences there would be. Sure enough, not a single diagnostic finding out of 49 distinct findings reported was identified by all 10. The woman’s actual diagnosis was stenosis; she was given physical therapy and education and is said to be doing just fine. But had one of the 10 interpretations of her MRI been used, she might have been sent for unnecessary surgery and/or drugs — big expenses with a poor outcome.

 

The adage ‘you get what you pay for’ is as true of medical providers as it is for anything. Try to partner with area providers that A: understand the world of workers’ comp — and if there are none, start educating area physicians; and B: have low litigation rates and high return-to-work outcomes.

 

Likewise for other medical providers, such as physical therapists. Look at the number of treatments, their average cost, and the outcomes.

 

Once you’ve identified the best providers, partner with them and direct injured workers to them where possible. In states where the employer cannot direct care, you can still provide information that lets the injured worker know who the top providers are.

 

 

  1. Pharmacy Benefit Managers

 

Pharmacy benefit managers with good track records can be invaluable to a workers’ comp program. But again, you need to make sure you’re getting one that adds value to your company.

 

Where PBMs initially added value through lower prices, many have implemented clinical management programs to lower costs further and improve outcomes. It’s important to look at a PBM’s overall program to make sure you’re getting the best for your money.

 

Consider such things as pharmacy charges vs. pharmacy costs; the percentage reductions below the state’s fee schedule; the PBM penetration rate; cost per script; percentage of medications dispensed by pharmacies vs. physicians; and first fill rate.

 

 

  1. Involvement of Nurses

 

Nurses can be brought in to help with a claim — nurse case managers; or they can be the initial source to help determine medical treatment — nurse triage.

 

NCMs are the point person for the injured worker and medical providers. Those who do it in-office are telephonic case managers, whereas those who go out of the office are field case managers. Evaluating the effectiveness of NCMs is easiest with a large database, to compare things like the cost of claims and number of lost workdays with and without a NCM. Your insurer and/or third-party administrator may be able to help.

 

To find the value of nurse case triage, you can look at the number of calls divided by the number of claims actually reported for workers’ comp, to get the number of claims avoided by percentage.  It’s also important to look at the training and experience of the nurses involved. One thing to be aware of is how invested the triage nurse is involved in the claim. Triaging is at the initial stage of the claim, not manage the claim — which is the job of the NCM, if there is one.

 

 

  1. Bill Review

 

Medical Bill Review fees can be hidden and pricey, so it’s important to look for transparency from the claims administrator. There are many claim service providers now that have modified their BR fee structures so the costs are more obvious. Ideally you want a lower administrative cost for BR, combined with maximized savings.

 

You can find the net savings of your BR service by taking the gross savings (total charges minus total paid) and subtracting the BR service fees. Additional things you can measure to ensure you’re getting value are the percentage of net savings, the turnaround time, and the denied bill rate.

 

 

Conclusion

 

Price alone should not be the deciding factor for medical management tools; a holistic view of your services is best. However, you also want to make sure you aren’t shelling out more money than you are saving. Whether you are evaluating your current tools or looking for new ones, just make sure they lead to improved outcomes and lower costs, to get the best from your investment.

 

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices.

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

You Win If Your IME Doctor Shows Up At The Comp Board

comp-board-imePicking the correct doctor for your Independent Medical Examination (IME) can determine whether you win or lose your workers’ compensation case.  This is based on a number of factors, which hinges on the ability of the examiner to prepare a persuasive report based on the facts provided to them.  Sadly, this is an area when claims management teams and other interested stakeholders defending workers’ compensation claims often cut corners.

 

Now is the time to change your thinking and be open to using the right medical examiner for the case. The IME is one of the few points where the outcome of the claim can be influenced, and you want to know that you have the right expert to WIN.

 

 

Preparing for the IME

 

In most jurisdictions, the employer and insurer get only one opportunity to have the employee seen and examined for purposes of the IME.  Due to the nature of the examination in the adversarial process, it is important to treat it with upmost importance.  A number of factors go in the examination, which often include:

 

  • The education and training of the expert. The practice of medicine is highly competitive.  Choosing a doctor with a reputable background is important.  It is also critical your expert has an updated Curriculum Vitae (CV) that includes information on their ongoing education training and reputation within the medical community.

 

  • Specialization is key. This is especially important in today’s cases where medicine is specialized and medical care and treatment is scrutinized by experienced compensation judges or members of the compensation board; and

 

  • Independence is essential. Your medical expert will be asked to give an opinion on issues regarding causation, the nature and extent of injuries, reasonableness and necessity of medical care and treatment, and need for future care.  The judge or hearing officer will view your expert as a more objective witness if he is truly independent and does not have any financial ties to the client/employer or vendor that is setting up the IME.

 

 

Show Up & WIN

 

In addition to the factors mentioned above, it is important to work with an independent medical examiner that adds value to the defense of the case.  This includes adding certain intangibles when the case boils down to a “battle of the experts.”

 

One such area an IME doctor adds value is the time they spend on a case.  IME physicians are paid a flat rate for their services.  A low fee paid to the provider means he will be unlikely to spend significant time reviewing the medical records and history, seeing and examining the employee, preparing their report, or being available to show up at a hearing to defend the case.

 

On the other hand, high quality IME service providers fairly compensate the right physicians to offer a meaningful opinion, and be available to show up at a hearing to defend their position. While this may increase the cost of the IME, the dividends can pay off significantly in future savings when settling cases.  Other benefits of working with service providers who provide a higher quality IME expert include:

 

  • A higher degree of accuracy and precision in the findings and opinions contained within the IME report;

 

  • Better familiarity with the file and its materials. This allows the doctor to develop their medical theory on direct examination and guard against losing credibility on cross examination; and

 

  • It avoids the wrongful perception the IME report is merely “bought and paid for” by the insurance carrier.

 

 

Conclusions

 

Workers’ compensation cases are often won or lost with an IME.  If service providers hinder the ability of their medical experts to do a complete job, the results may be disastrous to your file load.  When medical experts are fairly compensated for their time, they are able to reduce workers’ compensation costs and move your cases toward a reasonable settlement.

 

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices.

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

 

 

©2016 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC.  . He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

Can You Authorize Up To $6,000 For A Winning IME?

doctor-imeThe cost of litigation in workers’ compensation is a driving factor that can impact a claim.  Most claim management teams require defense attorneys to submit detailed litigation budgets and hold their counsel to it.  While budgets are unavoidable in today’s marketplace, flexibility can be given in certain situations when it comes to costs associated with an Independent Medical Examination (IME).

 

 

Why Are IMEs Important?

 

The IME can make or break your case.  It can determine the direction of your claim and is used to defend issues concerning causation, the reasonableness/necessity of medical care, treatment parameters or other medical related issues.

 

Failing to use the right IME service provider will impact your claims based on a number of important issues.  These include:

 

  • Available panel selection of medical experts;

 

  • Quality control issues; and

 

  • Customer service issues, including the timeliness of IME reports.

 

 

Developing Trust with an IME Service Provider

 

When dealing with these matters, it is important to evaluate an IME service provider on how they perform in the following areas:

 

  • Service support during the examination process. This includes turning around reports in a timely manner and superior customer service;

 

  • Their panel selection and variety of medical experts. This is important in many instances where an area of specialization is vital to defending a claim; and

 

  • Other intangibles. This includes “best in class” service, the ability of medical experts to clarify issues and add value during all aspects of the examination process.

 

Having confidence in your IME service provider is paramount.  The IME service provider can assist attorneys, members of the claim management team and other interested stakeholders when it comes to evaluating their case and selecting a medical expert.  This is especially important in high exposure cases.

 

 

High Exposure Cases Require Trust & Flexibility

 

An IME cost will range between $500 – $1,800 depending on the provider and the state. This can include a review of all medical records and other documents pertinent to the employee’s background.  In most instances, this includes a summary of the employee’s deposition that has a description of their everyday work activities and specifics concerning the mechanism of injury.

 

Some cases, however, are not average cases and require more than the average IME, with potentially more than one expert opinion.  It is these situations where flexibility and a trusted IME provider relationship is paramount.

 

 

Can You Authorize Up To $6,000 To Get This Done?

 

The timing and execution of an IME requires a medically sensitive determination, and the selection of the right physician expert to make this determination is critical.  The best IME vendor relationships will be trusted and authorized to spend additional funds when necessary to select the right expert from their physician panel at the right time in a high exposure case. This expertise and specialized knowledge makes the IME vendor an invaluable partner to the claims management team.

 

This can be the case when you are dealing with the following issues:

 

  • Cases that include claims for mental/mental or physical/mental injuries. In cases involving a mental component, IME’s will often include multiple medical experts and an array of tests and procedures;

 

  • Instances where the employee has suffered significant physical injuires to multiple body parts. In other matters, future surgical procedures that are complex in nature often drive the cost of an IME; and

 

  • The prior claims history of the employee is also important to consider. When dealing with “experienced claimants,” it may be imperative to select an IME doctor who is not hindered by a budget and can go the extra mile to drive the matter toward settlement.

 

 

 

Conclusions

 

Litigation budgets are an important component of workers’ compensation cost containment.  When it comes to an IME, it can be an invaluable asset to allow for flexibility when defending a high exposure claim.  Develop a trusted relationship and leverage the expertise of your IME vendor as an invaluable partner to your claims management team.

 

 

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices.

 

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

 

 

©2016 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

Donald Trump, Hillary Clinton, and Workers Comp Medical Decisions

***Please note, the resources mentioned in this video are recommended to be used as a resource for when further intervention by a trained medical professional is required***

Hello, Michael Stack here with Amaxx. This past weekend was the second Presidential debate between candidates Donald Trump and Hillary Clinton. It was a 90-minute snapshot of information, with their policies, their views and unfortunately a lot of their personal indiscretions. It’s designed to give us information as the American public of who we want to decide individually who we want to be our next president.

 

There are individuals who have spent hours, weeks, months, years participating in the talk shows, reading the policies, learning every minute detail about their candidate in order to make their decision. There’s millions of Americans who don’t have the time or frankly the interest to study to that level of minute detail. They use the debates in order to make that decision, in order to get that information, to get that snapshot to make the extraordinarily important decision on Election Day for themselves.

 

It got me thinking of how this relates to Worker’s Compensation and the important decisions we make in a claims organization almost every day in regards to these medical decisions. There are doctors and people in the medical community who similarly will spend their entire career studying the biology to the minute detail in order to create determinations in regards to two specific points of injury duration and causation, of whether that injury is work related or not.

 

 

Work Comp Snapshot of Medical Information

 

What’s the snapshot? What’s that information that we can turn on for 90 minutes and hopefully get some information in order to help us make that decision? I’m going to give you two resources here in regards to injury duration and causation.

 

 

MD Guidelines / ODG Guidelines

 

Injury duration, the resource is MD Guidelines and ODG Guidelines. These are published by medical professionals and give you an idea of the expected duration of a particular injury, whether that’s 2 weeks, 5-10 weeks, 15+ weeks based on a various number of factors. You could look at a shoulder injury, a back injury, a wrist injury, a knee injury, whatever the case and get an idea of the expected duration of that injury. If it’s expected to be 5-10 weeks based on a certain number of factors for a shoulder injury and you’re getting a 9, 10, 11 weeks and that individual is not back to work, that’s cause to bring in some additional intervention strategies to get things going on the right track.

 

 

AMA Guide to Causation

 

Let’s talk about causation. I want to give you a resource here. The AMA Guide to Causation. In depth book. This is a book you can find on Amazon, will give you an understanding from the medical perspective and it’s really written and designed for the person that is not a medical expert but has some medical knowledge to understand the elements of causation.

 

Injury duration and causation, AMA Guide to Causation and the MDG and ODG Guidelines. Great resources in order to help you make that extraordinarily important decision.

 

Again, I’m Michael Stack with Amaxx, and remember, your success with Worker’s Compensation is defined by your integrity, so be great.

 

 

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

 

 

©2016 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

Know The Difference Between Sprain & Strain To Save Work Comp Dollars

sprainIn order to properly monitor and control workers compensation losses, it is necessary for the employer to have a working knowledge of traumatic injuries and occupational diseases.  For adjusters this knowledge is mandatory.

 

 

The Exposures:

 

The following sample questions demonstrate the need for medical fact information knowledge and understanding:

 

  • What are usual treatments for the injury or disease?
  • What are the normal recovery periods?
  • Will there be any residual disability?
  • What are the problems associated with improper treatment?
  • Did the mechanics of the loss or job exposures cause the injury claimed?
  • What underlying health conditions might be aggravated by this injury?
  • Is treatment in compliance with accepted medical practice?
  • Is there a prior record to demonstrate apportionment possibilities?
  • What apportionment ratios are possible?
  • What are indications that point to the need of an independent medical examination?
  • What questions and findings need to be presented to the examining medical practitioner?
  • Should the examination be done by a specialist, a general practitioner or physician’s assistant?
  • Are all facts of the occurrence and medical treatment available for presentation to the examining doctor?

 

 

Difference Between Sprains & Strains

 

The difference between sprains and strains is a classic example.  The terms are often used interchangeably, yet the actual injuries are quite different.  Their cause, severity, course of treatment, and residual possibilities vary greatly.

 

 

Sprains

 

Sprains are generally associated and limited to ligament stretching or tissue tearing.   Typically, they occur to knees, ankles, or wrists, and happen while walking, running, jumping, or falling.  The incident is usually abrupt or sudden and is prominent in sports or sports like activity.  Falling, while limbs are in out stretched position, or sliding, are ways sprains happen.

 

Symptoms are usually apparent almost immediately.   There is pain, swelling, bruising, loss of functional capacity, and weight bearing or applied pressure may be intolerable.  The patient may feel a pop or tearing sensation.  The symptoms can vary on intensity depending on the degree of severity.

 

Treatment generally consists of an x-ray or MRI, immobilization, pain medication, and applications of external heating or cooling devices, non-weight bearing, physio therapy, and possibly surgery. Use of crutches, slings, wheel chairs, walkers, and canes may also be necessary.

 

Recovery Disability can range from several days to twelve weeks without surgery. Hospitalization can range from several days to weeks depending on severity, and total disability can range from days to months.

 

 

Strains

 

Strains are caused by twisting, or pulling of the muscle or tendon.  They also occur from prolonged repetitive movement, and/or over use.

 

A strain is an acute situation brought about by trauma, blows to the body, improper lifting, and stressing.  The symptoms may be immediate or develop over a few days.  Strain symptoms are pain, localized swelling, cramps, muscle spasm, inflammation, loss of muscle function, general weakness of the muscles involved, and radiating symptoms following nerves.

 

Chronic strains develop over time as a result of repetitive motion or over use and symptom onset is delayed.  These cases may be accepted for other possible medical conditions.

 

The treatment and grades of strains are similar to strains, however full rupture of muscles often occurs and requires surgical repair.  Carpel Tunnel Syndrome is one of the chronic strain injuries and may need surgical intervention at the wrist level.

 

Recovery Disability parallels that of strains.

 

Learning and Reference Sources:

 

In addition to formal medical education courses, there are other places where medical knowledge can be obtained.  A few are:

  1. ACOEM and/or ODG Guidelines
  2. Local First aid and EMT classes
  3. Medical dictionaries
  4. Medical hand books designed for lay people and to be used in home or business
  5. Training sessions led by Medical Practitioners

 

Summary:

 

A strong medical knowledge of traumatic injury and occupation diseases is necessary.  This will allow for expected treatment, recovery periods, residual disability, and medical payments.

 

 

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

 

 

©2016 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

The Doctor Will See You: Using Treatment Parameters in Work Comp

Reducing workers’ compensation claim costs requires that members of the claims management team and other interested stakeholders know and understand the law.  Part of this includes using medical treatment parameters as a tool to promote the effective management of medical costs.

 

 

What are Medical Treatment Parameters?

 

Medical treatment parameters are not present under every workers’ compensation act.  About half of all jurisdictions employ some form of these guidelines.  This requires the claims handler to research the jurisdiction they are working in to understand if they are available.

 

The use of treatment parameters were developed to provide reasonable guidelines for care of all compensable workers’ compensation injuries.  All interested stakeholders, which included medical providers, vocational experts, developed them and attorneys from both sides and other parties involved in the process.  The result is they serves as a baseline to measure the effectiveness of medical care and treatment and promote quality health care.

 

 

When do Treatment Parameters Come into Play

 

Generally, all medical care and treatment provided to an injured worker is required to be reasonable and necessary to cure and relieve the effects of the work injury.  Workers’ compensation medical treatment parameters, which are not applicable in all situations, require that a medical provider demonstrate the medical care they provide results in continuous improvement in injury care that moves the employee toward maximum medical improvement, or full resolution.  When it comes to medical treatment parameters, it is important to remember they only apply in the following situations:

 

  • Claims where primary liability has been admitted, but there is a dispute concerning the treatment plan, or whether the medical care and treatment is reasonable and necessary; and
  • Instances where primary liability is denied, but later admitted. At that point, the treatment parameters can be used as a defense to the medical care and treatment being received by the employee.

 

It is important to review applicable statues and regulations before asserting a defense based on medical treatment parameters.

 

 

Using Medical Treatment Parameters in Your Claim

 

There is a statutory presumption that the medical treatment parameters are reasonable and necessary.  In essence, they are a “one size fits all” for workers’ compensation medical care.  While it is impossible to categorize all work-related injuries, a vast majority of them are covered under these guidelines.  Major injuries covered include:

 

  • Injuries and conditions to the spinal cord, including disc herniations, vertebrae fractures and pain symptomology;
  • Upper extremity conditions including fractures, dislocations, and common syndrome including carpal tunnel and lateral epicondylitis (tennis elbow);
  • Traumatic brain injuries and cognitive dysfunctions;
  • Psychological, psychiatric care and mental illnesses; and
  • Reflex sympathetic dystrophy (RSD) or other neurological conditions.

 

 

 

What is Covered under Medical Treatment Parameters?

 

Medical treatment parameters set forth the frequency of medical care and treatment provided to the employee.  The rationale is this avoids excessive care, waste and abuse within the system.  Common procedures covered include:

 

  • Imagining such as x-rays, MRIs and CT scans;
  • Use of prescription medications, including the use of opioid-based drugs;
  • Physical therapy and chiropractic care; and
  • Procedures that must be attempted prior to surgery.

 

It is important to note that departures are permissible in jurisdictions with medical treatment parameters.  An example of who this works can be found in Jacka v. Coca-Cola Bottling Co., 580 N.W.2d 27 (Minn. 1998).  In Jacka, the Minnesota Supreme Court noted that “the treatment parameters cannot anticipate every exceptional circumstance, we acknowledge that a compensation judge may depart from the rules in those rare cases in which departure is necessary to obtain proper treatment.”

 

 

Conclusions

 

Workers’ compensation medical treatment parameters are designed to avoid waste and abuse within the system, while at the same time ensuring injured workers receive their entitled care.  This requires members of the claims management team to determine if their jurisdiction has applicable parameters, understand how they can be used and effectively use them in the claim handling process.

 

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

 

 

©2016 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

Learn To Diagnose Your Diagnostic Test Diagnosis

When an injury fails to resolve within 4-8 weeks (sometimes sooner) physicians will likely order a diagnostic test to be performed.  The test will give them an inside look at what is going on structurally, and provide evidence to injury or pain generator, so they can focus care on resolving the issue.

 

Surprisingly enough, these tests are open to physician interpretation.  If the answer is not a clear silver bullet, such as a massive disc herniation or radically pinched nerve, you will see some difference in opinion on what could actually be wrong and how it is related to the work injury.

 

This is where the adjuster plays a key role.  Their relationship with a diagnostic provider or certain physicians can be what can swing a claim one way or another.  It can mean the difference if the injury is surgical or not, and even bigger, whether the claim and ongoing treatment is related to this work injury rather than an ongoing degenerative issue.

 

 

EMG Should Be Performed By Independent Physician

 

If a worker claims on occupational injury that was not traumatic in nature, chances are the injury was caused by repetitive motion within the course of their employment history.  After treating for a period of time and the worker has made no progress, the physician will likely perform an EMG to see what is going on.

 

Believe it or not, every doctor is not an EMG expert.  Even though they perform EMG tests and they make it a part of their regular practice, this doesn’t make them effective at interpreting the results.  It is typically not in your best interest to have the treating doctor performing the EMG.  A physician is in business to treat people. This is how they make money.  And by giving “positive” EMG results, this leads to possible surgery, more physical therapy, more treatment and overall more money for this doctor and for their practice.  We would like to think that all doctors are ethical and would do the right thing, but unfortunately this is not always the case.  If this is going on with your claim, the adjuster will likely get an outside opinion from another physician, likely one that is credentialed by the “American Association of Nueromuscular Medicine (AANEM). These physicians have strict criteria for performing EMGs and interpreting their results.  And since they have no financial interest in the overall treatment plan in the claim, they can give you an objective opinion without bias.

 

If the adjuster fails to obtain another opinion, and decides to go with the treating doctor’s opinion, this can lead to huge surgical costs and other medical costs that may not be related to this work injury.  This practice over time leads to thousands and thousands of dollars wasted by the insurance carrier or TPA, otherwise known as “Leakage.”  The worker puts themselves through possibly unnecessary surgery, rehab, medication, and so on.  Your adjuster should get a second opinion every time. It is better to be safe than sorry, especially when it comes to claims and surgical costs.

 

 

 

MRI More Difficult to Interpret

 

It is typically more difficult to interpret the results of an MRI.  If 20 people off the street that had no back pain took an MRI, many of them would have arthritis, bulging discs, herniated discs, and so on.  Just because these things are present on an MRI does not mean that they are pain generators, or that they are related to whatever work injury may have occurred.

 

A treating physician may or may not decide to interpret the MRI themselves.  Some will rely on the radiologist’s opinion, and just repeat the conclusion to the patient.  Others will ask to see the actual films, and they will draw their own conclusions, in addition to whatever the radiologist concluded.

 

 

Results Should Be Confirmed With Second Opinion

 

This can lead to an ethical treatment issue.  The key is the doctor relating a positive MRI back to the work injury.  This should not just be stated, they should be using objective medical evidence and the mechanism of injury to tie it together.  Even if this done properly, a good adjuster will obtain another opinion from a qualified physician or get the MRI read by another radiologist with credentials to interpret the results.  If you have ever viewed an MRI report, two radiologists can read the same films and one report may be three paragraphs, and the other may be three pages long.  This depends on the style of the radiologist. Your adjusters should have certain ones that they like and whose opinion they trust.

 

Despite the radiologist’s opinion, they will only read the MRI.  It is typically up to the surgeon to determine the cause of the injury. A radiologist may offer an opinion, but it is rarely a clear yes or no answer. There are too many variables involved since everyone’s body and function in day to day life is different.  It is up to the adjuster to work on the treating doctor, using thoughtful objective questions, to push him to make a decision on the causal relationship of the injury. If this correlation cannot be made, then by no means should a surgery proceed with authorization by the claims adjuster.

 

Failure to Obtain Causal Relation Statement Can Cost You

 

Failure to properly obtain a causal relation statement can yield thousands of dollars spent in error.  Once a surgery is performed, there is no taking it back.  Your worker had an invasive surgery performed, and medical complications are always a risk. In addition, a surgery doesn’t always mean a cure for all of ailments.  Significant leakage can occur if a positive MRI is not work related and your adjuster deems a claim, surgery, rehab, etc. compensable.  If the surgery was a multilevel spinal fusion, then you have medical cost leakage, wage leakage, vocational issues, further surgeries, and so on.

 

Before you authorize any surgery, take the time to get a few other opinions from not only qualified physicians, but qualified radiologists as well.  Most IME vendors and diagnostic providers will also have a radiologist on their roster, and this person can oftentimes be an overlooked resource. In the end, it could save you tens of thousands of dollars, if not hundreds of thousands upon the lifetime of a particular claim.

 

 

Summary

 

Remember just because a person is a physician, it doesn’t make them automatically qualified to properly read and interpret diagnostic reports.  Unreliable interpretation of diagnostics can lead to costly results for you and the worker.  Communication with the worker at this point is critical.  The injured worker may know nothing about medical, and they are going on the advice of their treating doctor.  Facing a surgery or major injury is a scary thing, and you want to relay to the worker that you are taking the time to get all of these extra opinions for their benefit, not only for the overall compensability of the claim.

 

Some injured workers respond to this as “Doctor shopping until you can find one that will deny my claim” but this is not the truth.  Adjusters have to have a clear, concise answer to causal relation. My response to the “doctor shopping” question is to respond by saying that the worker is the one that has to undergo the surgery, the lost wages, the rehab, the medication, the travel time, and the overall stress of dealing with an injury.  Whether it is work related or not, I’m going to want to cover all of the bases so you get a proper diagnosis and treatment plan.

 

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

 

 

©2016 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

Understanding Artificial Disc Technology In Your Claim

Medical technology is changing medical care and treatment injured workers receive.  One of these areas is in the field of back injury care.  This includes the use of spinal fusion surgery and artificial disc replacements.

 

 

The Changing Landscape of Back Injury Care

 

The spinal cord is the core of a person’s central nervous system.  It is composed of a series of parts that starts at the medulla oblongata near one’s brain and extends to the coccyx, otherwise known as the tailbone.  It contains a number of bones, which are called “vertebrae.”  Material referred to as “discs, which serves as a cushion between each vertebrae.  Injury to one’s spinal cord can result in damage to these discs, which include nerve root impingement and misalignment of the vertebrae.

 

Traditional surgical procedures involving the spinal cord and discs include fusion surgery.  When this procedure is performed, hardware is affixed to adjoining vertebrae to reduce the impingement of nerves.  While this procedure is often effective, the downside is it will decrease motion within the spinal column.

 

To address this downside, medical device manufactures have created artificial disc technology.  The use of this procedure, commonly referred to as an “intervertebral disc arthroplasty,” eliminates the need for a fusion surgery by providing the same benefits as a fusion, but without the loss of motion in the spine.

 

 

How Does this Affect My Claim?

 

There are a number of pros and cons associated with the use of artificial disc technology.  Claims handlers working on files that involve such procedures require caution.

 

  • Pros related to artificial disc technology:
    • Quicker healing times and possible return to work;
    • Less loss of motion following surgery, which can reduce exposure for claims related to Permanent Partial Disability; and
    • Increased satisfaction with post-surgical results.

 

  • Cons related to artificial disc technology:
    • Evolving technology that sometimes does not have a consistent result;
    • Hardware failure can be catastrophic; and
    • Varied surgical costs that can be more expensive from traditional spinal fusion procedures.

 

 

Defending Cases that Involve Artificial Disc Replacements

 

There is a growing body of case law dealing with the reasonableness and necessity of artificial disc replacement requests across the country.  Several years ago, this advance in medical technology was rarely considered and viewed by many as questionable even though it was being used with increasing frequency outside the United States.  The FDA has been reviewing these procedures and they are gaining acceptance in domestic medical treatment.  The result is more injured workers opting for an artificial disc replacement following a severe back injury.

 

Important issues to consider when analyzing these cases from a claim management standpoint include:

 

  • The prior medical history of the claimant and their response to surgical requests. The prior use of cigarettes and tobacco products is another important matter to consider.  Patients who have used or are currently using these products have a well-documented poor response when recovering;

 

  • The potential medical costs of artificial disc procedures compared to spinal fusions. Medical technology is constantly changing.  So are the costs of these medical procedures.  As the technology develops and becomes cheaper, it may be more difficult for insurance carriers to argue the standard approach of fusion surgeries is appropriate; and

 

  • Interested stakeholders would also consider the expertise of their independent medical examiner when defending a case where use of an artificial disc replacement could be an issue. It is well documented that a compensation judge may ultimately accept one expert’s opinion over another if they have a background in this area, or at least the proper foundation and scientific knowledge to give a credible opinion.

 

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

 

 

©2016 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

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