When A Doctor Will Not Release Employee To Light Duty

A doctor holding an injured worker “hostage” and not releasing them to light duty work when applicable is a challenge that will never go away.  Over time I think many doctors have gotten better with this issue, but sadly many have not.  For those that have not, the end result is a claim that costs more dollars due to increased claim expense in the way of work comp wage loss payments.  These payments can go on for months, and it is 100% unnecessary and can be avoided.

 

So how do you handle a doctor that is holding your worker hostage?

 

  1. Get a field nurse case manager on the file. The main culprit to a worker not being given light duty work restrictions is due to a lack of communication. The doctor asks the worker if there is light duty available, and the worker answers “No.”  So, the doctor takes their word for it, and leaves it at that.  Despite you faxing over questions and leaving messages to talk to the doctor, those requests fall on deaf ears.  They are taking the patient’s word, and leaving it at that.  This is not acceptable, and you should utilize a field nurse case manager to interject the fact that you can accommodate light duty with any restriction.  Use the nurse case manager as your voice, and see what result you get.

 

  1. Explain that you want to focus on what the employee CAN do.  If you make your stance more about what the injured worker CAN do, rather than what they CAN’T do, you are going to get some results.  Asking questions such as “Can the worker drive?  Can they get groceries for themselves?  Can they sit/stand as needed?  Can they climb the stairs on their deck to get in to their house?”  If the answer to all of these questions is yes, then you have created your own restrictions.  If the worker can drive a car, walk around a grocery store, climb stairs, clean their house, mow their lawn, etc, then they can certainly perform a sedentary job at work.  After all if they can drive to the store they can drive to their job, walk in the door, and complete a sedentary job that is just the same as sitting home on their couch.  In all of my years I have never heard of a doctor saying a worker can drive to the grocery store but should not be driving to work.

 

  1. Provide a detailed light duty job description the doctor can keep in their file. Many times a doctor will not release a worker to light duty because they were burned by it in the past. The doctor released a worker back to light duty, and then the worker was “forced” to complete job tasks outside of their restrictions and then further injured themselves.  I imagine this is rare, but all it takes is for that to happen one time and the doctor is hesitant to release another worker on a light duty work program. You can explain to the doctor that you have a formal program, a job description, enforcement of the duties, and monitoring of the position as a whole.  If this is explained to the doctor, they are going to feel a lot better about releasing this worker to light duty rather than just saying “Yes, we have light duty.”

 

  1. Use an IME if you have to. Sometimes all of your efforts are going to fall short with the treating doctor.  Actually, if you threaten an IME to the treating doctor all this is going to do is make the treater pass the buck to the IME doctor.  If that is the case, so be it.  One IME bill is certainly worth getting a worker back to light duty versus allowing the worker to sit at home collecting a wage loss check .

 

  1. As a last resort, use the legal tactic. This last tactic is not my favorite, but it is effective when needed. When a doctor holds a worker off of work and refuses to allow light duty or even to address activities of daily living as a basis for light duty work, use your legal maneuvers.

 

Doctors that hold their patients hostage are never going to go away.  But when you confront them with some of the tricks outlined above, you are going to have a greater success rate for getting your injured workers back to work.  Every job within your light duty work program is an important one, and this should be explained to the doctor every time.

 

Remember, your local physicians and clinics are supposed to be your assets, and not your adversaries.  Remind them of the common goal to get your worker whole again, and how psychologically a worker that stays working recovers quicker than one sitting at home watching attorney commercials on TV.

 

 

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 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 monthly basis 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.

 

 

©2015 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.

 

Be Proactive About Developing Effective Nurse Case Management

Over the years I have seen many a nurse case manager come and go.  They were in various stages in their career:  Younger, older, male, female, some with kids, some without kids, some with claims experience, some with no idea what they are doing–they just know they are no longer working in an ER Dept at 2am.  

 

 

An Effective Nurse Case Manager Is Important Adjuster Tool

 

Whatever the case may be, an effective nurse case manager is (Or should be) one of the claim adjusters most important tools.  Not only are they eyes and ears on the ground, but they should be confronting the treating doctor with the questions the adjusters needs in order to move the claim forward, address compensability, or to reach MMI.

 

It always surprises me when a claims adjuster doesn’t really know who their nurse case manager is.  What is their experience?  How long have them been doing case management?  Have they worked for any other vendors?  Did they work at a carrier as a telephonic case manager?  All of these questions have importance.

 

The relationship between adjuster and nurse case manager is very important, so I did some additional research on this topic. Does an adjuster really care about which nurse is on the file?  After all, nurse case management is an important role and has a lot of influence on the file.  So, what is the dynamic?

 

 

Nurse Case Manager Story From A Seasoned Adjuster In The Trenches

 

To answer this, I asked my adjuster friend of mine named Toby.  Toby is a field claims adjuster, and travels to his accounts and handles files on his own.  He stated that he has a nurse case manager specific for each account.  Not only does he bring the nurse in to tour the facility regularly, but he also creates a good working relationship between the nurse and the insured contact.  The three of them create their own triage group.  By keeping one specific nurse for each account, the nurse becomes a huge asset for the file.  This nurse knows the employer floor plan and work stations, knows the job duties, who to email with questions about repetitive motion, light duty assignments, and so on.  This makes life easier for Toby as an adjuster because he is allowing the nurse to run the medical portion of the file. 

 

He has developed a significant amount of trust in this relationship.  He knows the nurse has an ER department background, and said when they first met he explained his role as a claims adjuster, took the time to explain what his needs are, what he expects, why he expects it, and why it is important.  He taught the nurse about some of the legal challenges and medical challenges he faces in his role, and why the case nurse is such a crucial benefit to him, especially being out in the field.

 

Toby started him off with some files, and monitored if the nurse delivered on what he said he could do.  Many years later, he trusts this nurse with some of his most important accounts, and the outcome is mutually beneficial.

 

 

Be Proactive About Developing Your Own Relationships

 

The question becomes how you go about developing your own relationships. The answer Toby suggested is trial and error.  He stated when he was developing relationships in areas outside of his trusted nurse’s geographic region that a lot of nurses and their marketing vendors would promise the moon, but then when push came to shove their weaknesses would surface.  Some nurses were not aggressive enough.  Some talked a good game, but when it came time to do the dirty work they would roll over.  Over the years, he has seen some good nurses come and go, but he is always trying to meet new contacts, to strengthen his network of reliable, dependable, and effective nurse case managers.  To do this takes time, and each relationship has always started over a lunch. 

 

It is basically an interview process.  Those that have delivered for Toby have become a part his team of vendors he uses regularly on files.  As the months and files go by, the working relationships grow stronger, better, more efficient, and essentially seamless.  It becomes a team effort, with mutual goals and a strong knowledge of what to expect from each other.

 

 

 

How Well Do You Know Your Nurse Case Manager?

 

It is simply not enough for an adjuster to blindly put the trust of very important dollars in the hands of a nurse that they do not know.  The nurse represents the adjuster, carrier, and employer.  Cases spiral out of control all of the time, and the adjuster has a duty to either prevent that from happening, or to control the vortex as quickly and effectively as possible. 

 

So how well do you really know the nurse case manager you are putting on your file?

 

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, and founder of COMPClub an interactive training program teaching workers’ comp cost containment best practices.  Through this platform he is in the trenches on a monthly basis with risk managers, brokers, consultants, attorney’s, and adjusters teaching timeless workers’ comp cost containment strategies, as well as working with members to develop new tactics and systems to address the issues facing organizations today. This unique position allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com

 

©2015 Amaxx LLC. All rights reserved under International Copyright Law.

 

Employers/Carriers/TPAs/Brokers/Vendors looking for additional information FREE resources for Workers Comp cost containment best practices are invited to access Amaxx Workers’ Comp Cost Containment Essentials training series

 

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

 

Effectively Handling Retraining Claims

Under many workers’ compensation programs, injured parties have a statutory right to vocational rehabilitation benefits.  These benefits include the right to retraining when other efforts such as job placement and search are not successful.  Due to the significant costs associated with retraining, it is important to claim handlers to understand how to handle claims of this nature.

 

 

What is Retraining?

 

Retraining in a typical workers’ compensation program involves a formal course of study in a school setting.  The purpose is to return an injured worker to suitable gainful employment.  Retraining can also include a spouse of a deceased employee.

 

In most instances, a claimant seeking these benefits must demonstrate through prior efforts that they lack the transferable job skills to attain a comparable post-injury economic status.  Other factors that come into play include the inability of the claimant to successfully re-enter the labor market given other barriers, including economic factors within their community.

 

 

Retraining Limitations

 

Most jurisdictions impose limitations to a retraining program.  These limitations can include the following:

 

  • A specified number of weeks to complete a retraining program;
  • Receipt of other workers’ compensation benefits, including indemnity benefits; or
  • Payment for other associated expenses with the retraining program.

 

Understanding the scope of the laws and rules related to retraining are important as they vary by jurisdiction.

 

 

Retraining Eligibility

 

As a general rule, a retraining program will be evaluated under the following criteria:

 

  • Whether the proposed retraining program is reasonable to return the employee to comparable positions.
  • The likelihood that the employee with complete the program based on prior academic and vocational experiences, and their existing abilities and interests.
  • Whether there are existing employment opportunities available for the position they are retraining.
  • Potential future economic status once the employee has completed the retraining program.

 

 

Defending a Retraining Claim

 

In most jurisdictions, there are no statutory caps on the costs of a retraining program.  There are numerous workers’ compensation cases nationwide were an injured worker sought and was awarded advanced degrees, including a law school education.  It is important to review cases for potential future exposure and defend a claim properly from the onset.

 

  • Early identification is key. While most might assume retraining is something for older employees, it should also be something to evaluate in cases involving younger employees.

 

  • Investigate the employees past academic and vocational performance. This is especially true to people who may have dropped out of high school or failed to pursue a post-secondary education.  Retraining can also include vocational training, so never assume someone who does not graduate from a traditional four-year college will not seek retraining at a vo-tech institution.

 

  • Obtain an expert opinion on the proposed retraining plan and the likelihood the employee will successfully complete the program. As part of using an expert in this area, it is important to identify deficiencies in the employee’s rehabilitation attempts and to determine also other retraining alternatives.

 

  • Evaluate the costs of various options and seek opportunities to provide an equivalent program at a comparable, but cheaper institution. An example of this is whether a retraining candidate can receive a two-year education and have essentially the same outcome as if they would receive a four-year degree.

 

 

Conclusions

 

Retraining can be a costly part of any workers’ compensation claim.  Proper claim management, investigation and aggressiveness can help mitigate retraining costs.

 

 

Author Michael B. Stack, Principal, COMPClub, Amaxx Work Comp Solutions. He is an expert in employer communication systems and helps employers reduce their workers comp costs by 20% to 50%. He resides in the Boston area and works as a Qualified Loss Management Program provider working with high experience modification factor companies in the Massachusetts State Risk Pool.  He is co-author of the #1 selling book on cost containment, Your Ultimate Guide To Mastering Workers Comp Costs www.reduceyourworkerscomp.com, and Founder of the interactive Workers’ Comp Training platform COMPClub. Contact: mstack@reduceyourworkerscomp.com.

 

©2015 Amaxx LLC. All rights reserved under International Copyright Law.

 

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

 

Using Telemedicine in Workers Compensation

Telemedicine is viewed by many as an opportunity to reduce the cost of medical expenses and promote efficiency in the workers’ compensation system.  While this practice may be new in workers’ compensation claims, it should be something claim management teams look at to reduce the overall costs of a workers’ compensation program.

 

 

What is Telemedicine?

 

According to Wikipedia, telemedicine is “the use of telecommunication and information technologies in order to provide clinical health care at a distance. It helps eliminate distance barriers and can improve access to medical services that would often not be consistently available in distant rural communities. It is also used to save lives in critical care and emergency situations.”

 

 

Telemedicine in Practice

 

The concept of telemedicine is not new.  In fact, it has been used for over a decade in some areas.  By using the technology in the Internet and advances in other telecommunications, medical practitioners have been using “telemedicine” to care for remote patience.  It has also been used for practitioners to connect to others in the medical community to discuss case studies, review patient histories and provide better care.

 

Telemedicine is also being used to address a shortage of general practitioners and other specialists.  In most instances, the use of this service benefits doctors by allowing them to see more patients.  It also benefits patients who are not able to travel to a doctor’s office for a scheduled visit or have a disability that inhibits their mobility.

 

 

Uses of Telemedicine in Workers’ Compensation

 

Given the nature of telemedicine, there are a number of practical applications for this practice in the context of workers’ compensation.  These include the following:

 

  • Reduce the expense of having an on-site medical professional;
  • Allows doctors and triage nurses to assess injured workers from a remote location;
  • Enables medical experts such as radiologists to evaluate images and prepare reports;
  • Uses fully integrated technology to access information on a number of cases.

 

Medicaid and Medicare have also recognized the value and benefits of telemedicine initiatives.  These two important government programs are in the process of evaluating the effectiveness of it as a tool to meet the challenges of the 21st century healthcare system.

 

 

Drawbacks to Effective Telemedicine Programs

 

As is typically the case with new initiatives, it is important to remember that there are drawbacks as the concept gains acceptance.

 

  • Licensing of physicians. Many states are in the process of addressing these issues through regulatory reform and legislative mandates.

 

  • Technological considerations. The key to any successful telemedince program is reliable Internet access for all parties.  This is sometimes an issue with people living in remote locations or from a lower socio-economic status.

 

  • Patient satisfaction. While telemedicine allows people to communicate and see the person they are talking to, there is sometimes the lack of a personal touch people have grown to expect when receiving medical care and treatment.  Addressing these comfort levels in the context of the adversarial workers’ compensation system is important.

 

 

Conclusion

 

While there are some drawbacks, such as in-person contact, the use of telemedicine can improve the quality of care and reduce the costs in a workers’ compensation program.  It is worth the time for any serious claim management team to investigate their options in this area and determine if changes can be made to meet the needs of all stakeholders.

 

 

Author Michael Stack, Principal of Amaxx Risk Solutions, Inc. He is an expert in employer communication systems and helps employers reduce their workers comp costs by 20% to 50%. He resides in the Boston area and works as a Qualified Loss Management Program provider working with high experience modification factor companies in the Massachusetts State Risk Pool.  As the senior editor of Amaxx’s publishing division, Michael is on the cutting edge of innovation and thought leadership in workers compensation cost containment. http://reduceyourworkerscomp.com/about/.  Contact: mstack@reduceyourworkerscomp.com.

 

©2015 Amaxx LLC. All rights reserved under International Copyright Law.

 

SALES TO PAY FOR ACCIDENTS CALCULATOR:  http://reduceyourworkerscomp.com/sales-to-pay-for-accidents-calculator/

MODIFIED DUTY CALCULATOR:   http://reduceyourworkerscomp.com/transitional-duty-cost-calculators/

WC GROUP:  http://www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE: Workers Comp Resource Center Newsletter

 

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

 

Deliver Critical Medical Information Immediately For A Healthy Claim Outcome

One of the drivers of the high cost of medical care in workers compensation is the in-ability to get the right care, from the right provider, at the right time.  A network of medical providers and a strong pharmacy relationship may be in place that can deliver quality care at a reasonable, negotiated price.  However, if injured workers are not utilizing these networks, the opportunity for cost savings is lost.

 

This is especially true with workers’ compensation as the employee is rarely prepared for what to do in the event of an injury at the workplace.

 

 

Network Information Often Difficult to Access

 

At the time of injury the supervisor is often left in the precarious position to have to make a medical determination on the treatment for the injured worker.  He has limited information and limited resources to be able to give the proper direction for the highest quality care at the most cost effective price.

 

This lack of information is also a challenge for the medical providers, injury coordinators, and adjusters.  It frequently results in delays in medical treatment and can lead to unnecessary duplication of medical services, delayed return to work, lack of first fill pharmacy capture, and other inefficiencies.

 

 

Provide Critical Medical Information To Expedite Proper Care

 

Information For Medical Provider

 

The health ticket is a web based communication tool providing all the necessary information on the medical treatment to the medical providers, employer, employee and the claims payer. The health ticket will inform each medical provider of:

 

  1. The employee’s name
  2. The employer’s name
  3. An identification customer number assigned to the employer
  4. The date of injury
  5. The workers’ compensation adjusting company’s name and address
  6. The adjuster’s claim number
  7. The nature of the injury
  8. The name of ancillary network vendors and contact information
  9. A telephone number to call with any general questions they have in regards to the injured employee’s medical care.
  10. The medical care is limited to medical care arising from the date of injury only and for the specific injured body part.

 

 

Information for Injured Employee

 

The health ticket is also provided to the injured employee. It gives the injured employee the same information given to the medical providers.  In addition, the health ticket provides the employee with:

 

  1. A phone number to call to locate additional medical providers – Or – refers the employee to the posting of panel physicians at the place of employment

 

 

Information Regarding Pharmacy:

 

Drug costs are the fastest growing component of medical care and often one of the most neglected areas of workers compensation cost control.  Providing the injured worker complete pharmacy information greatly increases the chances to capture the first prescription fill to take advantage of negotiated payment arrangements and utilization management services of the Pharmacy Benefits Management vendor.   The pharmacy information included is:

 

  1. Participating pharmacies
  2. Network identification numbers
  3. Rx help desk

 

 

Information Regarding Utilization Review

 

As different workers’ compensation insurers usually have different limitations and different requirements on what medical care they can provide without the insurers approval and what medical care needs to be approved through Utilization Review, medical providers frequently have to delay care (adding extra return medical visits to the medical provider) while the medical provider determines whether or not Utilization Review is needed.  The health ticket will provide the medical provider with a list of the more frequent medical procedures needing prior approval, including [partial list]:

 

  1. Non-emergency hospitalization, surgeries (both in-patient and outpatient)
  2. Physical therapy
  3. Pain management
  4. Imaging procedures
  5. Facet, trigger point or epidural steroid injections
  6. Bone growth stimulators
  7. Second surgical opinions
  8. Durable medical equipment

 

The health ticket will provide the medical provider with the telephone number to call to obtain the Utilization Review, which minimizes the delay while the additional medical treatment is reviewed.

 

 

Information on Additional Services

 

The medical providers can also obtain from the health ticket the information needed to schedule additional services like:

 

  1. Durable medical equipment
  2. Home health care
  3. Orthotics and prosthetic devices
  4. Diagnostic imaging
  5. Transportation and translation services
  6. Physical therapy

 

Information to Connect With Adjuster Regarding Return to Work

 

Most importantly (from the work comp adjuster’s point of view) is the instructions on the health ticket to contact the adjuster for information on coordinating the employee’s light duty return to work.

 

 

Easily Accessible For Seamless Medical Treatment

 

The health ticket can be transmitted via the medical case manager’s website, email or fax.  The health ticket can be transmitted to the injured employee’s smart phone or other smart device.  This allows the injured employee to always have all the medical information available.  All users of the health ticket can access the health ticket through the website and print the medical care instructions.

 

Having this medical information not only makes for near seamless treatment of the injured employee, it also provides many benefits for the employer including:

 

  1. A reduction in claim costs through:
    • Avoiding unnecessary medical treatments
    • Improved quality of medical care through medical network
  2. It is customizable for the employer’s or insurer’s needs
  3. Reduces the friction with the employee over the medical care
  4. Increases the PPO network penetration
  5. Increases voluntary compliance with Utilization Review

 

For more information on health tickets and how to utilize a managed care company providing these services, please contact us.

 

 

Author Michael Stack, Principal of Amaxx Risk Solutions, Inc. He is an expert in employer communication systems and helps employers reduce their workers comp costs by 20% to 50%. He resides in the Boston area and works as a Qualified Loss Management Program provider working with high experience modification factor companies in the Massachusetts State Risk Pool.  As the senior editor of Amaxx’s publishing division, Michael is on the cutting edge of innovation and thought leadership in workers compensation cost containment. http://reduceyourworkerscomp.com/about/.  Contact: mstack@reduceyourworkerscomp.com.

 

©2014 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

 

SALES TO PAY FOR ACCIDENTS CALCULATOR:  http://reduceyourworkerscomp.com/sales-to-pay-for-accidents-calculator/

MODIFIED DUTY CALCULATOR:   http://reduceyourworkerscomp.com/transitional-duty-cost-calculators/

WC GROUP:  http://www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE: Workers Comp Resource Center Newsletter

 

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

 

How Many Claims Justifies Having A Nurse Triage Program?

Curtis Smith HeadshotThis is a good question that seems simple, but is actually complex and can be answered in many ways.

 

How Much You Spend On Claims Bigger Factor Than How Many

 

First, here is a practical rule of thumb based on our experience over many years: most insured’s who have 100 or more claims per year find triage to be justifiable by any measure, regardless of their industry or state.  The savings from avoiding unnecessary claims and by improving in-network utilization far outweigh the cost of the triage call.

 

Also, many organizations with fewer than 100 claims find triage to be financially justifiable.  Here’s an example.  If an insured has 24 claims a year averaging $2,000 each, they would spend $48,000 a year on those claims.  Even a mediocre triage service could help avoid 25% of claims, saving $12,000.  (A top performing triage service could save almost twice as much!)  The 24 triage calls would cost under $2,400, yielding a net savings after triage fees of $9,600 or 4 to 1 on the triage investment.   In actuality, many claims incur much more than $2,000 each, and additional savings in claims administration fees and productivity are often realized.

 

The determining factor in cost justification is usually what an insured spends on claims, rather than its number of claims. High claims costs justify triage faster.

 

 

Here are some other considerations:

 

– Insured’s who are self-insured realize the savings from triage immediately.  Even on referrals which become claims, good triage providers improve in-network utilization, generating savings on medical fees.  Top tier triage providers also direct referrals to the right level of care (e.g. an occ health clinic vs an ER), generating additional savings.

 

– Employers in fully insured programs may think that they cannot benefit from triage because they incur the cost but the savings accrue to their carrier.  In fact, they save in several ways, though it takes time – here is one example: they improve their experience modifier, which significantly impacts their premium cost in the future.

 

– Some insured’s in time-sensitive industries with specialty jobs calculate that triage’s ability to help keep workers on the job is worth more than the claims savings.

 

– One of the most important considerations is the medical outcome – call it the “human factor.”  The best triage service is focused on getting the right care for the injured employee.  Sometimes that means early identification of a serious condition, or an unrecognized risk, and making a referral that creates a claim because it’s the right thing to do for the injured employee.

 

Bottom line: insured’s can justify triage in a variety of ways, not just by cost or claims count.  The quality and consistency of the triage provider is a key factor, too – poor triage risks poor clinical outcomes, disgruntled employees, and extra costs.

 

 

Author Curtis H. Smith, Executive Vice President, joined Medcor in 1995. He helped develop Medcor’s injury triage system and holds several US and foreign patents on injury assessments methods.  Smith has taught and practiced in EMS as a paramedic and dispatcher.  He currently supports Medcor’s business development and marketing teams. . http://medcor.com. Contact: csmith@medcor.com

Reduce Overall Costs of Work Comp Claims With “Direct to Specialist” Approach

Would a “Direct to Specialist” orthopaedic approach significantly reduce the overall cost of workers’ compensation claims in comparison to the managed care approach?

 

We are all aware that the factors which rapidly increase the costs of workers’ compensation claims are: Time off Work, Delayed Treatment of Injuries and Prolonged Medical Care. While an early return to work program is imperative to reducing disability costs of a claim (10%-15%). What about the medical and surgical costs?  

 

I believe that providing the highest quality of care and the most cost effective approach to reduce the cost of claims is through the “Direct to Specialist” approach.

 

Pre-employment physicals, drug testing, safety and risk management are prominent aspects of a company’s occupational health program. However, the most costly aspects are injuries, with most of them being orthopaedic in nature.  This includes acute injuries and chronic conditions as well.

 

 

What does it take?

 

Implementation of the Full Spectrum of On-Site Services: Orthopaedic Immediate Care, Occupational Health Services, Case Management, Physical and Occupational Therapy, ancillary services such as X-Ray, MRI, Ultrasound, EMG, as well as an Orthopaedic Ambulatory Surgery Center.

 

Will a “Direct to Specialist” approach reduce Time off Work, Delayed Treatment of Injuries and Prolonged Medical Care when these services are in one location and are managed under the direct supervision of Orthopaedic Specialists? YES

 

Orthopaedic Immediate Care means that employees are seen by Orthopaedic Specialists immediately after an injury occurs. Definitive care is provided immediately, whether that individual needs physical/occupational therapy, fracture care, laceration repair or surgery.

 

The fallacy is that referring directly to a specialist will increase the costs of claims. However, this is falsely based upon the incorrect reasoning that referral to an Orthopaedic Surgeon means that the patient will have surgical treatment as the first option.  All patients are treated with conservative measures at the outset and surgery only considered if non-operative measures fail to resolve the condition.  This of course excludes acute injuries which may require immediate surgical care.

 

In fact Atcheson, et. al. demonstrated as much as a 63% percent decrease in the cost of claims when patients were referred directly to specialists for their workers’ compensation injuries.  This was true even when specialists were paid at rates higher than for occupational health providers and primary care physicians.

 

 

Why?

 

One major difference they found is that the timeline of conservative treatment will be managed appropriately and not extended beyond a reasonable time period for resolution of a patient’s condition before surgery is considered. Furthermore, therapy will not be instituted when it is shown that injections alone are the mainstay of conservative management before surgery becomes necessary.  These two measures alone reduce substantially the costs of claims by eliminating unnecessary occupation and physical therapy prior to surgical reconstruction. Furthermore what is also not considered is the effect of prolonging painful conditions before definitive treatment is instituted? This only serves to prolong the post-operative course, as well as, increasing the amount of post-operative occupational/physical therapy which is required to return an employee to full active duty.  This increases both the medical and TTD costs exponentially.

 

 

Managed Care approach: (Example)

 

An employee who sustains a wrist fracture on a Thursday is sent to the urgent care clinic/emergency room (1-3hrs waiting) and is given a splint. They are then referred to see an orthopaedic specialist, perhaps unable to get an appointment until Tuesday or Wednesday, 5-6 days after the incident. The orthopaedic surgeon will need to re-take the x-rays to ensure that no fracture displacement has occurred since initial injury. At this point a cast will be applied if appropriate or the patient will be scheduled for surgery at the next block time day the surgeon operates. This can add from 1-5 additional days before definitive care is given. We are now approximately 6-12 days from the occurrence of the injury and your employee is out of work and is experiencing pain and yet to have definitive treatment. Is this the best way to manage and reduce your TTD and Medical costs?

 

 

“Direct to Specialist” approach:

 

An employee who experiences a wrist fracture on a Thursday, is now sent directly to the orthopedic specialist for immediate evaluation. X-rays are taken, a diagnosis is made and a plan of care implemented at the initial visit. A cast is applied if appropriate and the employee is sent back to work modified duty SAME DAY OR NEXT DAY.  Surgery, if required, is performed the SAME DAY OR NEXT DAY next day at an on-site Orthopaedic Ambulatory Surgery Center which costs 30-40% less than hospital facility fees.

 

 

Managed Care approach VS “Direct to Specialist” approach? You do the math

 

With a “Direct to Specialist “ approach no longer would an employee need to utilize costly emergency room services, urgent care centers or traditional occupational medicine clinics only to be stabilized and then triaged to the specialist for definitive care for an acute injury.  Furthermore, this would eliminate the repeating of much conservative management after initial orthopaedic referral for a chronic condition or in many cases eliminate altogether unnecessary physical and occupation therapy which is often prescribed for conditions for which corticosteroid injection therapy alone is the mainstay of conservative treatment such as Dequervain’s tenosynovitis.

Furthermore, the “Direct to Specialist” model will not only serve to improve employee morale following their injury, as they will see their direct referral to a specialist as concern on the part of their employer to ensure they obtain the highest quality medical and surgical care for their injury. This combined with an Orthopaedic practice with a strong return to work policy, and employer who institutes a restricted duty policy and you can see where the cost savings on a claim can be substantial.  This does not even factor into the equation that your employee is less likely to obtain legal representation when their impression is that their employer cares for their wellbeing.

As an employer, you have many aspects to your business. You must provide for the health and safety of your employees, reduce the ancillary costs of conducting business through aggressive risk management while maintaining growth and profitability. Reducing the costs of your workers’ compensation claims is an important component of your risk management program.

 

 

Author: David Adam, Work Comp Director/Practice Developer, MidAmerica Orthopaedics. David brings over 15 years of experience in business management and development to MidAmerica Orthopaedics. David develops relationships with surrounding businesses and communicates services that are available and beneficial to reduce business costs as it relates to workers compensation. He strives to educate, train, and mentor internal staff and fellow businesses on the benefits of a “Direct to Specialist” approach, adequate Return to Work and Occupational Health Programs.

 

 

Is Your Doctor Just What The Doctor Ordered?

You are undressed standing in a small room with your backside showing. You have a pain in your back and any moment someone is going to walk through the door. This isn’t a scene from a horror film, this occurs every day in doctors’ offices around the country.

 

We place an incredible amount of trust in doctors. They see us at our most vulnerable and we depend on them to make it all better. It is completely against everything we have been taught about this relationship to think that your doctor’s motives may not be 100% altruistic.

 

The reality is that doctors are running a business just like everyone else. The more care you receive, the higher their fees. In a world where consumers will sue at the drop of a hat, it is easy to see why a doctor would order a diagnostic test that could be considered reasonable, but not necessary.

 

I do not fully fault the doctors’; the system is set up just like the temptation challenges on the Biggest Loser. Sometimes the chocolate chip cheesecake with whip cream topping just looks too good to pass up. It is, however, extremely important realize that not all doctors are created equal.

 

 

Successful Outcomes Come From Successful Relationships

 

Like most things in life, successful outcomes come from successful relationships. As an employer, one of the requirements to controlling your workers compensation outcomes is to be proactive in building physician relationships. Here a simple idea to get you started:

 

• Visit or call doctors’ offices in your area to find out if they accept workers compensation and understand the reporting requirements. Are they looking for more business, or are they happy with what they have?

 

Once you have a few viable options, here are some considerations to finalize your selection(s):

 

Your company physician should:

 

1) Be responsive to your employees’ needs and be willing to return them to work as soon as possible.

2) Schedule your employees’ appointments immediately, without delay, and be flexible in scheduling.

3) Review your job descriptions and use your forms for transitional duty accommodations.

4) Provide a written release when the employee is ready to return to work, detailing any applicable medical restrictions.

5) Exhibit a caring attitude and pleasant manner.

6) Possess outstanding medical credentials, with an excellent reputation in the community.

 

 

Doctor Selection Varies By State

 

It is also important to be aware that doctor selection is regulated by state workers compensation statues. There are many variations of how providers are selected based in each state, but the three basic methods are a follows:

 

1) The employee selects the doctor

2) The employer selects the doctor

3) A blend of methods where the employee selects from a panel of doctors provided by the employer.

 

Clearly if the employer can direct the care of injured workers, it is easy to have your employees participate in your physician relationship. However, even in states where the employer cannot direct care, employees will often agree to see the company doctor if the doctor has a good reputation, is conveniently located, and deals fairly with people.

 

Trust your doctor. However, trust them because you have gotten to know them and appreciate their business practice, not just because they are wearing a white coat.

 

 

Author Michael B. Stack, CPA, Principal, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com.  Contact: mstack@reduceyourworkerscomp.com.

 

©2014 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

 

WORK COMP CALCULATOR:   http://www.LowerWC.com/calculator.php

MODIFIED DUTY CALCULATOR:   http://www.LowerWC.com/transitional-duty-cost-calculator.php

WC GROUP:  http://www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE: Workers Comp Resource Center Newsletter

 

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

 

How To Win Friends And Influence Your Treating Doctors

In the insurance profession, claims adjusters will see the same physicians over and over again. But instead of working with them for a common goal, they tend to view the treating doctor as the enemy.

 

To medically defend a claim you have to obtain a medical opinion from another physician that goes against the diagnosis and causal relation statement of the treating physician. Adjusters know the IME doctors that they like to use in certain scenarios, depending on the injury and whatever goal they are attempting to attain.

 

 

Catch More Bees With Honey – Work To Develop Relationship With Treating Doctor

 

But oftentimes they fail to create a good relationship with the treating doctors that they see nearly every day. These could be occupational clinic doctors, specialty doctors, and surgeons. Even when a claim is compensable, the adjuster is going to spend a lot of time dealing with the office of the treating doctor, but fail to really talk to the doctor over the phone.

 

Every treating doctor has their own style of treatment, and some are more thorough than others. Adjusters will send faxed letters over to the treating doctor asking them to address certain questions. If they do not get the outcome they expected, they spend the rest of the file with a chip on their shoulder.

 

This situation can be avoided by picking up the phone, or better yet, going to the office. Ask to speak with the office manager and see if that person will give you a tour of the office and to introduce you to the treating doctors. Explain your role and the common patients you have had. I would be surprised if they refused to show you around.

 

If the tour is successful, later on try to schedule a time to meet with a few of the doctors before or after their clinic hours. You may be surprised to find out that they know who you are as well!

 

The goal of this is to open the lines of communication. Talk to them about what your role is. Some treating docs have not had the best experiences with work comp adjusters, and they come in guarded with their own attitudes. Once you get the defense wall down, you may find out how willing they can be to help you in cases you have in common.

 

You may also find out that you have more information than what was shared with the doctor from the patient directly. You can help the doctor connect the dots between job descriptions, injury descriptions, return to work light duty programs, and so on. If the doctors knows that you are open and approachable, you may be able to better handle the file rather than jumping to an IME and incurring the additional costs.

 

 

If Having Trouble, Get A Referral From Nurse Case Manager

 

If you are striking out in getting access to a treating doctor’s office, try to use a nurse case manager. The Nurse Case Manager has a lot of face to face time with the treating doctor. If the Nurse Case Manager has a good relationship with the treating and they help refer you in, you have a good chance at being able to sit down and discuss your difficult case as a team.

The goal is to work with the treating doctors, so the battle lines are not drawn in the sand from the start. You will be seeing this doctor’s name many times throughout the course of a year.

 

The claimant has a certain amount of trust placed in to their treating doctors. Once you order and Independent Medical Evaluation, the claimant only sees that IME appointment as “The work comp doctor”. When the IME differs from the treater’s perspective, the claimant is quick to file a lawsuit.

 

 

Personal Relations Skills Can Go A Long Way

 

So try to go to the treating doctor first and clarify the opinion if there is a question or issue. Make sure they have all of the details and that they know as much about the injury as you do. You always have the IME in your back pocket if you need to use it, but you can save some litigation headaches if you can get that treater on your side to help the defense of your file. Also, it never hurts to bring them a coffee when you go for your discussion.

 

Even if you cannot visit the clinic in-person, a phone call can go a long way to show them that the file has your attention. Plus you want to be sure that they have all of the information regarding the injury that you do. One little detail can change the compensability of the case, even from the treating doctor’s view.

 

 

 

Author Michael B. Stack, CPA, Principal, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com.  Contact: mstack@reduceyourworkerscomp.com.

 

©2014 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

 

WORK COMP CALCULATOR:   http://www.LowerWC.com/calculator.php

MODIFIED DUTY CALCULATOR:   http://www.LowerWC.com/transitional-duty-cost-calculator.php

WC GROUP:  http://www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE: Workers Comp Resource Center Newsletter

 

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

Nurse Case Managers are Well Worth the Cost

Are most carriers taking advantage of using nurse case managers to help move claims along to facilitate closure?

 

I think it is safe to say some are, and some are not. Usually adjusters are told to use case management only on the severe high-exposure cases. These being major spine surgeries, multiple fracture injuries, and cases with multiple surgeries and different medical care needs to be implemented and coordinated.

 

But what about average surgical lost-time work comp cases? Carpal tunnel, a knee surgery, a bicep tear. Typically the adjuster is left to handles these claims themselves. They will use their diary system as their fallback so they can monitor what is going on medically with the claim.

 

But that is also the problem. If you have a lot of cases with the majority of them being cases involving lost time either surgical or not, then how are you being proactive in bringing the claimant back to work and back to full duty? Just monitoring the claim as it goes from doctor appointment to doctor appointment is not being very proactive. I understand that sometimes that’s what you have to do, but you have options.

 

 

 

Nurse Case Manager Brings Communication and Medical Expertise to Doctor Appointments

 

When you have a high caseload, you cannot be everywhere at once. This is where the nurse case manager comes in handy. The nurse can be your eyes and ears at the doctor appointments. They update you the day of the appointment after it is completed. IF you are just waiting for medical records, it can take weeks. Plus, chances are the nurse will be talking to the claimant more than you are, and can tip you off to potential red flags to recovery long before you spot them in medical records.

 

A nurse case manager can also help you to prevent a file from slipping through the cracks. Even the best adjuster has missed a file every now and then. These misses can be very costly, especially when wage loss is concerned. A nurse will keep you up to date, and will be more reliable than using just your diary system.

 

They also have the time to work the case from a medical standpoint. They talk with the doctor, and can help in claims where a pre-existing condition is also present around the compensable work injury. The hardest issue in these cases is separating the 2 conditions, and the case manager can help the doctor focus on the work injury while brushing aside the non-occupational condition.

 

 

Nurse Case Manager Can Assist With Referrals, Reserves, Medical Plan of Action

 

Nurses can also help to provide DME equipment quicker, and coordinate any other vendor activity you need done. If you need an Independent Medical Opinion, the nurse may know the perfect doctor for your case. They can also copy the medical records, send them to the IME doctor, draft the cover letter, attend the appointment, and talk with the doctor afterwards to get questions answered. As an adjuster, it would take you a good chunk of time to do that yourself. Plus the nurse will update you right after the appointment instead of waiting days to get the actual IME report.

 

Reserving can also be assisted by a nurse on the file. The nurse may have a better handle on medical costs, barriers to recovery, prescription costs, and the outlook to a favorable Maximum Medical Improvement projection.

 

Carriers may have the mindset that an onsite nurse is not cost effective on normal lost time comp cases, but I think this is where they come in the most handy. By being there for the adjuster, it allows the adjuster to focus attention on the more troublesome cases.

 

 

Adjuster is More Efficient With Expertise of Nurse Case Manager

 

If you have an accepted claim with a surgery, why not let the nurse run with it and let the adjuster be updated by the nurse? It takes time to place medical records requests, coordinate doctor appointments, and come up with a medical plan of action. The nurse knows how to do all of this. For what they charge, it is cost effective since it frees the adjuster up to handle more important tasks.

 

Several adjusters that I know have a great network of nurses, and trust their opinions. But they only use them when a severe case comes around. Try using the nurse case manager on normal lost time cases. You will find out that not only is it cost-effective, but it makes the adjuster more efficient at moving cases on to closure. It is all about efficiency these days, and anything that can make an adjuster more efficient should be seen as a positive.

 

 

Author Michael B. Stack, CPA, Principal, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com.  Contact: mstack@reduceyourworkerscomp.com.

 

©2014 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

 

WORK COMP CALCULATOR:   http://www.LowerWC.com/calculator.php

MODIFIED DUTY CALCULATOR:   http://www.LowerWC.com/transitional-duty-cost-calculator.php

WC GROUP:  http://www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE: Workers Comp Resource Center Newsletter

 

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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