The employer/workers compensation insurer has the obligation to pay for all medical care for a work-related accident. Medical care includes not only doctor visits; it includes surgical care, hospital care, nursing services, medicines, and durable medical equipment. However, this obligation is not unlimited. It is limited to what is reasonable and necessary. Also, in states where the employer can control medical provider selection, it can also limit what is authorized. (WCxKit)
6 Areas Where the Question of Reasonable and Necessary is Debated:
- Special devices.
- Home improvements.
- Massage, yoga and aqua therapy.
- Attendant care by non-medical assistants.
- Continuing medical maintenance.
- Diagnostic testing.
- Special devices
A question that often comes up when an employee has suffered a severe injury is the need for specialized equipment. While the adjuster is not going to question the need for a cane by someone who recently had back surgery, the criteria gets murky when the doctor states the employee needs a motorized wheelchair with four speeds, capable of doing wheelies. There is a tremendous cost difference between the non-motorized wheelchair for $99 and the motorized deluxe wheelchair for $1,999. Is it reasonable and necessary for the work comp insurer to pay for a deluxe piece of specialized equipment if the employee will only be using it for a month or so? The answer is, “No!” On the other hand, if the employee is going to permanently be in a wheelchair, the power version may definitely be reasonable and necessary.
- Home improvements
A medical provider who specializes in providing favorable impairment rating reports for plaintiff attorneys also wants to keep the injured employee happy. If the employee complains to the doctor she is not sleeping well, and the doctor writes a prescription for a new, extra firm pillow-top mattress, should the insurer have to pay for it? The answer is, “No!” Usually the doctor will not insist on such if the adjuster denies it. (In one situation, a doctor tried to justify a new mattress but the adjuster arranged for a furniture rental company to provide a mattress until the employee was at maximum medical improvement.) Other favorites include plaintiff-friendly doctors prescribing a new hot tub for an employee with a back injury, or a new Bowflex Ultimate Home Gym for an employee to do physical therapy at home. When physical conditioning home improvements are recommended, an adjuster should offer physical therapy, whether hot water soaks or stretching equipment, at a reputable physical therapy facility.
- Massage, yoga and aqua therapy
One well known “plaintiff friendly” Atlanta doctor sends all his back and neck injury clients to water aerobics, yoga, and massage therapy. Of course the doctor owns the water aerobics, yoga, and massage therapy facility. This is another situation where an adjuster must be vigilant to deny such medical services as not reasonable and necessary. If the doctor insists they are, then the adjuster should insist they be provided at a facility where the doctor does not have a financial interest.
- Attendant care by non-medical assistants
The seriously injured or debilitated employee may need some at-home assistance. Reasonable and necessary medical care in some states is not limited to medical professionals. If the employee needs at-home nursing services, the insurance company’s nurse case manager needs to consult with the primary medical provider to establish exactly what the employee needs in the way of home assistance. The work comp adjuster may have to approve the compensation for non-medical personnel to assist the injured employee with bandage changes or toilet needs. However, the adjuster should resist any efforts to expand the at-home assistance to cooking or doing laundry as not medically necessary.
- Continuing medical maintenance
Most states allow for continuing medical maintenance (a few states end medical maintenance when the employee is paid a permanent partial disability award and most states will allow future medical exposure to be transferred to the employee in exchange for compensation to the employee). When the medical is left open for continuing medical maintenance after the indemnity claim has been settled, the only reasonable and necessary medical care is medical services directly related to the initial injury. State laws vary but a significant number of states have statutes that close the exposure for future medical care if the employee has not sought any medical care for the injury in a specific time period — a year in many states. After that point, the adjuster should maintain that long-delayed medical care is not reasonable or necessary.
- Diagnostic testing
Diagnostic testing is an area in which some adjusters have difficulty determining whether the medical care is reasonable and necessary. Often it is necessary for the doctor to run various tests to determine the precise nature of the injury. If testing is a duplication of testing that has already been completed — for example, a repeat MRI — the diagnostic testing can be denied as not medically necessary. If testing is for a different body part — for example the cervical MRI on an employee who injured his lower back — the diagnostic testing should be denied as not being reasonable and necessary.(WCxKit)
Most industrial commissions and state work comp boards will approve anything the medical provider determines is medically necessary. However, in the areas discussed here, commissions and boards will often side with the employer when the medical necessity of an item or service is questionable and available alternatives are proposed.
Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing, publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.
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