The majority of medical clinics treat patients ethically and in compliance with their applicable local/state/federal statutes. That being said, medical clinics are a service business — needing to stay in business and be profitable by generating traffic. An empty waiting room equals a clinic out of business. Therefore, the temptation to keep clients/patients coming back for treatment longer than necessary becomes a real possibility.
Without painting with a broad brush, there are certain areas susceptible to over treatment, continued treatment when the patient fails to heal or reaches maximum medical improvement, or just plain “never let go of this patient” syndrome. These five types of therapy, often called holistic, can and do offer very legitimate and useful treatments and are often an excellent adjunct to more traditional medical care, providing the injured worker achieves good results.(WCxKit)
It is the role of the employer/adjuster to pay attention and manage these holistic therapies by realizing the results may be very subjective, not work for everyone, and must be results-centered. Results-centered means taking measurements of the worker’s status before, during, and after therapy and setting down expected improvement goals, and remeasuring to track healing. The minute healing stops, end therapy .
Unfortunately chiropractic therapy is the number one stereotyped method of medicine open to overused/abused without much gain. Chiropractors include occupational injuries, such as carpal tunnel, epicondylitis, arthritis, radiculopathy, etc., as areas benefiting from chiropractic manipulation. In certain situations, chiropractic medicine is beneficial. Some people swear by these treatments. From a claims standpoint if the injured worker makes objective gains on a strain injury, then continue treatment. However if three times a week therapy continues for two or three weeks without improvement (reduced swelling/pain/mobility) it is time to move on to a more effective medical treatment. Chiropractors may attempt to continue treating the patient even though no gains are made. The adjuster must stop treatment before the claim incurs any more medical cost without objective benefit.
HOT TIP: Make therapy authorization in limited time quantities, like 2-3 times a week for 4-6 weeks and then re-evaluate. Some clinics see dollar signs when given unlimited authorization and may be tempted to let therapy go on and on.
- Physical Therapy
Many physical therapists are great at rehabbing patients back to full duty. Sometimes, they keep patients around a little too long before discharging them to a home exercise program. If the therapist is placing a cold pack on the injured party and directing some stretching exercises, it is probably time to check with the doctor and see if the injured worker still needs formal therapy or if discharge to a home exercise program is appropriate. Formal therapy and work hardening programs are expensive, and the frequency per week or month can lead to a higher claim cost over time. It is beneficial to be proactive while reading the therapy notes to see exactly what the therapists are doing with their modalities and treatment plans. Make sure they are staying involved and getting the patient into a rehab program that continues to make objective medical gains.
HOT TIP: Watch out for a “shift” in therapy goals. The patient presented with a diagnosis of a torn meniscus and as therapy is winding down, it is suggested she might possibly have another, unrelated condition for additional treatment. (This actually happened to our blog editor!) Adjusters need to educate everyone that only the medically diagnosed condition appended with a doctor’s written orders is eligible for benefits and any collateral treatments will not be paid for. Employees need to know they may become liable for unauthorized treatments.
- Pain Clinics
Pain clinics are one the most expensive types of therapy. An injured worker is referred to a pain clinic usually after surgery fails, or is achieving no benefit from several other types of treatment. A combination of medications, mostly narcotics, are prescribed and follows a treatment plan of strategically placed injections for pain alleviation. These prescriptions are very expensive, can be highly addictive, quite painful and given in a series of three per type. If an injured worker receives 2-3 injections without benefit, the doctor tries a different location, with possibly a different solution of medicine, to see if that helps lessen the patient’s pain.
When an injured worker is referred to a pain clinic, the adjuster must be very aware of what is going on, reading the medical notes to see the patient’s complaints and setting up a dialog with the treating physician to monitor the success (or not) of treatment. Ask: Is the patient getting better?
When pain treatment fails, the claimant may show signs of drug-seeking behavior, (addiction) and pain complaints escalate over and beyond the objective evidence of injury. It is at this point a claim may unravel. Adjusters must watch very closely that the treatment rendered is necessary and of benefit to the injured worker.
HOT TIP: Think – Do you want to be paying for drug rehab also?
In occupational injuries, certain injuries can call for some acupuncture/yoga/massage as a treatment. While not seen a lot these days, it depends on the physician. Certain strains/sprains benefit from these treatments. Again lack of objective gain after a few weeks should lead to discharging the patient and moving onto another modality of treatment recommended by the treating physician to rehab the worker back to transitional or full duty status.
- Primary Care Physician (PCP)
The PCP, with whom most people enjoy a good relationship, is normally the first doctor seen for an injury. Since they trust the doctor, injured workers try to stay with their PCP as long as possible, depending on the injury, before referral to a specialist.
The danger of staying with PCPs is they may try to diagnose and treat conditions not part of their specialty. As long as the patient keeps coming back, the PCP attempts to treat. The adjuster must intervene to ask the doctor to refer the patient to a specialist when no objective healing is taking place. (WCxKit)
HOT TIP: It is not a bad idea for the adjuster to intervene sooner than later since running up medical bills with the PCP becomes a duplication of payments when the worker, failing to heal, starts over with a specialist.
- Holistic treatments must be monitored for effectiveness.
- The adjuster must be in involved in monitoring every treatment and successful outcome.
- Treatment must move toward healing.
- When no gains occur, it is time to change treatment modalities/physicians.
- The treating modality/physician must not only be good but also have the right credentials to bring the worker to maximum medical improvement quickly, efficiently, and at the lowest cost.
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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