Most states allow an injured worker to seek care with whatever physician the employee prefers. There are some rules to follow, but as long as the doctor cooperates there usually is not a problem.
But when there is a problem, it is a big problem. When the adjuster is working with a doctor that does not want to cooperate and respond to certain questions, that is a major issue. This issue will affect the injured worker by affecting care and time off of work. It can cause the claim to go to litigation, etc. So something as simple as going to the doctor for an injury can morph into a really big deal. Here are some warning signs that a claim could be heading down the bumpy road.
The physician places the worker off of work with no restrictions and no explanation
This one item frustrates adjusters more than any other. If a person comes in with a hand laceration, and the doctor places them off of work for 4 weeks, how is that legitimate? The worker has another hand that is perfectly fine. Even if the workplace is a dirty environment it does not mean it is risky to be at work with a hand laceration to one hand.
Physicians familiar with workers comp know better. They know if they place a worker totally off of work and do not address restrictions, the adjuster will call. In the world of workers comp, if a worker is on total off work status that means the employee either just had surgery or sustained a major injury.
There are 2 roadblocks to return to work: (1) the employer does not cooperate with creating light duty work for the injured workers, and (2) the doctor totally disables the employee for no good reason. But it depends, if this injury is acute and very severe, then certainly some time off of work is warranted for rest. But the doctor has to explain why. There is nothing the adjuster hates more than to see a back injury, and the worker is totally disabled, but in physical therapy. So the worker is good enough to go to therapy, but not good enough to go do some light desk work for the employer?
Physicians have to explain the diagnosis and work restrictions, and they have to have good objective evidence to support the decisions. The adjuster has the right to demand that the doctor answer specific questions, and if the doctor disregards that, then it can affect the benefits being paid out on the file. So warning sign #1 if there is an off work slip with no real explanation as to why.
Makes a return appointment in 3-4 week intervals
A doctor that is monitoring a condition on a comp claim knows the worker’s main goal is to get back to work. So they closely monitor the situation. They schedule to see the injured party at least once every week, if not sooner depending on the injury. A warning sign for a complacent doc is a return visit in 4-6 weeks. That is a long period of time to go without being evaluated. If it is a surgical claim, and this worker is post-surgery, and starting rehab, then this may be ok. But for early on in a comp claim, anything over 7-10 days I would raise an eyebrow. He will drag out the claim costing the employer more money.
Everyone at work knows the physician or has treated there
If the injured worker goes to Dr. Smith, and everyone knows Dr. Smith at the shop, and everyone treats with Dr. Smith both for personal medical issues and for workers comp injuries, I would be concerned. Maybe Dr. Smith prescribes a lot of Vicodin for simple injuries. Maybe Dr. Smith disables them from working for a longer time than anyplace else. It could be anything, but if this particular clinic is a place where 85% of your workplaces treat, something is awry. It may not be “illegal” activity, but there is some trend that this doctor does that nobody else in town will do. And that is always cause for concern in an insurance claim.
The doctor prescribes narcotics for minor strain injuries
This is perhaps the most popular trend these days. I have observed countless claimants going to the doc for a simple strain and walk out of the clinic with a 30-day RX for Vicodin. That is never a good sign. I am not a physician. I did not go to med school. If Vicodin is needed for 3-5 days, that is warranted. But for an initial visit, for a simple strain, that is not really all that severe, a 30 day supply is unnecessary. RX stands for “prescription.”
The cost of the RX is determined by quantity and type of drug. If you look at the work slip and the doctor prescribed Vicodin and Percocet, Valium, and Motrin, that is not acceptable. Not only did this doc over-prescribe by giving the worker 2 similar narcotic drugs (Vicodin, Percocet) but also prescribed Valium, which may or may not even be needed for this particular case. Probably the only RX a simple strain needs is the Motrin. All the other RX’s are warning signs that this doctor is happy to prescribe anything at will, and these medicines are not cheap, and some are not even necessary.
Recommend physical therapy (at his clinic) for everything
I recall a while back there was a large occupational clinic that would give anyone that walked in a script for physical therapy (PT). You can have sprained your hand, and you were going to go for 4 weeks of PT. Back injuries, finger lacerations, elbow pain, the answer was PT. They were using PT as a stall tactic, not the way it should be used by reputable doctors. Finally enough people must have stepped up and said “This is ridiculous! You mean to tell me every person that walks in needs PT?”
But this shows a crucial point. Some physicians are also financially tied in to therapy facilities as well as to other testing facilities. So not only do they make money off office visits for evaluating the patient, but they make even more money billing for 12-16 PT visits. Then they will probably see the patient again at the clinic for another evaluation. And maybe more PT is needed. And, before you know it, the cycle begins. In most states this is illegal and unethical. Excessive PT is an indicator that something fishy is going on, and you can use your tools, such as an IME, to deem if more PT is really reasonable and necessary treatment in your given claim. Employers can eliminate the risk of using the wrong PT facilities by using the services of a Physical Therapy Management Company instead of simply working with the least expensive PT network. Physical therapy can be extremely effective in facilitating recovery and return to work when used appropriately. I know, I’ve been there, done that.
Hesitant to refer out to a specialist
This is a warning sign because the physician wants to keep seeing the patient and wants to keep billing the carrier/TPA. As soon as the patient goes to an ortho or other specialist, that patient no longer treats at this clinic. So, the doc has incentive to keep that patient around for a longer period of time. Repeat business is what makes money, and if the patients are continually coming back, that is more money in someone’s pocket. So if it has been a few months and the injured party is no better, it is way beyond time to be evaluated by a specialist. And if the treating doctor is not bringing this up, you may need to force the issue.
No dictation and very few hand-written notes
The adjuster will always want to see the doctor’s actual notes or transcribed dictation. This is where the adjuster can see exactly what the patient said, what the doctor saw on examination, and what the doctor’s plans are for resolving this medical condition.
If the adjuster requests the notes, and they consist of 1-2 sentences of barely visible hand written scribbles, this is not good. Not only is it worthless to the adjuster, it is worthless in general. There is no info about the patient, about the exam, or about the treatment plan. These doctors are out there. An example of their medical note could consist of the items below.
“Jack feels the same. Continue therapy for 4 weeks and return afterwards.”
As crazy as that seems, that sometimes is it. And the bill was probably $100-$150 for that “exam.” So beware of the doctor that does not dictate or does not have properly typed notes. It does not mean the doctor is necessarily bad, it just means that if the worker continues to treat with this physician, it is going to be a struggle to get information and clarification the longer the claim goes on. Those issues are very important, and if you struggle getting that much needed information, the rest of the claim will be a struggle as well.
There are good doctors, and bad doctors. There are doctors that care about their patients, and doctors that could care less. There are doctors that write up fantastic notes, and some that jot down a sentence or 2. Physicians are just like everyone else. They all have a unique style. They have good days and bad days. Some have successful practices, and some do not.
But the bottom line is if a doctor is going to treat the injured worker, in a workers comp situation, then they have to abide by the rules. And if they choose not to do so, it is going to complicate the claim one way or another. Use the above warning signs to evaluate current claims for rough roads ahead.
Author Rebecca Shafer, JD, President of Amaxx Risk 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. She is the author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.com. Contact: RShafer@ReduceYourWorkersComp.com.
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