Proper evaluation of the medical treatment an injured employee receives is one of the most daunting tasks facing either the self-insured employer or the workers’ compensation claims adjuster. When a medical provider makes a statement regarding the nature and extent of an employee’s injury, the tendency of most people is to accept the medical provider’s statements at face value. In states where the injured employee (or the employee’s attorney) selects the medical provider, the acceptance of the medical provider’s diagnosis, prognosis, and recommended treatment without question can be a serious and costly mistake.
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“The 6-Step Process To Determine Workers’ Comp Injury Causation”
Physician Review Services Determine Most Appropriate Medical Care
Fortunately, the better medical management organizations offer physician review services (PRS) to address whether or not the injured employee is receiving the most appropriate medical care for the injury incurred. These are objective peer-to-peer review services where a highly qualified physician assesses the accuracy and quality of the medical care by reviewing the medical history of the employee’s injury and any comorbid factors influencing the needed medical treatments. By evaluating the medical necessity of medical services, the PRS prevents unnecessary medical treatment, saving both medical and indemnity costs by shortening the period of time the injured employee is off work.
In selecting a PRS, the workers’ compensation adjuster or the self-insured employer looks for the following characteristics:
• A reputation for professionalism.
• Credentialed and board certified highly experienced physicians.
• A large panel of diverse physicians.
• Physicians who understand workers’ compensation.
• A panel covering all major specialty areas.
• Multiple panel physicians in the larger specialties.
• A panel providing thousands of determinations each year.
• The PRS is accredited by the Utilization Review Accreditation Committee (URAC).
URAC accreditation is important because both certification organizations establish quality standards for evaluating and assessing medical care. IRO and URAC require the PRS to have quality benchmarking programs keeping pace with rapid changes in the medical field. Both IRO and URAC require the PRS to have continuing education, ensuring the physicians are up to date on the latest medical treatment methods.
When a PRS utilizes a credentialed, board certified highly experienced physician to evaluate the medical care an injured employee receives, it identifies when the employee’s medical provider is exhibiting inadequate medical knowledge of the best treatment methods for that injury. The PRS physician also identifies any situation where the treating physician is deviating from the standard of medical care needed by the injured employee. (Frequently when a medical provider is struggling with the best course of treatment for an injured employee, the medical provider appreciates the PRS physician’s input and guidance.)
Rebecca Shafer, President of Amaxx Risk Solutions, states ”Ever since managing the claims of a Fortune 500 organization, I have used MD’s as an indispensable part of my program. Quite often we forget that workers compensation claims are medical injuries, and the best qualified person is often a medical doctor.”
Return on Investment From Top Quality Physician Review Service
It is a costly mistake, as noted above, when PRS is not used to manage and control the medical cost in a workers’ compensation claim. The return on investment of top quality physician review services can be impressive. Data provided to us from Broadspire’s medical department show the following figures:
o Medical necessity/appropriateness of requested services: 3.9 – 1.0
o Medication reviews (prior authorization non formulary): 8.1 – 1.0
o Medication reviews (comprehensive pharmacy): 48.9 –1.0
o Return to Work / MMI: 43.4 –1.0
o Impairment rating validation: 5.7 – 1.0
o Appropriateness of treatment plan: 29.9 –1.0
o Causality determinations: 378.2 – 1.0
o Functional Impairments (STD / LTD): 99.3 –1.0
o Medical Bill Review (hospitals; ambulatory surgery facilities): 89.4 – 1.0
Physician review services are especially important on long-term or severe injury claims. The use of a PRS is recommend any time there is a question about the validity, length, or quality of medical treatment.
For assistance in identifying and selecting a Physician Review Service, please contact us.
Author Michael B. Stack, CPA, Director of Operations, 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: [email protected].
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