The Doctor Will See You: Using Treatment Parameters in Work Comp

Reducing workers’ compensation claim costs requires that members of the claims management team and other interested stakeholders know and understand the law. Part of this includes using medical treatment parameters as a tool to promote the effective management of medical costs.

What are Medical Treatment Parameters?

Medical treatment parameters are not present under every workers’ compensation act. About half of all jurisdictions employ some form of these guidelines. This requires the claims handler to research the jurisdiction they are working in to understand if they are available.

The use of treatment parameters were developed to provide reasonable guidelines for care of all compensable workers’ compensation injuries. All interested stakeholders, which included medical providers, vocational experts, developed them and attorneys from both sides and other parties involved in the process. The result is they serves as a baseline to measure the effectiveness of medical care and treatment and promote quality health care.

When do Treatment Parameters Come into Play

Generally, all medical care and treatment provided to an injured worker is required to be reasonable and necessary to cure and relieve the effects of the work injury. Workers’ compensation medical treatment parameters, which are not applicable in all situations, require that a medical provider demonstrate the medical care they provide results in continuous improvement in injury care that moves the employee toward maximum medical improvement, or full resolution. When it comes to medical treatment parameters, it is important to remember they only apply in the following situations:

• Claims where primary liability has been admitted, but there is a dispute concerning the treatment plan, or whether the medical care and treatment is reasonable and necessary; and
• Instances where primary liability is denied, but later admitted. At that point, the treatment parameters can be used as a defense to the medical care and treatment being received by the employee.

It is important to review applicable statues and regulations before asserting a defense based on medical treatment parameters.

Using Medical Treatment Parameters in Your Claim

There is a statutory presumption that the medical treatment parameters are reasonable and necessary. In essence, they are a “one size fits all” for workers’ compensation medical care. While it is impossible to categorize all work-related injuries, a vast majority of them are covered under these guidelines. Major injuries covered include:

• Injuries and conditions to the spinal cord, including disc herniations, vertebrae fractures and pain symptomology;
• Upper extremity conditions including fractures, dislocations, and common syndrome including carpal tunnel and lateral epicondylitis (tennis elbow);
• Traumatic brain injuries and cognitive dysfunctions;
• Psychological, psychiatric care and mental illnesses; and
• Reflex sympathetic dystrophy (RSD) or other neurological conditions.

What is Covered under Medical Treatment Parameters?

Medical treatment parameters set forth the frequency of medical care and treatment provided to the employee. The rationale is this avoids excessive care, waste and abuse within the system. Common procedures covered include:

• Imagining such as x-rays, MRIs and CT scans;
• Use of prescription medications, including the use of opioid-based drugs;
• Physical therapy and chiropractic care; and
• Procedures that must be attempted prior to surgery.

It is important to note that departures are permissible in jurisdictions with medical treatment parameters. An example of who this works can be found in Jacka v. Coca-Cola Bottling Co., 580 N.W.2d 27 (Minn. 1998). In Jacka, the Minnesota Supreme Court noted that “the treatment parameters cannot anticipate every exceptional circumstance, we acknowledge that a compensation judge may depart from the rules in those rare cases in which departure is necessary to obtain proper treatment.”

Conclusions

Workers’ compensation medical treatment parameters are designed to avoid waste and abuse within the system, while at the same time ensuring injured workers receive their entitled care. This requires members of the claims management team to determine if their jurisdiction has applicable parameters, understand how they can be used and effectively use them in the claim handling process.

Author Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%. He works as a consultant to large and mid-market clients, is a 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 is the founder & lead trainer of Amaxx Workers’ Comp Training Center, which offers the Certified Master of Workers’ Compensation national designation.

Contact: [email protected].

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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.