Medical directors can play a crucial role in any workers’ compensation program seeking to reduce program costs and make better decisions. This is because a medical director can work with the claim management team to make better decisions regarding various issues that face the individual claim handler daily. A medical director can also work with other interested stakeholders on topics such as return to work. When done correctly, any program will see a positive impact and reduction in costs.
Responsibilities of a Medical Director
The medical director plays many vital roles in a workers’ compensation program. They can also work with insureds to make important recommendations on improving their workers’ compensation program and reduce the frequency and severity of injuries. Other common roles include:
- Develop relationships within the industry to drive best practices;
- Visit insureds regularly to make suggestions on making the workplace safer; and
- Review policies and procedures with the legal department to ensure proper compliance.
A medical director can also be used on the front lines of the claim handling process to promote a more efficient workers’ compensation program.
Issues Concerning Primary Liability and Causation
Members of the claim management team and other interested stakeholders face issues concerning questions of primary liability and causation issues that pivot on physiology issues. A medical director can work with these partners so that better decisions can be made. Their role includes the following activities:
- Participate in roundtable meetings concerning questionable claims and make recommendations on issues of further investigation;
- Serve as a resource on occupational exposure claims where matters are very dependent on the facts of the case; and
- Provide feedback on pre-existing conditions that may play a role in the claim.
Medical providers possess important knowledge that can be used by members of the claim team so that all legitimate claims are accepted, and meritless claims are denied.
Assistance Related to Independent Medical Examinations
Claim handlers and managers face many challenges when it comes to the timing of independent medical examinations. These issues can include:
- Selection of the right medical expert to perform the examination;
- Determinations as to whether multiple examinations may be necessary when the claim involves more than one injury; and
- Assistance in drafting the letter to the medical expert.
As a valued member of the team, a medical provider can guide the claim management team. They can review files, make recommendations, and assist in preparing and drafting the cover letter to the expert. A medical provider can also be used to determine what questions that expert should answer following the examination.
Questions Regarding Change of Medical Provider
In most jurisdictions, the employee has the right to choose their medical provider. Once a selection has been made, the employee is prohibited from making further changes unless they can demonstrate it is in the “best interests of the parties.” This issue often creates unnecessary litigation and creates problems for claim handlers.
In these situations, a medical provider can provide better direction and assist in challenging requested changes. The review of the issue can include:
- Determining if the additional medical care will lead to excessive charges;
- Delay the progression of the employee’s medical care; and
- Whether the request to change medical providers is merely a litigation tactic.
Medical directors can also comment on whether consultations and ongoing medical care beyond the treatment parameters are reasonable and necessary.
Recommendations on Return to Work
Every workers’ compensation program should focus on returning an injured employee to work promptly. This includes exploring options such as in the pre-injury position, modified position, or “work on loan” possibilities. When working with a medical director on this issue, there is an opportunity to obtain feedback and direction on the following:
- Work restrictions imposed by the treating doctor and whether they are reasonable;
- Options regarding the modification of job roles at the pre-injury employer; and
- Coordination with employer representatives regarding their return to work efforts and improvements that can be made.
There are many roles and responsibilities of medical directors. They can help address challenges that face the claim management team members, such as compensability, independent medical examinations, and reducing the need for litigation regarding changes in medical providers. They can also help get injured employees back to work. When used correctly, a medical director is a valued team member that can help reduce workers’ compensation program costs.
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.
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