What is Reasonable and Necessary?
In a 1964 free speech case, the United States Supreme Court was tasked with defining obscenity and creating a sound constitutional standard. In writing a concurring opinion for the majority, Justice Potter Stewart famously exclaimed, “I shall not today attempt further to define the kinds of material I understand to be embraced within that shorthand description [“hard-core pornography”], and perhaps I could never succeed in intelligibly doing so. But I know it when I see it…..”
Like Justice Stewart, members of the claim management team are responsible for reviewing requests for medical care and determining if it is reasonable and necessary to cure and relieve the effects of the work injury. Medical care not meeting this standard must be denied.
So what is “reasonable and necessary” medical care? The following factors are often considered when making such determinations:
- Evidence of Treatment Plan: Treating doctors and health care providers should prepare a plan at the commencement of medical care. This plan should be based on the etiology of the event and objective findings. The plan should include the frequency and duration of care and outline the necessary treatment modalities.
- Documentation of Treatment Details: Once a plan is implemented, more than the “copy/paste” approach to care should be outlined in medical records generated from an office visit. This should include rating the employee’s subjective pain level and complaints. Other items to ensure are present include the relief received with the prior visit, its duration, and what care was provided.
- Degree and Duration of Relief: This should be documented with every visit and measurable over time. Be on the lookout for care that does not provide relief, allowing the employee to remain disabled and failing to allow the employee to return to work. Skeptically question documented “exacerbations” and symptoms and ensure a reasonable explanation is given. These questions should also be asked during a recorded statement or deposition.
- Frequency of Treatment: A review of frequency will depend on the stage the employee is at following a work injury. Immediately after a work injury, the employee is considered in the “acute” phase of care and will be seen by a doctor regularly. This can include several times in one week. As the employee’s care progresses, that frequency should diminish. At that point, look for trends in care – is it being provided with the same frequency, or is the employee going for differing periods before needing to be seen.
- Connection Between Medical Care and Return to Work: All medical care proposed to the employee needs to have the goal of returning them to work. This should be something included in a treatment plan. If it is absent, ask the healthcare provider for additional details. Failure of that provider to respond should signal the care is excessive.
- Potential Aggravation: Some medical care may aggravate the underlying condition and make it worse. Examples include chiropractic care that increases pain levels in the impacted area or physical therapy that is not making a difference. Skeptical questions should be asked before approving additional medical care that caused a spike in someone’s pain level.
- Duration of the Treatment: Reasonable medical care is never open-ended. Never approve medical care that does not have a defined frequency and duration.
- Cost: All medical care should be cost-effective. Questions need to be raised when there is a request for care with less expensive options. Medical care should also be directed to avoid costly surgical procedures.
Members of the claim management team need to examine and question medical care that does not meet the above criteria.
Conclusions
Experienced claim handlers should develop a knack for knowing reasonable and necessary medical care when they see it. It is essential to review medical records for objective findings or subjective complaints that are out of proportion and ask questions. Never be afraid to demand additional details when concerns and red flags arise. Developing this skill will improve the claim handling process and allow for cost savings to any workers’ compensation program.
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