Medical Cost Containment Archives

Using Results-Based Physical Therapy to Control Workers’ Comp Costs

September 30, 2019 by Michael B. Stack

When an employee has a musculoskeletal injury keeping them from returning to work, it is routine practice for orthopedic doctors to recommend a physical therapy program. The purpose of the physical therapy program is to assist the injured employee in restoring function, regain a pre-injury level of mobility, control pain, and prevent permanent physical disability. This can be accomplished with physical therapy, providing both range of motion exercises and strengthening exercises.

Members of the claim management team and other interested stakeholders need to understand physical therapy and implement claim handling changes to control program costs. This allows them to control workers’ compensation costs and return the injured employee back to work in a timely manner.

The Basics of Physical Therapy

The doctor treating the injured employee will prescribe the amount of physical therapy that is necessary to restore an injury. Some doctors are very good at estimating the number of physical therapy sessions an injured employee will need, and hopefully, prescribe it accordingly. For instance, the doctor will prescribe physical therapy for the lumbar spine “3 x 4,” which tells the physical therapy facility to treat the injured employee three times per week, for four weeks. The return appointment with the doctor’s office is normally scheduled after the anticipated date of the last physical therapy treatment. This allows the doctor to assess the benefits of the physical therapy treatment program, but it is after the fact.

On the other hand, other medical professionals will prescribe the same amount of physical therapy for just about every patient they see. If every patient is “3 x 4,” or “3 x 6,” some injured employees end up having excessive medical care and treatment. This not only impacts the cost of workers’ compensation claims but does not resolve a work injury in a timely manner. When the injured employee does not get enough physical therapy, they return to the doctor before they have not recovered from their injury. The doctor then prescribes more physical therapy and sets up another return visit to the doctor’s office.

“Results Based” Physical Therapy

When the orthopedic describes physical therapy, the physical therapy facility wanting to ensure payment will normally call the workers’ compensation claim handler for approval. The claim handler may not know whether physical therapy is needed. In many instances the claim handler will not question the need for physical therapy – use the thought process that if the doctor requested it, the care must be needed. This results in the injured employee receiving more physical therapy than needed.

One approach to this dilemma when reviewing a request for physical therapy is to refer the request for to utilization review. Utilization review can eliminate some excessive physical therapy treatment by allowing trained medical professionals to assist in the determination based on the information in the medical notes. Utilization review will not know if the injured employee recovers faster than normal, resulting in the injured employee continuing to go to unreasonable and unnecessary medical care and treatment.

A recent innovation in managing the physical therapy treatment is the development of “results-based” treatment approach. Instead of the injured employee going to the physical therapy office 15 times because the doctor wrote a “3 x 5” script, the injured employee goes to the physical therapy office for as many or as few times needed for the employee to make a proper recovery from their musculoskeletal injury.

In the traditional fee for services model of physical therapy treatment, it is in the financial best interest of the physical therapy facility to continue physical therapy treatment until the doctor sees the injured employee again. This often results in excessive treatment. The results-based approach to physical therapy aligns the interest of the employer and the insurer with the physical therapy facility. A timely recovery and return to work benefits all parties including the employee.

Conclusions

A results-based approach to physical therapy allows a single flat fee for service. It reduces paperwork for the claim handler, by leaving them with only one bill to pay, rather than multiple forms related to ongoing medical care. Results-based physical therapy treatment is also an innovative way for employers and insurers to manage the physical therapy treatment process, and to provide the injured employee with the treatment needed in a timely manner.

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 founder & lead trainer of Amaxx Workers’ Comp Training Center .

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

Filed Under: Physical Therapy & Physical Rehabilitation

Watch Chiropractic Care for Excessive Medical Bills

July 11, 2019 by Michael B. Stack

The use of chiropractic care is a recognized way to treat many workers’ compensation injuries. This includes injuries to joints, the back, and neck. If an injured employee is receiving medical care and treatment through a chiropractor, it is important to take note of several issues that will save money in a workers’ compensation program. It is also essential to develop effective claim handling techniques to get the employee back to work promptly.

Areas of Concern with Chiropractors

By definition, chiropractors are considered “doctors” who are capable of providing medical care and treatment in workers’ compensation cases. They are sometimes suspect as they do not have a formal medical education that an “MD” obtains through an accredited medical school. The focus of their medical education is concentrated on the diagnosis, treatment, and prevention of disorders of the neuromusculoskeletal system. There is also an emphasis on a holistic approach to health care that includes an understanding of the central nervous system plays.

Factors to Consider When Evaluating Chiropractic Care

There are various areas where members of the claim management team should focus their review of billing and provider issues related to chiropractors. These areas should include the following:

Evidence of a reasonable treatment plan: This plan should be reasonable based on the nature and extent of the work injury. It should include information on the duration of care and its frequency.

Documentation of the details of the treatment: A common complaint of chiropractors is their treatment notes outline the same complaints and care provided with every visit – it is almost as if the provider was using the “copy/paste” function on a word processor.

The degree and duration of relief resulting from the treatment: A review of what is stated in chiropractic medical records should always be reviewed for consistency. This includes whether the care being provided is advancing the patient’s care and consistent with their deposition testimony, and findings at an independent medical examination.

The frequency of treatment: This element evaluates how often the injured employee is treating and how they are scheduling appointments. Initial care with a chiropractor is typically set at certain intervals. After a period of time, that care should diminish, or be on an as-needed basis.

The relationship of the treatment to the goal of returning the employee to suitable employment: A successful return to work should be the goal of any medical care and treatment provided to an injured employee. This becomes paramount when dealing with chiropractic care as frequent, ongoing care can leave someone at their baseline with no improvement in pain relief or functional ability; and

Cost of Chiropractic care: This is an important factor to consider, especially when an injured employee is seeking approval for care after 10-12 weeks of care.

Issues to Review When More Care is “Required”

When it comes to chiropractic care, it is important to obtain detailed information from the injured employee on how they were referred to the chiropractor. Closer scrutiny should take place when this is someone the employee has seen in the past or based on a family member referral. A claim should be heavily scrutinized if the chiropractor shares a building with, or located in close proximity to a physical therapist also treating the injured employee.

Other issues to consider when challenging excessive care, or approving additional chiropractic care should include:

The injured employee’s opinion as to relief obtained;

The duration of relief from symptoms;

Whether symptoms return once care stops;

The use of other “alternative” medical care;

Whether the injured employee is psychologically dependent on chiropractic treatment;

Whether the frequency of treatment is warranted;

The cost/benefits analysis regarding treatment provided compared to the relief obtained;

The employee’s overall activities and the extent of the employee’s ability to work; and

The potential for aggravation of an underlying condition.

Conclusions

The goal when approving medical care and treatment should always concern the nature and extent of the injury and getting the employee back to their pre-injury condition. This can be obtained through chiropractic care. When handling a claim involving this treatment modality, it is important to be vigilant and ensure it is effective in providing lasting relief.

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: https://blog.reduceyourworkerscomp.com/

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

Filed Under: Medical Cost Containment

Expertise of Senior Nurse Reviewers Generates Work Comp Savings

April 30, 2019 by Michael B. Stack

Complex and severe injury claims are a leading driver of workers’ compensation claims costs. The greater the complexity and severity of an employee’s injury the larger the number of medical providers involved in the medical treatment. The primary physician often engages other specialists, therapy services, diagnostic testing, pharmacy usage, etc. The result of involving many different medical providers in the injury claim is the primary physician is often not fully aware of all aspects of the injured employee’s medical treatment.

Doctor Standard Treatment Protocol Not Designed in Employees Best Interest

A primary doctor has many individual patients, making it difficult to impossible to spend the time evaluating the overall best course of medical treatment for a particular injured employee. To compensate for the limited amount of time a physician can spend with any one patient, it is the doctor’s normal practice to follow a standard protocol for each injury type. These standard treatment protocols tend to have various built-in tests and procedures designed not in the best interest of the injured employee but designed to protect the doctor from claims of negligence and/or medical malpractice when the injured employee does not achieve expected results.

Senior Nurse Reviewer Provides Medical Expertise to Help Adjuster Make Good Decisions

Workers’ compensation adjusters often wonder if all the diagnostic tests, therapy sessions, injections, prescriptions, and repetitive office visits are really worthwhile. Adjusters, not being trained medical professionals, may doubt the need for various medical procedures and attendant costs but are without the skill set needed to discuss with the primary medical provider the various medical services being utilized. Fortunately, there are workers’ compensation medical professionals – senior nurse reviewers – who have the expertise to review with the primary medical provider, and all other medical service providers, the need for each medical service provided to the injured employee.

Senior Nurse Reviewers – nurse case managers with the highest level of medical expertise and experience – assist employers, adjusters, medical providers, and severely injured employees with guidance and coordination of complex injury claims. By overseeing the medical care and coordinating medical treatment, the senior nurse reviewer reduces or eliminates unneeded medical services while the injured employee receives all necessary medical services promptly.

A senior nurse reviewer reduces claim costs in a variety of ways, including:

• Assisting the injured employee in the navigation of the medical universe.

• Facilitating communication between the injured employee, the medical providers, the adjuster, and the employer.

• Creating a care plan for the injured employee and updating the care plan as needed.

• Questioning and addressing unnecessary medical treatment.

• Keeping all medical care on track, eliminating delays in treatment, thus reducing the time the injured employee is off work.

• Coordinating the timely delivery of diagnostic testing, therapy, and medical appointments with other medical specialists.

• Providing on-going case oversight to eliminate unnecessary medical services.

• Identifying and addressing obstacles to the employee’s recovery.

• Addressing any deviation from established disability duration guidelines.

• Facilitating the quickest possible light duty or full duty return to work for the employee.

Senior nurse reviewers are not physicians but nurses with many years of experience. If the senior nurse reviewer and the medical provider disagree on what is the best interest of the injured employee, the senior nurse reviewer turns to doctors and medical specialists, who have contracted with the senior nurse reviewer’s company to provide a high level of expertise within their medical specialty. The senior nurse reviewer then has the contracted medical specialist consult with the injured employee’s doctor on a peer-to-peer basis to arrange for the best course of medical treatment for the employee.

Overall Impact of Senior Nurse Reviewer is Reduction in Claim Costs

The overall impact of using a senior nurse reviewer on complex and severe workers’ compensation claims is a reduction in the employer’s overall claim costs. The use of senior nurse reviewers results in two types of savings:

• Lower indemnity cost by the injured employee quicker return to work.

• Lower medical cost by eliminating unnecessary medical services.

For assistance in locating a senior nurse reviewer for your complex and/or severe claims, please contact us.

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: https://blog.reduceyourworkerscomp.com/

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

Filed Under: Coordinating Medical Care

3 Elements Needed In Workers’ Comp Medical Networks

March 25, 2019 by Michael B. Stack

How to Select the Right Workers' Comp Doctor

So last week I’m having lunch with a business associate and he says to me, “You know, I haven’t done a lot of business in work comp. Can you explain to me how it all works?” Hello, my name is Michael Stack and I’m the CEO of Amaxx and that question is a great question, particularly for those outside of our industry and also for many, many of individuals within our industry, trying to figure out the complexity of the work comp industry itself. As you look at it from the outside, it’s extraordinarily complex but at its core, it’s extraordinarily simple.

Getting Injured Employees Proper Treatment Is Core of Workers’ Comp

You’ve got an employee and an employer, that employee gets hurt and our job is to just help them get better and get back to work. Very, very simple and to do that, you need a lot of help and you need a lot of people. One of those individuals and one of the emerging markets and emerging sub-markets even within the physician world, is the emergence of networks and specialty networks. Today I want to talk about that specialty network and what you should look for when you’re setting this up so you can get those individual employees the treatment they need and help them get back to work. Let’s talk about a couple things here.

Broad vs Narrow Networks

First thing you’re going to do is you’re going to look at whether you’re going to be using a broad versus a narrow network. The narrow network, these are the ancillary networks, these are the specialty networks that has been really quietly emerging within our industry over the last several years. It’s not a bad idea to have a combination of the two. You’ve got the broad network to cover most of your organization, and then the narrow network to bring in some of those experts in those particular fields. Now, these can be physical therapy, these can be mental health, these can ambulatory service centers, these could be chiropractic, a whole host of specialties within the medical field that put together these ancillary or specialty networks.

A couple things that I want you to just be aware of. There’s a lot that obviously goes into this, but what we’re trying to do, think about the core of what we’re trying to do is, we’re trying to get that individual employee the treatment that they need to get them back to work. Now, how do we do that? Bringing in these best medical providers, leveraging the fee schedules, the discounts on the fee schedules that can often come from these. So, a couple of things that I want you to just look for, particularly if you’re evaluating a network and evaluating whether or not to bring in some of these specialty or ancillary or networks, which again have been emerging in the last several years.

Network Coverage

First thing that I want you to look at his coverage, next is access and the last one, or at least the last one we’re going to talk about today, is credentials, so coverage, access and credentials. Can you cover the entire geographic area of where your employees are? If you’re a regional or a national employer, is there the appropriate coverage that that employee could actually get to that provider in a reasonable amount of time to get the treatment that they need?

Network Access

Number two, are they accepting new patients? Are they accepting new patients? Workers’ comp specific patients. I can’t tell you how many conversations I’ve had with injured workers where they said, “You know, I got a list of five doctors and the first three I called, they didn’t take work comp at all and the fourth one I called, he wasn’t taking any new patients, and then the fifth one did take new patients and took work comp, but he was two hours away.” Coverage and access, incredibly important to get to that fundamentally simple concept of what it is we’re trying to do in this industry, help our employees get better, help them get back to work. You got to have the right doctors that are going to help them do that.

Credentialing

And then finally, particularly as it comes to network, what credentialing are they doing? Are they board certified? Do they have X amount of experience? Do they have certain criteria as far as the outcomes that they’re delivering? What is their credentialing of the networks? Work comp can be extraordinarily complex in how it’s all put together, but remember at the core, what it is we’re trying to do. Just get our employees the treatment that they need and help them get back to work. These couple of tips in regards to providers and network can help you do that.

Again, I’m Michael Stack, CEO of Amaxx and remember your work today in workers’ compensation can help you have a dramatic impact on your company’s bottom line, but it will have a dramatic impact on someone’s life, so be great.

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: https://blog.reduceyourworkerscomp.com/

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

Filed Under: Coordinating Medical Care

Marijuana: A Medical Perspective

March 4, 2019 by Marcos Iglesias, MD

We have a drug problem.

Americans consume more opioids than anyone else in the world. We are also among the highest consumers of marijuana. As a nation, we continue to rely on passive treatments for chronic conditions, instead of active management.

There is widespread acceptance of marijuana in the United States. A recent Quinnipiac University poll of US voters found that 63% of respondents believe that marijuana should be legalized and 93% support its use for adults with a medical prescription by a physician. The 2016 National Survey on Drug Use and Health estimates there are almost 38 million marijuana users in the United States. Thirty states and the District of Columbia currently have legalized marijuana in some form (most of these are so-called medical marijuana states). Eight states and the District of Columbia have legalized marijuana for recreational use.

Yet marijuana continues to be classified as Schedule I drugs under the Federal Controlled Substances Act and, therefore, illegal to manufacture, distribute, or dispense.

When it comes to the legality of medical efficacy of marijuana use, there are a number of factors at play. These include:

Pharmacology — how exactly do the relevant chemical compounds, THC and CBD, interact with the body? And, given the non-traditional routes of administration for marijuana (usually inhalation or ingestion), how can we anticipate or regulate what the response will be?
Adverse effects — we’ve all heard about the euphoria and impairment of memory, judgement, reaction, and other mainstream effects. But what about adverse physical effects? Or, the link to psychological disorders like depression, schizophrenia, or psychosis?
Efficacy — in some circles, marijuana is touted as a harmless cure with the ability to cure everything from cancer to chronic pain. The challenge with these claims is that there are few methodologically rigorous trials that can back the claims up. Is there something here for doctors to work with or should the claims be dismissed as nothing but rumors from idealistic hippies?
Workplace impact and safety — with additional increases in marijuana use, both recreational and otherwise, seeming inevitable, what is the link to workplace safety? And how can employers, insurers, and claims handlers respond?

As part of our dedication to staying at the forefront of medical advancements and opportunity, we have prepared a white paper and recorded webinar to dive deep into these questions. Using evidence-based research, we separate fact from fiction and seek to find out if there is legitimate use of marijuana in our industry’s future or if all the claims will go up in smoke.

Author: Dr. Marcos Iglesias is Broadspire’s senior vice president and chief medical officer with more than 25 years of experience in workers compensation, disability evaluation and treatment, and insurance leadership. Iglesias has a special interest in the prevention and mitigation of delayed recovery and disability. He is driven to help ill and injured workers live active, productive and fulfilling lives, which has led him to develop innovative, comprehensive disability management solutions that focus on returning workers to preinjury function. Iglesias is board certified in family medicine and utilization review and quality assurance. He is also a fellow of the American Academy of Family Physicians, American College of Occupational and Environmental Medicine and the American Institute of Healthcare Quality.

Filed Under: Medical Cost Containment

Evaluating Medical Evidence to Make Better Workers’ Comp Decisions

February 13, 2019 by Michael B. Stack

Members of the claim management team are called upon to evaluate the medical evidence and determine issues of reasonableness and necessity of medical care and treatment, along with determinations of causation and primary liability. These decisions have a significant impact on an individual claim and the effectiveness of a workers’ compensation program.

Evaluating the Medical Evidence from a Physiological Standpoint

Imagine the next claim that lands on your desk involves a meat production worker. The employee is a 62-year-old man who’s work activities requires him to process meat on a bench that is no higher than their waist. During this process, the employee will turn in one direction to place the finished product for further processing and sale, and turn in the other direction to place the undesirable portions of the product for disposal. None of their work activities require the employee to lift objects above chest level or over his head. The employee is now claiming a progression of symptoms that involve stiffness, which has now culminated in “frozen shoulder” syndrome. Should the alleged injury be accepted?

While the cutting of meat and its processing are repetitive, not all claims of repetitive trauma are compensable.

Making the Right Assessment

Claim handlers deal with many barriers when reviewing matters and determining questions that have real consequences. This includes rigid timelines that can result in sanction or penalty if not done right or within a timely manner. Questions that must be considered include:

Did a work injury actually occur – even if it only aggravated or accelerated an underlying condition?

What role if any, did the work activity contribute to the injury, disability and/or need for medical care and treatment?

Even taking into consideration the employee’s age and possible prior injuries, did the work activity advance the underlying condition to the point of compensable injury?

Does the overall medical evidence as presented fit the alleged injury?

In terms of the above scenario, the claim handler worked with a medical expert to review the claimed mechanism of injury, prior medical records and other information to allow for a primary denial. It was noted that the contemporaneous medical records and work history did not support a work injury and the claimed mechanism was inconsistent with the subsequent medical diagnosis. In sum, because the physiological body mechanics in question did not fit injury, the proactive claim handler was effective and proactive in denying the claim.

Application in Claims Handling Practice

It is important for members of the claim management team to review their files and determine if the medical evidence fits in not only workplace exposure/repetitive injury claims, but also specific incident injuries. Examples of how this can be used in specific injuries include:

How the employee fell or what they were doing when they fell;

Angles of fracture and the type of fracture following a slip/fall; and

The nature and extent of an injury based on pre-existing conditions such as degenerative disc disease for back and neck claims, and claims involving joints such as knees, shoulders, and

The list of possibilities is really endless.

Conclusions

Members of the claim management team face many challenges in their position on a daily basis. It is of utmost importance that claims handlers make proper decisions after having investigated a claim in a timely manner and making evidence-based decisions. This includes taking the time to obtain information on how the injury took place, they can save time and money for their program and clients.

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: https://blog.reduceyourworkerscomp.com/

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

Filed Under: Medical Cost Containment

Establishing and Changing Primary Care Doctors in Workers’ Comp

December 18, 2018 by Michael B. Stack

A common method to control costs in workers’ compensation claims is the designation of a primary treating medical provider. This is important for a number of reasons and is something claim handlers need to understand. Failure to recognize its significance can result in excessive costs in the claim management process.

Threshold Issues to Consider for Primary Care Doctors in Work Comp

Determinations regarding the establishment of a primary care doctor are usually defined by statute or administrative rule under a jurisdiction’s workers’ compensation law. In many instances and employee establishes their primary doctor based upon the number of times or frequency an injured employee receives medical care and treatment following an injury.

Time to Consider a Change in Healthcare Providers?

A health care provider is typically considered the “primary doctor” once they direct and coordinates the course of medical care provided to the employee. Employees are usually allowed to only have one primary health care provider at a time. Once an employee establishes a primary treating physician, their ability to change that provider are limited. Circumstances that permit change without initiating a legal process include the following:

Death or retirement of a physician, doctor or other health care provider;

Termination or suspension of a provider’s health care practice; or

Referral from the primary provider to another provider.

Failure of an employee to receive advance approval of a change in health care provider can have a significant impact on a workers’ compensation claim. One common consequence of this action is the ability of the workers’ compensation insurer to avoid legal liability for medical care and treatment received by the employee even if the medical care is reasonable, necessary and causally related to the work injury.

Other Factors to Consider When a Request for Change Occurs

If a change is not approved by a workers’ compensation insurer, employee’s generally have the ability to initiate a legal process to change their primary health care provider. While factors to consider in this process vary, they generally include the following issues:

Whether the requested change is an attempt to block reasonable treatment or avoid acting on the provider’s opinion concerning the employee’s ability to return to work: A change is sometimes requested when an injured employee is hesitant about proposed medical care and treatment. Failure to follow the proposed treatment plan can also delay recovery.

Development of a litigation strategy rather than to pursue appropriate diagnosis and treatment: This can occur in instances where an employee is malingering or exhibits unsafe habits such as seeking opioid-based prescription medications.

The provider lacks expertise to treat the employee for the injury: Medicine is complex. Sometimes a medical provider may lack the necessary training or experience to properly care for an injured employee. There are also health care providers known to enable an employee by seeking excessive care or unnecessary procedures.

Other factors to consider: It is important to evaluate a request for change in a health care provider in terms of travel costs to see a particular health care provider and other unnecessary expenses. Members of the claim management team should be skeptical of a request for change when it is certain the employee does not require additional care.

Members of the claim management team also need to consider the best interests of all parties. What these means is often vague and uncertain. This requires the application of the “smell test” to determine if such change is really necessary.

Conclusions

Claim handlers need to be vigilant of excessive medical costs as long as it continues to drive workers’ compensation program costs. One area of focus should be a determination on the employee’s primary medical provider following a work injury and what circumstances truly necessitate a change.

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: https://blog.reduceyourworkerscomp.com/

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

Filed Under: Medical Cost Containment

6 Ways Nurse Case Managers Add Value to Workers’ Compensation Claims

December 17, 2018 by Michael B. Stack

Nurse case managers can be invaluable to an injury management program. They can have a tremendous impact by helping organizations attain better outcomes for their injured workers and saving significant dollars.

But far too often industry stakeholders misunderstand how and when to use them. Like many aspects of claims management, Nurse Case Managers are a tool that should be employed judiciously and with forethought to garner the most value.

Expectations

NCMs are not miracle workers. However, when incorporated into the right types of claims they can be instrumental in getting the injured worker healed and back to work in a timely fashion, resulting in the types of savings reported above.

Here are the many ways NCMs help with a claim:

Patient advocacy. This is where NCMs shine. Injured workers are often confused and scared, especially if the injury is severe. Unlike being injured at home and going to see whatever physician they choose, the rules for injured workers are different. They are often told what doctor to see and when. They may also be concerned about how they will get money if they are out of work for any length of time. And they may fear losing their job. A NCM can guide the injured worker through the process, allaying his fears and answering his questions. They can

Explain the process and restrictions
Discuss likely recommendations from doctors
Provide options for various specialists, regardless of the rules for physician choice in a jurisdiction. Where the injured worker has the option to visit any physician, the NCM can recommend physical therapists, orthopedists, or others. In employer-directed care states, the NCM can discuss various in-network providers known to her.
Review meds. The NCM can explain the medications that are prescribed and look at possible interactions with other pharmaceuticals the injured worker may be taking.

Reduce litigation rates. One of the benefits of NCMs is the trusting relationship they develop with the injured worker. Research shows injured workers who work closely with a NCM are much less likely to sue their employers.

Increase engagement and ensure compliance. Injured workers can be notoriously unfaithful to the treatment plans — forget to take their medications, miss PT or other provider appointments, failing to do assigned exercises that aid recovery. Again, having a trusting relationship with a NCM who is clearly advocating for the injured worker is likely to result in better adherence to a treatment regimen.

Communicate. Because he is closely involved with the injured worker, the NCM is the best person to act as the liaison to all stakeholders.

With the employer. The NCM can keep the employer updated on the injured worker’s progress. He can discuss restrictions and ways the employer can accommodate the worker. He can also discuss the capabilities the injured worker has during the recovery process to help identify light-duty work.
With the treating physician. Especially in states where workers have a choice of providers, the NCM can explain the workers’ compensation system and the emphasis on return to work.
With the claims adjuster. The person handling the claim may be unaware that the injured worker has been released to return to work, for example, requiring a change in the benefits.

ID then need for peer review. Sometimes claims go off the rails because the treating physician is not following evidence-based medicine guidelines, or doesn’t understand the goal of return to work. A medical provider who is not an occupational physician may continually say the injured worker should not go back to work in any capacity. The NCM can detect such incidents and get a medical provider from the insurer or third-party administrator to review the case and possibly talk with the treating provider.

Coordinate interventions. Psychosocial issues may be present that could derail the claim unless they are addressed. The NCM may be the first person able to detect these and seek cognitive behavioral therapy or other intervention. A pain management program may be warranted, which the NCM can coordinate.

Conclusion

NCMs are one of the most effective ways to achieve best win-wins for injured workers and employers. But it’s important for stakeholders to know how and where they can add value. For example, they should not be used on every claim.

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: https://blog.reduceyourworkerscomp.com/

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

Filed Under: Medical Cost Containment

Marijuana: A Medical Perspective — White Paper

November 26, 2018 by Marcos Iglesias, MD

We have a drug problem.

Poll Found 93% Support Medical Marijuana

Yet marijuana continues to be classified as Schedule I drugs under the Federal Controlled Substances Act and, therefore, illegal to manufacture, distribute, or dispense.

Medical Efficacy Factors of Marijuana Use

When it comes to the legality of medical efficacy of marijuana use, there are a number of factors at play. These include:

Pharmacology — how exactly do the relevant chemical compounds, THC and CBD, interact with the body? And, given the non-traditional routes of administration for marijuana (usually inhalation or ingestion), how can we anticipate or regulate what the response will be?
Adverse effects — we’ve all heard about the euphoria and impairment of memory, judgement, reaction, and other mainstream effects. But what about adverse physical effects? Or, the link to psychological disorders like depression, schizophrenia, or psychosis?
Efficacy — in some circles, marijuana is touted as a harmless cure with the ability to cure everything from cancer to chronic pain. The challenge with these claims is that there are few methodologically rigorous trials that can back the claims up. Is there something here for doctors to work with or should the claims be dismissed as nothing but rumors from idealistic hippies?
Workplace impact and safety — with additional increases in marijuana use, both recreational and otherwise, seeming inevitable, what is the link to workplace safety? And how can employers, insurers, and claims handlers respond?

Dr. Marcos Iglesias, senior vice president, and chief medical officer at Broadspire has prepared a comprehensive white paper and recorded webinar diving deep into medical considerations surrounding marijuana.

This objective whitepaper using evidence-based research can be found here.

Dr. Marcos Iglesias is senior vice president and chief medical officer of Crawford & Company’s global TPA, Broadspire. He has more than 25 years of experience in workers compensation, disability evaluation and treatment, and insurance leadership. In addition to being a physician, executive, national speaker and author, Iglesias is known for his compassion for patients, progressive and inspirational leadership, and integrated approach to injured worker care. Iglesias has a special interest in the prevention and mitigation of delayed recovery and disability. He is driven to help ill and injured workers live active, productive and fulfilling lives, which has led him to develop innovative, comprehensive disability management solutions that focus on returning workers to pre-injury function.

Filed Under: Medical Issues

Writing the Perfect Independent Medical Exam (IME) Letter

October 10, 2018 by Michael B. Stack

On many occasions, members of the claim management team need to write a cover letter to the independent medical examiner. This is an important part of defending a workers’ compensation claim for mean reasons. It includes preparation, planning and having accurate information. When drafting this letter, it is important to consider a number of factors and include the right questions.

Expert Foundation for Medical Opinions

It is important that your expert has the proper foundation to provide their findings and opinions within a reasonable degree of medical certainty. As part of your cover letter, consider asking for the following information:

Please set forth the amount of time that you spend with «Name of Employee» in your evaluation.

Please set forth the medical records which you reviewed as part of your evaluation.

Information on the Injury and Its Nature and Extent

It is important to demand precision for your medical expert. Help ensure you receive the information you need by asking for the following:

What is your diagnosis and prognosis of «Name of Employee»’s «Body Part/Condition»?

What is the substantial contributing cause of any diagnosis you make? Further, what is the etiology of any diagnosis you make?

If there is a question as to whether the work activity contributed to the condition, you might want to consider asking:

In your opinion, did the claimed events of «Date Here,» aggravate, accelerate or otherwise substantially contribute to the onset and progression of «Name of Employee»’s diagnosed condition?

Otherwise, it is important to verify the condition is work related, along with its nature and extent.

In your opinion, did «Name of Employee» sustain a work injury on «Date Here»? If you find that «Name of Employee» sustained a work injury on «Date Here,» was that injury permanent or temporary in nature? If temporary, how long did it last?

If there is more than one substantial contributing cause to «Name of Employee»’s condition, please apportion responsibility for any medical care and treatment, surgery, disability and permanency for these injuries.

Other Matters to Consider

The IME can be used to determine a number of other legal issues. Maximum medical improvement or the “end of healing period” is one of these important matters for the expert to address. The payment of ongoing benefits can depend on this status. Be sure to consider asking the following:

In your opinion, has «Name of Employee» reached Maximum Medical Improvement for all diagnosed conditions? If so, when did the Employee reach Maximum Medical Improvement? If not, when would you expect the Employee to reach Maximum Medical Improvement for all diagnosed conditions?

Issues concerning permanent partial disability are also important to consider asking about:

Did «Name of Employee» sustain any ratable permanent partial disability, pursuant to the workers’ compensation permanency guidelines as a result of the work injury of «Date Here»? If so, please state what you would attribute any permanent partial disability, citing the specific section in the workers’ compensation permanency guidelines?

The need for future medical care and treatment is also important. Be sure to ask about the following matters:

Has «Name of Employee»’s medical care and treatment been causally related to the (claimed events) events of «Date Here» to his/her «Body Part/Condition»? Why or why not?

Has «Name of Employee»’s medical care and treatment been appropriate under the workers’ compensation treatment parameters (if applicable)? Why or why not?

What medical care and treatment do you propose «Name of Employee» undergo, if any? Also, could you please state what its frequency and duration would be for any recommendations that you have.

Is «Name of Employee» in need of any restrictions on his/her ability to perform activity, if any? If so, please state what restrictions you would place on «Employee»’s activity. Also, please state what you would attribute the need for any such restrictions?

In your opinion, is «Name of Employee,» capable of sustained gainful employment with regard to his «Injury Here,» and if so, what restrictions, if any, would you place on his work activities?

Is the Employee undergoing functional overlay for secondary gain?

Please provide any additional relevant comments.

Final Considerations

A well-written independent medical examination letter is clear, concise and free from bias. Remember that any letter sent to a medical expert is discoverable and can be submitted as evidence. By following these guidelines, members of the claim management team can ensure their expert’s opinion receives full consideration from a compensation judge.

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: https://blog.reduceyourworkerscomp.com/

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

Filed Under: Independent medical exam (IME)

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