Establishing and Changing Primary Care Doctors in Workers’ Comp

Establishing and Changing Primary Care Doctors in Workers’ CompA 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.

 

 

 

Michael Stack - AmaxxAuthor 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: https://blog.reduceyourworkerscomp.com/

 

©2018 Amaxx LLC. All rights reserved under International Copyright Law.

 

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

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

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

 

  1. 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.

 

  1. 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.

 

  1. 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.

 

  1. 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.

 

  1. 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.

 

  1. 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.

 

 

 

Michael Stack - AmaxxAuthor 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: https://blog.reduceyourworkerscomp.com/

 

©2018 Amaxx LLC. All rights reserved under International Copyright Law.

 

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

Marijuana: A Medical Perspective — White Paper

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.

 

 

Poll Found 93% Support Medical Marijuana

 

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.

 

 

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.

Writing the Perfect Independent Medical Exam (IME) Letter

Independent Medical Exam (IME) LetterOn 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.

 

 

 

Michael Stack - AmaxxAuthor 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: https://blog.reduceyourworkerscomp.com/

 

©2018 Amaxx LLC. All rights reserved under International Copyright Law.

 

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

Educate Stakeholders on Effective Alternatives to Opioids

Educate Stakeholders on Effective Alternatives to OpioidsA combination of ibuprofen and acetaminophen does a better job of relieving acute pain than opioids. Despite clear evidence that the combination of the less dangerous medications provides equal or greater pain relief, many physicians still prescribe opioids for injured workers with pain.

 

This statement was just one point made in a recent session at the Workers’ Compensation Institute’s Annual Conference in Orlando presented by:

 

  • Marcos A. Iglesias, Chief Medical Officer of Broadspire
  • Mark Pew, senior VP for Product Development & Marketing at Preferred Medical.

 

 

The Problem

 

The opioid epidemic in the U.S. has been well documented in recent years. Researchers say Americans consume more opioids than any other country, regardless of the myriad physical and psychological problems associated with their unnecessary use.

 

While stakeholders in the workers’ compensation system have made progress in curbing the unnecessary use of opioids in recent years, it will take a concerted effort of educating providers as well as employees about chronic pain, and effective treatment alternatives said Iglesias and Pew.

 

Findings released by the Society for Internal Medicine on a one-year comparison of patients with chronic low back pain who were treated with either opioids or ibuprofen included:

 

  • No difference in function
  • Those given opioids had statistically worse pain control

 

Among the side effects of opioids are

 

  • Drowsiness
  • Confusion
  • Nausea
  • Constipation
  • Euphoria
  • Slowed Breathing

 

Because opioids repress the respiratory system, using them can result in hypoxia — a condition in which too little oxygen reaches the brain. It can lead to coma, permanent brain damage or death. The drugs can be especially dangerous when combined with other medications, such as benzodiazepines, certain antidepressants, some antibiotics, and sleeping pills.

 

 

Expectations

 

Even in the face of the research and statistics, many providers continue to look to opioids as the gold standard for pain management. One of the biggest problems is the mindset of western medicine and civilizations.

 

“There is an expectation in the U.S. that we shouldn’t feel pain, we are reducing the supply of opioids, but not limiting the demand,” Pew said. “There needs to be an effort in this country to educate people and change their minds about pain, so they realize opioids are not the answer” added Iglesias.

 

Eliminating all pain forever is just not realistic for many people. But they can — and do — learn to cope with their pain and live happy, normal, and functional lives.

 

 

Education

 

In addition to realigning expectations, education is key to reducing unnecessary opioid use. Many people may not be aware of the extent of the problem. “One-third of individuals that are taking an opioid do not know they are taking it,” Iglesias explained. “There needs to be more awareness in the population.”

 

Additional points stated include:

 

  1. Locus of control. Unlike in some other countries, many people in the U.S. have a passive acceptance of medical treatment and believe somebody or something should take care of the problem. Typically, many think a pill is the answer. However, drugs often mask the problem rather than addressing the root cause.
  2. Employers can take actions to improve the fitness levels of employees. Encouraging more walking, providing healthier foods in vending machines and making all programs free of charge are suggestions to get started.
  3. Self-advocacy. Injured workers and others should be encouraged to take charge and be responsible for their medical care.
  4. Reduce unrealistic expectations. Employers can work with medical providers to create and send a letter to injured workers outlining what to expect after an injury occurs. It can include suggestions on how to manage pain and some options.
  5. Sleep hygiene. Sleep is crucial for recovery from injuries. There are a variety of non-pharmacological recommendations to help people get more and better sleep.
  6. Education on dealing with depression can go a long way in helping injured workers cope with their pain and injuries. They should be encouraged to work with the Employee Assistance Program, if applicable, or given community resources that may be helpful.
  7. Behavioral techniques. Cognitive behavioral therapy (CBT) has been shown to be one of the most effective ways to help people cope with chronic pain. It is short term, skill-based, and typically does not incur a psychiatric diagnosis. Along with CBT, additional behavioral techniques include:
    • Mindful meditation.
    • Deep breathing skills.
    • Increased physical activity.
  8. Focus on function rather than pain. Focusing on pain only makes the level of pain increase. Discuss function rather than pain with an emphasis on progress.
    • Iglesias example “you told me you picked up the mail, last time we talked you weren’t able to get off the couch.”

 

Conclusion

 

The persistent opioid crisis has taken years to develop and will take a multifaceted effort to reduce and eliminate.  An improved focus by employers and payers on the education of opioid alternatives is a positive step toward better treatment and outcomes.

 

 

 

Michael Stack - AmaxxAuthor 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: https://blog.reduceyourworkerscomp.com/

 

©2018 Amaxx LLC. All rights reserved under International Copyright Law.

 

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

 

Is It Time to Explore Reducing Your Work Comp Costs with Telehealth?

Is It Time to Explore Reducing Your Work Comp Costs with Telehealth?Telehealth and telepresence are changing the way members of the claims management team, and other interested stakeholders are reducing workers’ compensation program costs.  By using this advancing technology, parties looking for better ways to provide effective healthcare can manage their bottom line and provide better outcomes for injured workers.

 

Telehealth is not a magic bullet solution; however, it can be an effective tool when used in accordance with workers’ comp management best practices and evidence-based medicine.

 

 

What are Telehealth and Telepresence?

 

Believe it or not, but the concept of “telehealth” is not new.  It has been around in some manner for over 40 years.  Recent enhancements in technology have only changed how it is viewed in the delivery of scarce healthcare resources.

 

  • Telehealth: Refers to the distribution of health care services and counseling via telecommunication technology that includes the use of telephone, computer or other transmission services. In the context of health delivery, it often refers to the long-distance patient/clinician care and counseling that includes reminders, education, intervention, monitoring and remote admissions.

 

  • Telepresence: Refers to the use of technology that allows a person to feel as if they are present via telerobotics, which includes the live interaction between persons in different locations. It adds the sense of two or more parties to feel as if they are in the same location.

 

 

A Case Study: Effective Use of Telehealth in Work Comp

 

There are many complaints about the delivery of healthcare and access to quality medical care and treatment following a work injury.  This includes traveling to appointments, waiting to be seen by a doctor and other prolonged delays.  It can also mean not having access to specialists who treat a variety of injuries, which may otherwise require long-distance travel and other miscellaneous expenses.

 

On average, an employee seen by a medical professional can spend over two hours of their time for each office visit. Multiply this by many encounters and one spends countless hours just traveling to and waiting to be seen by a doctor.

 

  • Lack of access to general practitioners and other healthcare The average employee spends about 90 minutes completing paperwork in the office, waiting and actually being seen by a healthcare provider;

 

  • Time wasted traveling to/from appointments and in the waiting room. The average employee spends about 40 minutes traveling for each appointment; and

 

  • Delays in receiving medical care and treatment from a specialist. These delays are hard to estimate, but it can be substantial.  Everyone can be frustrated.

 

Imagine the following scenario:  The employee sustains a work-related injury in a rural area.  Given the nature of their condition, they need to be seen by a specialist practicing in a far away metropolitan area.  While the employee will need to be seen in person initially by this physician, the cost of follow-up appointments can be time-consuming and costly.  On average, this could cost over $300 for the office visit alone.  Workers’ compensation programs may also be required to reimburse the employee for food, lodging, and medical mileage.

 

By using telehealth and telepresence technology, the employee can have a conversation with this far away health care provider from the comfort of their own home.  Instead of spending time traveling to appointments and waiting in an uncomfortable waiting room, that time can better be spent focusing on one’s recovery.  The 1.1 billion hours wasted traveling to and waiting for appointments can be reduced to an average visit time of 15 minutes, and a fee of about $105 – nearly a 64% savings to the workers’ compensation program.

 

The net results are significant:

 

  • Less travel and waiting times = less frustration

 

  • Reduces costs to a program = greater savings

 

Advances in technology and cybersecurity are also making the use of this innovative way to treat employees suffering from a workers’ compensation claim safely and securely.  This includes the protection of someone’s Protected Health Information. (PHI).

 

Conclusions

 

Interested stakeholders seeking to reduce workers’ compensation costs should become familiar with the benefits of telehealth and telepresence technology. When used in accordance with worker’ comp management best practices and evidence-based medicine it reduces costs to programs and the time employees spend waiting to see a health care provider.  It also can allow for injured workers to receive care with a variety of experts in far away locations in an effective manner.

 

 

Michael Stack - AmaxxAuthor 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: https://blog.reduceyourworkerscomp.com/

 

©2018 Amaxx LLC. All rights reserved under International Copyright Law.

 

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

Save Time & Money By NOT Using an Independent Medical Exam

Save Time & Money By NOT Using an Independent Medical ExamIn the course of claim and medical management in workers’ compensation, adjusters can and should take advantage of available clinical resources, if and when necessary.

 

The first line of assistance is generally provided by registered nurses who have prominent roles in utilization review and case management, the latter performed either telephonically, or in the ‘field’ in direct contact with claimants and treating physicians.

 

However, a resource that is often underutilized is physician expertise which can be provided in various ways. This article discusses the options and optimal avenues of physician review based on the circumstances and requirements of the request.

 

 

File (Peer) Review:

 

Physician review consists of a review of the medical records and is often supplemented with a telephone call between a reviewing and treating physician (peer-to-peer conference).

 

In this scenario, there is no contact (i.e., physical examination) between the peer reviewer and the claimant. All the information required for the decision is obtained via:

 

  • medical records
  • imaging reports
  • claim records
  • data obtained by the reviewer’s conversations, if any, with one or more treating physicians.

 

There should be an attempt to match the expertise of the reviewing physician with that of the treating physician, referred to as specialty-matching. This ensures that treating physicians cannot assert their cases have been evaluated by physicians with a lesser degree of training and experience than they possess.

 

Peer review physicians may be “medical directors” of payer organizations (carriers, TPAs, managed care companies,) but more commonly they are practicing physicians independently-contracted by these organizations to perform peer reviews.

 

It is important to credential all peer reviewers to ensure that they are board-certified, have active and unrestricted state licensure, and have no record of significant sanctions that would present a credibility obstacle if a determination were to be challenged. Many payers establish relationships with vendors providing national networks of credentialed peer review physicians in all specialties, and this may be a convenient and effective approach that eliminates the need of the payer to “build” a panel of reviewers from scratch.

 

 

When is a peer review appropriate?

 

  • Utilization Review

 

If a medical service subject to prior authorization is deemed questionable by an R.N., then peer review is required to make a final decision. Note that some states require the reviewing physician to be licensed in the jurisdiction where the claim occurs; most states do not have this requirement. This review process can also be applied to the review of non-formulary drugs.

 

  • Causation

 

Peer review physicians can be helpful in advising a claim adjuster as to whether an alleged injury or illness is occupationally-related, and therefore compensable.

 

  • Appropriateness of a Treatment Plan

 

When a claim adjuster or case manager is faced with a case that is not progressing well towards resolution, a peer review of the entire course of evaluation and treatment may yield suggestions for a reassessment of the diagnosis, and/or alternative therapeutic interventions that might be more successful.

 

  • Return-to-Work (RTW) Determinations

 

Reviewers can indicate whether, based on objective findings in the file or reported by a treating physician, a claimant is functionally able to RTW, either at full-duty or modified by specific restrictions or limitations. Reviewers may also be able to opine on the face-validity of impairment ratings assigned by treating physicians.

 

 

Independent Medical Examinations (IMEs):

 

IMEs entail a referral to a physician for a comprehensive physical examination and responses to specific questions posed by claim adjusters.

 

As with file reviewers, the right specialty should be selected for the exam, and the qualifications and standing of IME physicians must be established via a thorough credentialing process. Casual referrals to local physicians are often not the best approach; the use of vendors with established networks of IME physicians subject to careful quality control is recommended.

 

When is an IME appropriate?

 

  • IMEs are not useful for:
    • utilization review of services and drugs, except in a few exceptional circumstances.
    • causation determinations, or treatment planning, both of which are relatively easy to accomplish based on a review of medical files and current familiarity with evidence-based medical practice guidelines.

 

  • IMEs may be useful when a physical examination by the responding physician is important
    • determinations of maximum medical improvement (MMI) status;
    • definitive impairment ratings based on the impairment guide mandated in the jurisdiction of the claim.

 

  • IMEs will hold greater weight in litigated claims, particularly when an appearance at a state board hearing is scheduled or anticipated.

 

 

Peer Reviews Should be First Option

 

In general, peer reviews should be considered the first option for obtaining physician expertise, unless an IME is strongly indicated by the above criteria.

 

Speed

 

  • Peer reviews can be obtained very quickly. Depending on the nature of the review, decisions are typically available from the same-day up to 5 days from referral.
  • IMEs require advance scheduling, and usually reports are not available for 10-14 days. Therefore, the handling of a claim can be expedited via peer review.

 

Cost

 

Given the great cost disparity, a peer review is often a reasonable and cost-effective initial tool, even if one ultimately may need to resort to an IME.

 

  • From a cost perspective, peer reviews range in price from $75- $300, again varying based on the type of review.
  • IMEs, on the other hand, tend to range between $300-$2000, based on provider specialty and location, and the negotiating leverage that is applied.

 

Collaboration

 

In addition to access and cost factors, a peer review with a peer-to-peer conversation also has the advantage of facilitating a constructive and collegial dialog between the peer reviewer and the treating physician.

 

  • When the peer review is well-handled, one can often engage the treater as a partner in the effective management of a claim, rather than as an adversary, and this can result in timely recovery and resolution of the claim.
  • IMEs do not offer this opportunity for collaboration.

 

 

Jacob Lazarovic MD, Medical Advisor at Amaxx LLC, has considerable experience in managed care, including 18 years as chief medical officer at Broadspire , a leading TPA. His department produced clinical guidelines and criteria to support sound medical claim and case management practices; participated in analysis, reporting and benchmarking of outcomes and quality improvement initiatives; developed educational and training programs that updated the clinical knowledge and skills of claim professionals and nurses; provided expertise to enhances the medical bill review process; and operated a comprehensive and unique in-house physician review (peer review) service. He has been published extensively in industry journals and has held several senior medical management positions at companies including HealthAmerica, Blue Cross/Blue Shield of Florida and Vivra Specialty Partners

A Winning Approach in Workers’ Compensation

Article originally published in On the Frontline Magazine

 

A winning approach to workers' compensation

An injury or illness arising out of one’s work can be costly. For claimants and their employers, a complete recovery and return to work, as quickly as possible, are ideal, but how do we ensure this happens? The answer lies in medical management programs.

 

Historically, the longer a workers’ compensation or employers’ liability claim remains open, the greater its expense. As occupational health care costs rise, employers and health care payers want to contain expenses.

 

“Medical management programs enable early engagement on a claim and a faster return to work, which is good for both the employer and the employee. It’s a win-win for everybody,” says Danielle Lisenbey, president and chief executive officer of Broadspire, a Crawford company.

 

In medical management, the aim is to get the patient on the right track. This involves a combination of the right price, care coordination and optimizing outcomes. Broadspire also encourages employers to have a return-to-work plan in place, with senior management support, and clear responsibilities for the injured worker and employer.

 

“Medical management is not about securing the cheapest care; it’s about securing the most appropriate care,” said Jim Andrews, executive vice president of prescription benefit management services at Healthcare Solutions, an Optum company. The company, which provides data and care management services to Broadspire, focuses on improving care coordination, which ultimately produces better outcomes at less cost.

 

“Care coordination is a problem, especially in workers’ compensation. If you can coordinate care in a workers’ compensation claim, you can reduce the redundancy of services,” he says. “It’s a win for the employer because they get the injured workers back to work sooner.”

 

In workers’ compensation claims especially, medical management is an effective way to contain costs. “The medical component is becoming the dominant factor in a workers comp claim,” explains Paul Braun, managing director at Aon Risk Solutions. “From a concentration standpoint, it used to be that about 70% of the claim was for indemnity, and 30% was for medical. Now, it’s almost reversed.”

 

There has been a significant rise in medical costs over the past decade. Currently, U.S. healthcare spending is on track to hit $10,000 per person or $3.207 trillion in total in 2015, according to a Forbes report. “With the rise in medical costs, there has been a greater focus and need for medical management in all aspects of claims,” says Lisenbey.

 

“Claimants often are confronted with a lot of different information, from their doctors as well as employers,” she continues. “We help them understand what’s going on with their case, we engage them at the family level and help them understand what questions to ask in order to get the right care.”

 

 

 

Joining the Dots

 

Medical management services also deliver advanced analytics to employers, Lisenbey notes. Broadspire uses e-triage, a detailed interview process that captures claimant information including co-morbidities that might not be observable. “For example, the e-triage process might reveal that a claimant has a smoking habit, and medical evidence shows that smokers take longer to heal from injuries,” she explains.

 

That kind of data can help in applying different strategies to further improve the outcome. Similarly, provider analytics enable employers to maximize their physician networks by comparing factors such as durations and costs related to services the physicians provide.

 

Another tool that Broadspire utilizes is the ‘virtual peer’, a composite of data points that enables comparisons of employers’ experiences and claims trends, even among organizations in different industries. Data that is helping produce better outcomes also involves prescription drugs – one of the fastest-growing components of medical claim costs.

 

Danielle Lisenbey, President and CEO, Broadspire®

 

“Our data is available in almost real time, which means it becomes available for analysis in near real time,” says Healthcare Solutions’ Andrews. “Paper-based medical bills take much longer to receive and analyze. Although data analysis on prescriptions can quickly show trends, “it doesn’t always mean that you can do something about it immediately.”

 

Worrisome drug-related trends in workers’ compensation include: physician dispensing, increasing use of compound pharmaceuticals and use of narcotics to relieve pain. “With narcotics and opioids, it’s important to manage those from an injury and recovery standpoint. You need to offer other services to help people with intractable pain. You can’t just say no to the drugs without offering something else, or coordinating care with the primary physician,” says Andrews.

 

 

Modern Day Nursing

 

Broadspire’s senior nurse reviewer (SNR) program has also driven significant savings since its launch in 2005. It reviews cases and determines an appropriate medical management intervention, with periodic review until a favorable outcome is reached. Among its benefits are: an average reduction in claim payments exceeding 10%, improved closure rates, and reduced litigation rates.

 

“In workers’ compensation, a cost-saving factor is a return-to-work program,” Aon Risk Solutions’ Braun says. “Return to work is critical, and getting someone like a nurse case manager to assist and support that model is very important.”

 

In the UK, Broadspire provides medical management services that help employers and claimants navigate the single-payer National Health Service. “The NHS is the first port of call for anyone who’s injured, and hospital and point-of-service medical treatment is covered,” says Deborah Edwards, head of rehabilitation at Broadspire.

 

“As patients progress through the NHS, the rehabilitation and recovery process becomes patchier,” she continues. “If someone is out of work, they might be waiting six months for surgery in the NHS that could be performed in a week if privately paid. We juggle those services with the goal of rapid return to work.”

 

 

 

Danielle Lisenbey became chief executive officer of Broadspire in 2012. Immediately prior to this role, she was chief operating officer for Medical Services, responsible for the operation of all of Broadspire’s medical and case management services. In this position, she drove the continued development and delivery of products and services that have generated cost containment results typically 10 to 15 percent better than those produced by other TPAs and medical management companies.

 

During her tenure as chief operating officer, many new service offerings were developed, including: the BOLD® Network, a unique, state-stratified, multi-tiered approach to a preferred provider organization (PPO) strategy; a durable medical equipment (DME) formulary that applies the cost management principles of a pharmacy formulary to medical equipment; and a new chronic pain protocol, a multidisciplinary approach to addressing the complex chronic pain conditions that drive the duration of workers compensation and disability claims.

 

 

Beware of Vocational Rehabilitation Costs

What is Vocational Rehabilitation?

 

Early workers’ compensation laws did not include vocational rehabilitation benefits.  The purpose of adding these benefits was to rehabilitate someone suffering from a work injury and return them to the labor market with an economic status as close as possible to that the employee would have enjoyed without the disability or injury.

 

 

Rehabilitation Eligibility and Initial Consultations

 

The guidelines for vocational rehabilitation vary in each jurisdiction.  The majority rule does allow for injured employees to receive vocational rehabilitation benefits if they are not able to return to their pre-injury employment without residual disability or work restrictions.  Additional threshold issues include possible affirmative defenses the employer and insurer may assert.

 

Once an employee is determined to be eligible for vocational rehabilitation services, one would undergo a consultation.  The purpose of this discussion performed by a vocational expert includes:

 

  • Understanding the employee’s injury and need for future medical care and treatment;

 

  • Discussion regarding work restrictions related to the employee’s condition(s); and

 

  • Develop a rehabilitation plan to return the employee to work.

 

Proactive members of the claims management team need to review all claims from the onset to determine issues of eligibility for rehabilitation services.  This review should never be limited to the physical limitations of an employee.  It is important to pay attention to issues concerning compensability, which include:

 

  • Notice and statute of limitations;

 

  • Intoxication;

 

  • Prohibited Acts;

 

  • Self-inflicted injuries; and

 

  • Whether the injury arose out of and within the course of employment.

 

 

Development of Rehabilitation Plans

 

Following the rehabilitation consultation, a vocational expert will prepare a rehabilitation plan for the injured worker.  Issues addressed in this Plan include:

 

  • Whether the employee will be permanently precluded or likely to be permanently precluded from engaging in their usual and customary occupation;

 

  • Whether the employee is reasonably expected to return to suitable gainful employment with the date-of-injury employer, or another employer; and

 

  • What additional rehabilitation services the employee may require. These services can include such things as physical reconditioning, job search assistance and the possibility of retraining.

 

It is important for claims handlers to remain engaged following the issuances of a rehabilitation plan.  This plan includes the monitoring of ongoing rehabilitation services and keeping in contact with the qualified rehabilitation consultant (QRC) working with the employee.  Failure to do so can result in prolonged disability and excessive or unnecessary charges related to vocational rehabilitation services.

 

 

Moving Injured Workers Back to Work

 

The goal of every rehabilitation plan should be returning the employee to suitable gainful employment.  Tools to accomplish this goal include:

 

  • Disability Status Reports: These are required reports QRCs are required to file with the industrial commission and all parties on a regular basis.  It is important to monitor and scrutinize these reports.  Claim handlers should demand progress in moving issues concerning job search and related re-employment activities forward.  If consistent progress is not seen, one should consider having the employee undergo an independent vocational evaluation (IVE).

 

  • On the Job Training Plans: Many jurisdictions allow vocational experts to use these plans to develop transferable job skills.  A defined plan should include information on a desired position for the employee, skills the employee will acquire through this training, tools, and supplies needed to accomplish the plan’s objectives and an expected average weekly wage upon completion.

 

  • Written Job Offers: This is an opportunity to encourage re-employment by the date of injury employer when one feels the employee is ready to return to work.  Examples of a well-written job offer details the position being offered, length and frequency of activities to complete a task and wages the employee will receive.

 

 

Conclusions

 

Proactive members of the claims management team need to understand vocational rehabilitation benefits and how it impacts a claim.  This understanding includes being fully engaged and seeking opportunities to return the employee to work effectively.

 

 

 

Michael Stack - AmaxxAuthor 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 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: https://blog.reduceyourworkerscomp.com/

 

©2018 Amaxx LLC. All rights reserved under International Copyright Law.

 

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

How Evidence Based Medicine & Clinical Guidelines Impact Workers’ Comp

Evidence-based medicine (EBM) is the conscientious, explicit, and judicious use of current best scientific evidence in making decisions about the care of individual patients.

 

 

Hierarchy of Scientific Evidence

 

While we would like to think that scientific evidence has always been the basis of modern medical practice, over the last few decades there has been an exponential improvement in research study design and rigorous data analytics such that clinicians and administrators have been the beneficiaries of increasingly valid and actionable study results and conclusions.

 

With respect to study design, this is often depicted as a hierarchical pyramid in which, for example, single case reports are at the lowest tier and are the least persuasive, whereas randomized, blinded, controlled studies (RCTs) and systematic reviews/meta-analyses are at the peak of the pyramid, and constitute the “gold standard” of research methodology. So we have moved from a reliance on small, uncontrolled studies to large-scale (and often geographically widespread) studies in which matched patient populations are prospectively given one treatment or another  (or no treatment at all in the form of a placebo or sham procedure) and outcomes are measured over many years.

 

Furthermore, the results of multiple RCTs may be aggregated to produce sophisticated meta-analyses which have greater statistical power than any single RCT in isolation.

 

 

Critical Evaluation by Expert Panel

 

However, the process does not end there. There next needs to be a sifting and critical evaluation of the evidence produced through a myriad of studies on any single topic. This is the task of specially-constituted expert panels of physicians. These editorial advisory boards,(assembled by various clinical specialty societies, medical universities, government entities, medical publishers, and similar organizations), translate the research described above into treatment guidelines to be applied by medical practitioners in the course of clinical care. Of course, these same guidelines are equally useful for those evaluating the medical necessity and appropriateness of treatment being proposed or delivered by physicians, and also helpful for any other interested stakeholder in the medical management arena.

 

Let’s illustrate this using a procedure (one which I fabricated) called electromagnetic plasma fusion, or EPF, which is being promoted for various soft tissue injuries. The advisory panel (likely consisting of orthopedists, physiatrists, occupational medicine physicians, Ph.D. statisticians, etc.) gathers and reviews all the available research evidence about EPF, eliminating studies from the bottom of the pyramid, and placing greater weight on studies at its apex. After considerable discussion and the use of group consensus techniques, the panel may decide that EPF has not met the threshold to be deemed a scientifically beneficial technology, and it will publish a guideline with a “not recommended” determination, and its rationale for this decision.

 

On the other hand, the panel may feel that EPF has a place in the toolbox of treatment for certain conditions, and it will produce a clinical guideline that documents under what circumstances it should be offered, e.g. which patients may benefit; when to use it in addition to, or in place of, alternative therapies; how frequently it should be used, etc. All of this may be summarized in a graphical algorithm for ease of use by clinicians.

 

 

Free Resource for Published Guidelines

 

There are now thousands of published guidelines from many sources on multiple topics, and many are publicly available at the National Guideline Clearinghouse site:

 

 

 

Evidence-Based Medicine Guidelines for Workers’ Compensation

 

Particular sets of national guidelines have been uniquely developed for the workers’ compensation/disability market.

 

  • Treatment guidelines encompass best practice treatment for all musculoskeletal conditions, as well as other common conditions encountered as occupational injuries and illnesses
  • Duration guidelines include the expected and optimal return-to-work durations post-injury.
  • Drug guidelines (formularies) typically consist of all common classifications of drugs including opioids, muscle relaxants, anti-depressants, etc., and will indicate which drugs are, and are not recommended for use.

 

The guidelines below are available electronically via paid subscriptions.

 

  • ACOEM guidelines: produced by the American College of Occupational and Environmental Medicine, and distributed through MDGuidlines/Reed Group.
  • ODG (Official Disability Guidelines): produced by the Work Loss Data Institute.

 

Studies confirm that the use of clinical/duration guidelines results in measurable impact:

 

  • Medical cost-savings of 25%-60% (by state, payer, TPA, and health plan)
  • Average disability duration down 34%-66%, median duration down 30%

 

It should be noted that many states endorse or mandate specific guidelines to be used for formal utilization review and related medical management purposes, and typically either ACOEM or ODG have been selected by these states’ regulatory bodies. However, several states have developed their own sets of guidelines, which are freely available on state websites. Finally, some states are entirely silent on the subject of guideline selection. Consequently, it is important that guideline users be aware of the relevant regulations state-by-state, i.e. claim adjusters, utilization review and case management nurses, and physician reviewers.

 

 

Summary

 

  • Evidence-based medicine is based on high quality, peer-reviewed research.
  • Expert panels translate scientific data into applicable guidelines and update them regularly.
  • Clinical AND duration guidelines should be integrated into WC medical management to the greatest extent possible

 

 

Jacob Lazarovic MD, Medical Advisor at Amaxx LLC, has considerable experience in managed care, including 18 years as chief medical officer at Broadspire , a leading TPA. His department produced clinical guidelines and criteria to support sound medical claim and case management practices; participated in analysis, reporting and benchmarking of outcomes and quality improvement initiatives; developed educational and training programs that updated the clinical knowledge and skills of claim professionals and nurses; provided expertise to enhances the medical bill review process; and operated a comprehensive and unique in-house physician review (peer review) service. He has been published extensively in industry journals and has held several senior medical management positions at companies including HealthAmerica, Blue Cross/Blue Shield of Florida and Vivra Specialty Partners

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