Reduce Overall Costs of Work Comp Claims With “Direct to Specialist” Approach

Would a “Direct to Specialist” orthopaedic approach significantly reduce the overall cost of workers’ compensation claims in comparison to the managed care approach?

 

We are all aware that the factors which rapidly increase the costs of workers’ compensation claims are: Time off Work, Delayed Treatment of Injuries and Prolonged Medical Care. While an early return to work program is imperative to reducing disability costs of a claim (10%-15%). What about the medical and surgical costs?  

 

I believe that providing the highest quality of care and the most cost effective approach to reduce the cost of claims is through the “Direct to Specialist” approach.

 

Pre-employment physicals, drug testing, safety and risk management are prominent aspects of a company’s occupational health program. However, the most costly aspects are injuries, with most of them being orthopaedic in nature.  This includes acute injuries and chronic conditions as well.

 

 

What does it take?

 

Implementation of the Full Spectrum of On-Site Services: Orthopaedic Immediate Care, Occupational Health Services, Case Management, Physical and Occupational Therapy, ancillary services such as X-Ray, MRI, Ultrasound, EMG, as well as an Orthopaedic Ambulatory Surgery Center.

 

Will a “Direct to Specialist” approach reduce Time off Work, Delayed Treatment of Injuries and Prolonged Medical Care when these services are in one location and are managed under the direct supervision of Orthopaedic Specialists? YES

 

Orthopaedic Immediate Care means that employees are seen by Orthopaedic Specialists immediately after an injury occurs. Definitive care is provided immediately, whether that individual needs physical/occupational therapy, fracture care, laceration repair or surgery.

 

The fallacy is that referring directly to a specialist will increase the costs of claims. However, this is falsely based upon the incorrect reasoning that referral to an Orthopaedic Surgeon means that the patient will have surgical treatment as the first option.  All patients are treated with conservative measures at the outset and surgery only considered if non-operative measures fail to resolve the condition.  This of course excludes acute injuries which may require immediate surgical care.

 

In fact Atcheson, et. al. demonstrated as much as a 63% percent decrease in the cost of claims when patients were referred directly to specialists for their workers’ compensation injuries.  This was true even when specialists were paid at rates higher than for occupational health providers and primary care physicians.

 

 

Why?

 

One major difference they found is that the timeline of conservative treatment will be managed appropriately and not extended beyond a reasonable time period for resolution of a patient’s condition before surgery is considered. Furthermore, therapy will not be instituted when it is shown that injections alone are the mainstay of conservative management before surgery becomes necessary.  These two measures alone reduce substantially the costs of claims by eliminating unnecessary occupation and physical therapy prior to surgical reconstruction. Furthermore what is also not considered is the effect of prolonging painful conditions before definitive treatment is instituted? This only serves to prolong the post-operative course, as well as, increasing the amount of post-operative occupational/physical therapy which is required to return an employee to full active duty.  This increases both the medical and TTD costs exponentially.

 

 

Managed Care approach: (Example)

 

An employee who sustains a wrist fracture on a Thursday is sent to the urgent care clinic/emergency room (1-3hrs waiting) and is given a splint. They are then referred to see an orthopaedic specialist, perhaps unable to get an appointment until Tuesday or Wednesday, 5-6 days after the incident. The orthopaedic surgeon will need to re-take the x-rays to ensure that no fracture displacement has occurred since initial injury. At this point a cast will be applied if appropriate or the patient will be scheduled for surgery at the next block time day the surgeon operates. This can add from 1-5 additional days before definitive care is given. We are now approximately 6-12 days from the occurrence of the injury and your employee is out of work and is experiencing pain and yet to have definitive treatment. Is this the best way to manage and reduce your TTD and Medical costs?

 

 

“Direct to Specialist” approach:

 

An employee who experiences a wrist fracture on a Thursday, is now sent directly to the orthopedic specialist for immediate evaluation. X-rays are taken, a diagnosis is made and a plan of care implemented at the initial visit. A cast is applied if appropriate and the employee is sent back to work modified duty SAME DAY OR NEXT DAY.  Surgery, if required, is performed the SAME DAY OR NEXT DAY next day at an on-site Orthopaedic Ambulatory Surgery Center which costs 30-40% less than hospital facility fees.

 

 

Managed Care approach VS “Direct to Specialist” approach? You do the math

 

With a “Direct to Specialist “ approach no longer would an employee need to utilize costly emergency room services, urgent care centers or traditional occupational medicine clinics only to be stabilized and then triaged to the specialist for definitive care for an acute injury.  Furthermore, this would eliminate the repeating of much conservative management after initial orthopaedic referral for a chronic condition or in many cases eliminate altogether unnecessary physical and occupation therapy which is often prescribed for conditions for which corticosteroid injection therapy alone is the mainstay of conservative treatment such as Dequervain’s tenosynovitis.

Furthermore, the “Direct to Specialist” model will not only serve to improve employee morale following their injury, as they will see their direct referral to a specialist as concern on the part of their employer to ensure they obtain the highest quality medical and surgical care for their injury. This combined with an Orthopaedic practice with a strong return to work policy, and employer who institutes a restricted duty policy and you can see where the cost savings on a claim can be substantial.  This does not even factor into the equation that your employee is less likely to obtain legal representation when their impression is that their employer cares for their wellbeing.

As an employer, you have many aspects to your business. You must provide for the health and safety of your employees, reduce the ancillary costs of conducting business through aggressive risk management while maintaining growth and profitability. Reducing the costs of your workers’ compensation claims is an important component of your risk management program.

 

 

Author: David Adam, Work Comp Director/Practice Developer, MidAmerica Orthopaedics. David brings over 15 years of experience in business management and development to MidAmerica Orthopaedics. David develops relationships with surrounding businesses and communicates services that are available and beneficial to reduce business costs as it relates to workers compensation. He strives to educate, train, and mentor internal staff and fellow businesses on the benefits of a “Direct to Specialist” approach, adequate Return to Work and Occupational Health Programs.

 

 

Is Your Doctor Just What The Doctor Ordered?

You are undressed standing in a small room with your backside showing. You have a pain in your back and any moment someone is going to walk through the door. This isn’t a scene from a horror film, this occurs every day in doctors’ offices around the country.

 

We place an incredible amount of trust in doctors. They see us at our most vulnerable and we depend on them to make it all better. It is completely against everything we have been taught about this relationship to think that your doctor’s motives may not be 100% altruistic.

 

The reality is that doctors are running a business just like everyone else. The more care you receive, the higher their fees. In a world where consumers will sue at the drop of a hat, it is easy to see why a doctor would order a diagnostic test that could be considered reasonable, but not necessary.

 

I do not fully fault the doctors’; the system is set up just like the temptation challenges on the Biggest Loser. Sometimes the chocolate chip cheesecake with whip cream topping just looks too good to pass up. It is, however, extremely important realize that not all doctors are created equal.

 

 

Successful Outcomes Come From Successful Relationships

 

Like most things in life, successful outcomes come from successful relationships. As an employer, one of the requirements to controlling your workers compensation outcomes is to be proactive in building physician relationships. Here a simple idea to get you started:

 

• Visit or call doctors’ offices in your area to find out if they accept workers compensation and understand the reporting requirements. Are they looking for more business, or are they happy with what they have?

 

Once you have a few viable options, here are some considerations to finalize your selection(s):

 

Your company physician should:

 

1) Be responsive to your employees’ needs and be willing to return them to work as soon as possible.

2) Schedule your employees’ appointments immediately, without delay, and be flexible in scheduling.

3) Review your job descriptions and use your forms for transitional duty accommodations.

4) Provide a written release when the employee is ready to return to work, detailing any applicable medical restrictions.

5) Exhibit a caring attitude and pleasant manner.

6) Possess outstanding medical credentials, with an excellent reputation in the community.

 

 

Doctor Selection Varies By State

 

It is also important to be aware that doctor selection is regulated by state workers compensation statues. There are many variations of how providers are selected based in each state, but the three basic methods are a follows:

 

1) The employee selects the doctor

2) The employer selects the doctor

3) A blend of methods where the employee selects from a panel of doctors provided by the employer.

 

Clearly if the employer can direct the care of injured workers, it is easy to have your employees participate in your physician relationship. However, even in states where the employer cannot direct care, employees will often agree to see the company doctor if the doctor has a good reputation, is conveniently located, and deals fairly with people.

 

Trust your doctor. However, trust them because you have gotten to know them and appreciate their business practice, not just because they are wearing a white coat.

 

 

Author Michael B. Stack, CPA, Principal, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com.  Contact: mstack@reduceyourworkerscomp.com.

 

©2014 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

 

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

 

How To Win Friends And Influence Your Treating Doctors

In the insurance profession, claims adjusters will see the same physicians over and over again. But instead of working with them for a common goal, they tend to view the treating doctor as the enemy.

 

To medically defend a claim you have to obtain a medical opinion from another physician that goes against the diagnosis and causal relation statement of the treating physician. Adjusters know the IME doctors that they like to use in certain scenarios, depending on the injury and whatever goal they are attempting to attain.

 

 

Catch More Bees With Honey – Work To Develop Relationship With Treating Doctor

 

But oftentimes they fail to create a good relationship with the treating doctors that they see nearly every day. These could be occupational clinic doctors, specialty doctors, and surgeons. Even when a claim is compensable, the adjuster is going to spend a lot of time dealing with the office of the treating doctor, but fail to really talk to the doctor over the phone.

 

Every treating doctor has their own style of treatment, and some are more thorough than others. Adjusters will send faxed letters over to the treating doctor asking them to address certain questions. If they do not get the outcome they expected, they spend the rest of the file with a chip on their shoulder.

 

This situation can be avoided by picking up the phone, or better yet, going to the office. Ask to speak with the office manager and see if that person will give you a tour of the office and to introduce you to the treating doctors. Explain your role and the common patients you have had. I would be surprised if they refused to show you around.

 

If the tour is successful, later on try to schedule a time to meet with a few of the doctors before or after their clinic hours. You may be surprised to find out that they know who you are as well!

 

The goal of this is to open the lines of communication. Talk to them about what your role is. Some treating docs have not had the best experiences with work comp adjusters, and they come in guarded with their own attitudes. Once you get the defense wall down, you may find out how willing they can be to help you in cases you have in common.

 

You may also find out that you have more information than what was shared with the doctor from the patient directly. You can help the doctor connect the dots between job descriptions, injury descriptions, return to work light duty programs, and so on. If the doctors knows that you are open and approachable, you may be able to better handle the file rather than jumping to an IME and incurring the additional costs.

 

 

If Having Trouble, Get A Referral From Nurse Case Manager

 

If you are striking out in getting access to a treating doctor’s office, try to use a nurse case manager. The Nurse Case Manager has a lot of face to face time with the treating doctor. If the Nurse Case Manager has a good relationship with the treating and they help refer you in, you have a good chance at being able to sit down and discuss your difficult case as a team.

The goal is to work with the treating doctors, so the battle lines are not drawn in the sand from the start. You will be seeing this doctor’s name many times throughout the course of a year.

 

The claimant has a certain amount of trust placed in to their treating doctors. Once you order and Independent Medical Evaluation, the claimant only sees that IME appointment as “The work comp doctor”. When the IME differs from the treater’s perspective, the claimant is quick to file a lawsuit.

 

 

Personal Relations Skills Can Go A Long Way

 

So try to go to the treating doctor first and clarify the opinion if there is a question or issue. Make sure they have all of the details and that they know as much about the injury as you do. You always have the IME in your back pocket if you need to use it, but you can save some litigation headaches if you can get that treater on your side to help the defense of your file. Also, it never hurts to bring them a coffee when you go for your discussion.

 

Even if you cannot visit the clinic in-person, a phone call can go a long way to show them that the file has your attention. Plus you want to be sure that they have all of the information regarding the injury that you do. One little detail can change the compensability of the case, even from the treating doctor’s view.

 

 

 

Author Michael B. Stack, CPA, Principal, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com.  Contact: mstack@reduceyourworkerscomp.com.

 

©2014 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

 

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

Nurse Case Managers are Well Worth the Cost

Are most carriers taking advantage of using nurse case managers to help move claims along to facilitate closure?

 

I think it is safe to say some are, and some are not. Usually adjusters are told to use case management only on the severe high-exposure cases. These being major spine surgeries, multiple fracture injuries, and cases with multiple surgeries and different medical care needs to be implemented and coordinated.

 

But what about average surgical lost-time work comp cases? Carpal tunnel, a knee surgery, a bicep tear. Typically the adjuster is left to handles these claims themselves. They will use their diary system as their fallback so they can monitor what is going on medically with the claim.

 

But that is also the problem. If you have a lot of cases with the majority of them being cases involving lost time either surgical or not, then how are you being proactive in bringing the claimant back to work and back to full duty? Just monitoring the claim as it goes from doctor appointment to doctor appointment is not being very proactive. I understand that sometimes that’s what you have to do, but you have options.

 

 

 

Nurse Case Manager Brings Communication and Medical Expertise to Doctor Appointments

 

When you have a high caseload, you cannot be everywhere at once. This is where the nurse case manager comes in handy. The nurse can be your eyes and ears at the doctor appointments. They update you the day of the appointment after it is completed. IF you are just waiting for medical records, it can take weeks. Plus, chances are the nurse will be talking to the claimant more than you are, and can tip you off to potential red flags to recovery long before you spot them in medical records.

 

A nurse case manager can also help you to prevent a file from slipping through the cracks. Even the best adjuster has missed a file every now and then. These misses can be very costly, especially when wage loss is concerned. A nurse will keep you up to date, and will be more reliable than using just your diary system.

 

They also have the time to work the case from a medical standpoint. They talk with the doctor, and can help in claims where a pre-existing condition is also present around the compensable work injury. The hardest issue in these cases is separating the 2 conditions, and the case manager can help the doctor focus on the work injury while brushing aside the non-occupational condition.

 

 

Nurse Case Manager Can Assist With Referrals, Reserves, Medical Plan of Action

 

Nurses can also help to provide DME equipment quicker, and coordinate any other vendor activity you need done. If you need an Independent Medical Opinion, the nurse may know the perfect doctor for your case. They can also copy the medical records, send them to the IME doctor, draft the cover letter, attend the appointment, and talk with the doctor afterwards to get questions answered. As an adjuster, it would take you a good chunk of time to do that yourself. Plus the nurse will update you right after the appointment instead of waiting days to get the actual IME report.

 

Reserving can also be assisted by a nurse on the file. The nurse may have a better handle on medical costs, barriers to recovery, prescription costs, and the outlook to a favorable Maximum Medical Improvement projection.

 

Carriers may have the mindset that an onsite nurse is not cost effective on normal lost time comp cases, but I think this is where they come in the most handy. By being there for the adjuster, it allows the adjuster to focus attention on the more troublesome cases.

 

 

Adjuster is More Efficient With Expertise of Nurse Case Manager

 

If you have an accepted claim with a surgery, why not let the nurse run with it and let the adjuster be updated by the nurse? It takes time to place medical records requests, coordinate doctor appointments, and come up with a medical plan of action. The nurse knows how to do all of this. For what they charge, it is cost effective since it frees the adjuster up to handle more important tasks.

 

Several adjusters that I know have a great network of nurses, and trust their opinions. But they only use them when a severe case comes around. Try using the nurse case manager on normal lost time cases. You will find out that not only is it cost-effective, but it makes the adjuster more efficient at moving cases on to closure. It is all about efficiency these days, and anything that can make an adjuster more efficient should be seen as a positive.

 

 

Author Michael B. Stack, CPA, Principal, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com.  Contact: mstack@reduceyourworkerscomp.com.

 

©2014 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

 

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

Get Your Employees Immediate Medical Attention With Injury Triage

Employers frequently dread the filing of a new workers’ compensation claim. The time investigating the claim, the paperwork and the time rearranging the work scheduling to cover for the person who has been injured are hassles most employers prefer to avoid. The fear factor and dread is even worse for injured employees. They are concerned about having to deal with the insurance adjuster and how they will be able to support themselves and their families if they are unable to work.

 

 

Early Medical Attention Alleviates Employee Fears and Lowers Costs

 

Among the employees’ fears are concerns about the quality of the medical care, the frequency of their medical appointments, will they need specialists’ care, and how long the medical care will last. By providing medical attention for injuries from the moment they happen, employers can alleviate a lot of their employees’ fears and concerns while minimizing the overall cost.

 

 

Triage Nurse Evaluates Injury and Recommends Appropriate Care

 

If the injured employee’s injury does not create an emergency situation, the injured employee calls a toll free nurse access number. The nurse access number is staffed by triage nurses on a 24 hour/7 day a week basis. The nurse who answers the call (frequently referred to as a triage nurse) will be compassionate and supportive. The triage nurse evaluates the medical needs of the injured employee and recommends the employee to the appropriate level of care, whether it is a walk-in clinic, first aid on the job site, providing home-care instructions, or an emergency care facility. Costly emergency room visits and medical clinic visits are avoided when they are not needed.

 

The triage nurse provides immediate medical assistance when injured employees need it. Employees are normally appreciative of the fact that the triage nurse took immediate action to assist them to obtain quality medical care when he/she needed it. This is a definite morale booster and shows employees that their employer cares about their wellbeing.

 

 

Immediate Quality Medical Care With Injury Triage Has Multiple Benefits

 

Immediate quality care arranged by the triage nurse benefits the employer in several ways including:

 

• The chance of the adversarial relationship that sometimes develops between the employee and the employer over a workers’ compensation claim is greatly diminished as the employee knows he/she is getting prompt, quality care.

• The time the employee is off work is diminished as the employee goes immediately to the appropriate level of care.

• The recovery outcome is improved as the injured employee is treated by the most appropriate medical provider

• The fear factor that often leads employees to hire an attorney is greatly diminished.

 

 

Not All Triage Is Created Equal

 

It is important to note that not all Injury Triage companies are created equal. As injury triage has become a more popular strategy to contain workers compensation costs, more service providers have come into the market. Curtis Smith, Executive Vice President at Medcor stated “Injury triage results vary a lot between service providers, just as performance varies between TPAs, case managers, and other providers in the workers comp world. The best results come from dedicated systems and well-trained staff operating in an environment free from conflicts of interest.”

 

We strongly recommend early medical management with injury triage on every workers’ compensation claim. If you need more information on arranging early medical management for your company, please contact us.

 

 

Author Michael B. Stack, CPA, Principal, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com.  Contact: mstack@reduceyourworkerscomp.com.

 

©2014 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

 

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

Proper Management of Utilization Reviews by Nurse Case Managers

Utilization review (UR) is a medical management technique to verify medical care is appropriate, adequate and necessary for the treatment of a workers’ compensation injury. Normally, the UR is conducted by a highly experience registered nurse (RN). When the RN does not agree with the medical care being recommended or provided, a physician will review the medical information to verify that a denial of the medical care is appropriate.

 

 

Pre-Certification Review

 

There are three basic types of Utilization Review – pre-certification reviews, concurrent reviews and retrospective reviews. Pre-certification reviews are the type of Utilization Review most employers think of when they hear the term UR. In a pre-certification review, the RN obtains the medical information on the employee’s injury including the symptoms, the diagnosis, any diagnostic testing results and the medical provider’s reason for requesting the specific medical care. The medical information is compared with the normal criteria for treatment of the employee’s specific injury and an approval or denial decision is made.

 

 

Concurrent Review

 

With a concurrent review, the Utilization Review occurs while the injured employee is receiving medical care. Concurrent reviews occur while an employee is still hospitalized or is having a series of medical treatments over a period of time. The same information gathered for a pre-certification review is obtained for the concurrent review. Concurrent reviews frequently shorten the period of time the employee is in the hospital or the time the employee receives repetitive treatments like physical therapy or acupuncture.

 

 

Retrospective Review

 

Retrospective reviews occur after the medical treatment has been provided. The RN will gather all the necessary medical information and make a determination as to whether or not the medical treatment already provided was actually necessary.

 

 

Utilization Review Quality Control Criteria

 

When the employer accesses the claim management system to review the adjuster’s file notes and the nurse case manager’s file notes, there are certain aspects of the Utilization Review that should be documented by either the nurse case manager or the UR nurse. The quality control criteria should reflect the following being completed in regards to Utilization Review:

 

• Receipt of the Utilization Review request is documented the same day it is received

 

• The Utilization Review request was given to the UR nurse within a time frame that allows for accurate review of the medical information to determine medical necessity (of course there will be exceptions for when a rush UR is needed, but a rush UR should be the exception, not the normal practice)

 

• Logging or a tracking diary is established to ensure the Utilization Review is completed within 3 days for pre-certification reviews and concurrent reviews, and within 7 days for retrospective reviews

 

• All necessary medical information has been provided to the Utilization Review nurse with the UR nurse having access to information on the diagnosis, prior medical procedures, prior medical opinions, diagnostic testing, comorbidities, etc.

 

• Consideration is given to the Official Disability Guidelines for the employee’s injury type

 

• If the Utilization Review nurse determines the medical care under review is not necessary, the UR nurse has obtained a concurring opinion from a physician advisor who reviews all the medical information and the UR nurse’s reasons for denial

 

• The recommendation of the physician advisor is documented by the Utilization Review nurse

 

• If there is a recommendation of denial of the medical care, the medical provider has been given the opportunity to review the reasons for denial of the medical care and is allowed to provide any additional information the medical provider believes would justify a reversal of the decision to deny the care

 

• If the medical procedure has been denied, a letter explaining the reasoning for the denial of the medical care is provided to the employee, the medical provider and the adjuster

 

• If the medical treatment is approved by the UR nurse, the medical provider and the adjuster are notified timely of the Utilization Review determination

 

 

Proper procedures by the Utilization Review nurse are the norm, not the exception, as UR nurses know any deviations from established UR procedures can result in costly mistakes. However, it is still a good practice for the employer to review the UR process documented in the claims management system, especially any time the employer has a question about the necessity of an expensive medical procedure.

 

 

 

Author Michael B. Stack, CPA, Principal, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher. www.reduceyourworkerscomp.com. Contact: mstack@reduceyourworkerscomp.com.

 

©2013 Amaxx Risk Solutions, Inc. 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 about workers comp issues.

Obtaining the Best Possible Independent Medical Examination

An independent medical examination (IME) [also known as an independent medical evaluation in some jurisdictions] is one of the best tools available to the employer or the adjuster in confirming the nature and extent of an employee’s workers’ compensation injury. The IME can be used to verify compensability, to confirm a diagnosis, to evaluate the appropriateness of the current medical treatment, to establish the need for future medical treatment, and to assess the amount of permanent impairment when the employee has reached maximum medical improvement.

 

 

IME is Best Way to Verify Accuracy of Diagnosis

 

In jurisdictions where the employee selects the medical provider it is often difficult to know if the extent of the employee’s injury is as severe as claimed, especially if the employee has been treating with a “claimant friendly” doctor selected by the employee’s attorney. An IME is the best way to verify the accuracy of the diagnosis and the necessity of the current medical treatment regime. IMEs can also be used in states where the employer controlled the selection of the doctor if there is any reason to believe the medical treatment is off track or the impairment rating is incorrect.

 

When the adjuster or employer determines there is a need for an IME, the selection of the IME doctor should be undertaken with care. Adjusters and employers sometimes fall into the trap of thinking ‘the employee hired a radical doctor who is over treating and gives enormous impairment ratings, therefore I have to hire a doctor who is overly conservative and sends everybody back to work immediately with no impairment rating.’ There are two problems with this approach:

 

1. It defeats the purpose of the IME – to know the true extent of the employee’s injury, to know the future medical treatment needed, and/or the actual level of permanent impairment the employee will have.

 

2. The plaintiff attorneys, defense attorneys and the work comp Board know the reputations of the doctors as well and will discount any opinion from a doctor with known bias.

 

 

Own Experience or Doctor Specialty Good Ways to Select IME Doctor

 

Frequently adjusters and nurse case managers will know from experience which doctors will perform an objective IME, and will select the IME doctor based on prior experience. When the employer or adjuster does not know which doctor they should call on for an IME, they can often consult with the nurse case managers they use or with defense counsel.

 

If prior experience or other resources are not available, you can still obtain a good IME. To properly select a doctor for an IME, the adjuster or employer needs to knows not only a doctor’s specialty (for example: orthopedics), but also the doctor’s sub-specialty needs to be known (for example: knees). A copy of the doctor’s curriculum vitae, board certifications, lectures and publications can be utilized to establish the doctor’s expertise in his sub-specialty.

 

 

Provide IME Doctor With Proper Documentation

 

When the IME doctor has been selected and an appointment for the IME has been set, the adjuster or employer needs to timely provide to the IME doctor all the information available to assist the doctor in preparing for the IME. This would include:

 

• All medical reports related to the injury medical treatment, in chronological order

 

• All medical records of any pre-existing condition whether a comorbidity or a prior injury that has affected the medical treatment

 

• All treatment notes from physical therapy, acupuncturists, chiropractors, etc.

 

• All MRI, CT, x-ray or other diagnostic test results

 

• A copy of the employee’s recorded statement

 

• A copy of the First Report of Injury

 

• A copy of all surveillance tapes and reports

 

The documentation should be provided to the IME doctor with plenty of time for the doctor to review all the documentation prior to the IME.

 

A cover letter should be sent to the IME doctor when the above documents are provided to the doctor. In the cover letter, the adjuster or employer should ask questions to address the reason the IME was requested. The questions posed to the IME doctor should include:

 

• What is the nature of the employee’s injury?

 

• Is the injury:

 

o A new injury?

 

o An aggravation of a pre-existing injury?

 

o A reoccurrence of a prior injury?

 

o Not an injury, but some other medical problem?

 

• If an injury, was the injury a result of the described work accident?

 

• If an injury, is the opinion that the injury is work related based on the history provided by the employee, or is there objective medical evidence to support or to confirm the cause of the injury?

 

• Was the medical treatment of the injury reasonable and necessary?

 

• Has the employee recovered from the injury?

 

• If the employee has not recovered from the injury, what is the recommended course of future medical treatment?

 

• If the employee is at maximum medical improvement, will there be any level of permanent partial disability?

 

• If there is a level of permanent partial disability, what is the impairment rating?

 

• What restrictions, if any, will the employee have upon returning to work?

 

After the IME is completed; the doctor will write an IME report outlining the doctor’s findings. The IME report should be reviewed and compared with the medical reports from the employee’s doctor. Based on the findings of the IME doctor, the adjuster or employer can better determine the future activity needed on the worker’s compensation claim to move the claim forward to a conclusion.

 

 

 

Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact:RShafer@ReduceYourWorkersComp.com.

 

Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher. www.reduceyourworkerscomp.com. Contact: mstack@reduceyourworkerscomp.com.

 

©2013 Amaxx Risk Solutions, Inc. 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 about workers comp issues.

Maximize the Productivity of Your Injured Worker’s Medical Visits

These are some thoughts from a doctor’s perspective on how to make your employees’ medical visits more productive.

 

Establish a cooperative relationship beforehand. It is essential that your medical advisor is available to call the injured employee’s treating physician. This is a step that must be set up in advance so the medical advisor is very responsive and can take quick action when an injury occurs.

 

Have the Medical Advisor contact the treating physician prior to the exam. 

The medical advisor can let the treating physician know that the injured employee is coming and ask the doctor to call the medical advisor back after the exam. The medical advisor may ask specific medical questions, such as asking that the exam be conducted so that it helps distinguish a work-related injury from a non-work related injury. This may make the treating physician take a more careful history and be more aware of getting the person back to work. Of course, the medical advisor must have a signed medical release from the injured employee before contacting the treating physician.

 

The medical advisor can suggest something outside of the routine. Depending on the type of injury, the advisor might suggest a particular Waddell test if symptom magnification is suspected. “Waddell’s signs” are used to judge pain and injury behavior. Giving background such as letting the doctor know the worker is unhappy with the job situation can be helpful.

 

Treating Doctors should give medical restrictions.

The company then decides if they can accommodate the physical restrictions so that the employee can return to work. It is helpful to let the doctor know a company can accommodate nearly all restrictions.

 

Ask them to not give just “off duty” as a medical restriction.

If the doctor is contemplating taking someone off work, have them give specific medical restrictions unless the worker is bedridden. The restrictions should be as detailed as possible about what the injured worker can and cannot do, such as lifting, carrying, walking, standing and sitting. The doctor should keep in mind that a worker may not even know the company can make accommodations or that there is a transitional duty program. Ask the doctor specifically what accommodations could be made to allow the employee to return to work. The doctor may not have even considered that an employee who is restricted from driving may telecommute or that an ergonomic workstation may help an injured employee with back pain perform a transitional job.

 

Once there are medical restrictions, it is then up to the workplace to decide if they want to make those accommodations and how they will make them.

However, be aware that refusing to make “reasonable accommodations” may open up the employer to a discrimination lawsuit under the Americans with Disabilities Act (ADA). The Employer Assistance and Resource Network (EARN), a free service funded by the U.S. Department of Labor’s Office of Disability Employment Policy (ODEP) can help answer these questions.

 

Make sure the physical restriction form is easy to complete.  

It is easier to fill out a simple form with check boxes or items to circle that nearly all doctors are familiar with such as: “Lifting: heavy/ medium/ light”, “pushing or pulling”, sitting and standing time durations and a space for the doctor to write in any additional comments. Ask the doctor to complete your Work Ability Form.

 

The medical advisor or employer should request a Functional Capacity Evaluation (FCE). This is a physical examination assessing a person’s capacity for physical exertion and range of motion activities. Sometimes, FCEs are done by physical therapy operations, which is also a good option. The treating physician orders the FCE.

 

Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact:RShafer@ReduceYourWorkersComp.com.

Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher. www.reduceyourworkerscomp.com. Contact: mstack@reduceyourworkerscomp.com.

©2013 Amaxx Risk Solutions, Inc. 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 about workers comp issues.

The Dumbest Doctor In Med School Is Still “Dr.”

I never went to medical school. I do not have the luxury of putting cool stuff before and after my name. I’m just a person, like everyone else. However I happen to be a person that knows a lot about medical stuff. Not the fancy technical side of medicine involving neurons and parts of the brain but the “Real” side. This comes from job experience. It comes from watching injured people in insurance claims go through tons of medical procedures that failed. It comes from listening to people cry to me on the phone about how worried they are because it has been a year and they still have a lot of issues and they don’t know how they are going to get back to work. I never say that I have heard it all, but boy have I heard a lot over the years.

 

 

Our System Is Broken

 

This result is because our system is broken.

 

The only people that really win are the 3rd party outside vendors that provide a closed period service. They are in and out, cash their check, and move on to the next one.

 

The injured work doesn’t win in the long run. They are post-operative numerous surgeries that later on will cripple them in the golden years of their life.

 

Employers lose money on increased insurance premiums, loss of productivity, and strain on existing workforce to cover those out of work on injury.

 

 

Positive Doctor Outlook

 

So where do we place the doctor in all of this? Do they win as a 3rd party outside vendor, or do they lose because they maybe failed to get a patient back to how they once were? The doctors are unable to put humpty dumpty back together again. They just jammed the pieces back in and went to catch their 2p.m. tee time at the country club.

 

At least this is possibly your perception. Sure, the doctors have financial gain by treating those injured in insurance scenarios. Insurance carriers pay—not well, but they pay their bills. They usually pay them fast. Carriers deal with a lot of injury claims too, so there is incentive to please the Carrier and show them how great you are as a doctor. Maybe they will feed more patients your way, if you are in a State where you can direct care. This is a win-win scenario.

 

 

Negative Doctor Outlook

 

Or perhaps it is the other way. Doctors think that Carriers just ignore these poor injured people. People who get jerked around from insurance hack doc to insurance hack doc until one gives them the diagnosis they want. Then the carrier cuts benefits and litigates the file, only to settle for 33% of the real value. Carriers hate to pay bills unless they want to, so you constantly have to fight with them on reconsiderations, hearings over unpaid bills, on so on. If you are the treating doctor and the case goes to litigation, their Legal Counsel deposes you for hours, trying to find a crack until they finally do, then they try to destroy your credibility in the insurance community by labeling you a “Plaintiff doctor.”

 

 

Injured Worker Point of View

 

Let’s look at it from the injured worker’s point of view. They are in pain, and the work doctor told them to just take an Advil. They tried to go to their Primary care doctor and that doc wouldn’t touch them, since you stated you were injured at work and she “Doesn’t want to get involved in that headache again.” So you start to doctor shop around. Your neighbor sends you to a guy that is real good. He listens and has good office hours, but he doesn’t really prescribe you much to help with the pain. This doc suggests a pain management clinic, and all of the sudden you have lots of help with pain, including multiple narcotic medications, injections, procedures, diagnostics, ablations, and so on. Now you don’t even care what goes on, as long as your pain medicines continue to be paid for. Surprise, you are now almost a full-blown addict because not only have you been on massive amounts of narcotics but you also have been taking more and more of them, since the normal doses do not give you enough “help” anymore.

 

Everyone shrug your shoulders if you want, but all of these above views are out there. We have probably handled, seen, or heard of this happening. So who is to blame here? Where can we point the finger, and how can we start to repair this breakdown between adjuster, doctor, and claimant?

 

 

The Most Blame Can Be Pointed Toward The Doctor

 

In my opinion, all parties are to blame. But for me there is more blame to be pointed towards the doctor. The doctor has the most power in the scenario. They are directing care, prescribing medication, and they are in charge of overall care. The facts and studies are out there. Narcotic pain meds are prescribed more now than ever. Billing standards, frequency of care, and treatment modalities change when an insurance claim is present. I recall reading a statistic that an early MRI associated with acute back pain increased the likelihood of surgery by 8 times. That’s an eight-fold increase in the likelihood of surgery! Plus remember that most of these diagnostic tests are not needed, and in fact most patients do not possess any of the red-flag symptoms associated with the need for surgery.

 

We all know that once surgery is performed, the likelihood of return to work becomes less and less. As the months and years go by, what was a simple acute back strain has morphed into a full blown claim disaster. Let’s face it; the life of that injured worker is over. In those States where you cannot direct care, any attempts to thwart surgical intervention fail miserably. Claims adjusters go into disaster mode, and prepare themselves (And the reserves) for a lifetime claim.

 

For whatever reason, these doctors do not properly inform these patients of the ramifications of surgery, both immediate and long-term. It seems like they do not want to upset or cause conflict with the patient. I would love to see where in medical school does it state that the patient is always right, and you as the physician should just do whatever they want done?

 

The answer to this question lies in the title of this article. It is good food for thought to remember that the doctor that finished in last in their class at medical school still has the same title as the doctor that finished first.

 

My normal Disclaimer—not all doctors are bad, not all that finished last in school are bad, and not all claims with surgical intervention have this outcome.

 

Author Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher. www.reduceyourworkerscomp.com. Contact: mstack@reduceyourworkerscomp.com.

 

©2013 Amaxx Risk Solutions, Inc. 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 about workers comp issues.

What Are The Duties & Responsibilities of a Medical Director?

 

“In-house” doctors are company doctors who treat employees at the workplace. Companies may have an in-house clinic staffed by a nurse, nurse practitioner, physician’s assistant and/or a physician. This is typical for companies with many employees at one location.

 

Onsite occupational health clinics offer employers an effective way to direct medical care. Properly implemented, these clinics improve health outcomes and convenience for employees and reduce costs for employers. On-site clinicians can treat work-related injuries the moment they occur – early intervention at its best.

 

Clinicians become familiar with the work environment and policies so they can support safety, workers compensation and return to work programs.

 

Following evidence-based protocols, the majority of injuries can be appropriately treated on site, reducing the use of expensive off-site providers and the frequency of claims. On-site clinic staff manages referrals to off-site specialists when necessary, ensuring the right level of care. On-site clinics can add significant additional value by supporting OSHA reporting, drug testing, surveillance programs (such as hearing conservation and respiratory protection), new hire exams and other occupational health services.

 

 

What Is a Medical Director?

 

The medical director is a doctor who has extensive knowledge and experience in the evaluation of medical conditions and the implementation of appropriate medical care. The medical director will act as a consultant and adviser. The medical director can provide in depth medical reviews and collaborate with the treating physician on the best course of medical care for the employee.

 

Your medical director, medical department or consultant is a key resource to help interpret medical jargon accompanying work-related injuries or illnesses. Medical personnel can help you determine the extent of work-related injuries and design transitional duty jobs to get injured employees back to work.

 

Some companies retain a part-time medical director to talk doctor-to-doctor with treating providers, review medical records for alternative causation, and intervene in the independent medical evaluation (IME) process. The IME is one of the few points in the workers’ comp process where the outcome can be influenced. Thirty percent of IMEs are unnecessary or untimely.

 

 

Duties of the Medical Director

 

  • Identify the appropriate contact person to discuss worker injuries and workers’ compensation at your facility. Usually the appropriate person will be the workers’ compensation manager (injury coordinator) or middle manager.

 

  • Visit company facilities at least once per year.

 

  • Observe and document the physical requirements for all jobs to determine which have the potential to become transitional duty positions.

 

  • Assess the company’s transitional duty program positions.

 

  • Telephone treating medical providers BEFORE they prescribe time out of work for an injured employee, to discuss the possibility of transitional duty assignments.

 

  • Review injured employee’s file to ensure the necessary documentation is completed. If not, talk to the injury coordinator, who should obtain the documentation.

 

  • Work closely with your injury coordinator to resolve those work-related incidents requiring medical attention or lost time.

 

  • Coordinate with injury coordinator and employees’ treating physician to develop transitional duty job descriptions accommodating physical limitations of injured employees.

 

  • Define and document the boundaries of your role as in-house medical director to ensure delineation between medical director activities and adjuster activities.

 

  • Determine what medical privacy regulations are relevant to avoid potential violations. Have the medical director make sure medical records are complete prior to requesting an IME. Most adjusters assume medical records regarding a pre-existing injury are irrelevant as related to a workers’ comp injury. However, it is relevant when the claimant’s acute injury resolves but an underlying degenerative process is still progressing.

 

  • Write independent medical evaluation (IME) cover letters summarizing key information and asking requisite questions concerning the work-relatedness of the injury. A standard cover letter is very general, not highlighting crucial information or asking specific medical questions. In some states, the employer is allowed only one IME every six months. Don’t waste this opportunity to get a complete medical opinion based on all relevant information.

 

  • Review use of all nurse case management to make sure the service is needed and is brought in timely. Often nurse case management is brought in too early or too late.

 

 

Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact:RShafer@ReduceYourWorkersComp.com.
Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher. www.reduceyourworkerscomp.com. Contact: mstack@reduceyourworkerscomp.com.

 

©2013 Amaxx Risk Solutions, Inc. 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 about workers comp issues.

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