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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.

How On-Site Medical Clinics Curb Fast-Rising Costs of Medical Care in Workers Comp

 

On-Site Clinics Decrease Costs

 

Many medium and large employers in their never-ending battle to reduce cost and to provide benefits to their employees are opting for on-site medical clinics.  On-site medical clinics can decrease the cost of general health benefits programs and decrease the cost of medical care associated with workers’ compensation claims.  On-site medical clinics have proven they can curb the fast-rising cost of medical care for both personal and work-related injuries and illnesses.

 

Some employers are hiring clinicians themselves, and others are using contracted providers who also provide software, protocols and other tools to support the clinicians.

 

 

Medical Care Provided at Work Site, Convenient & Effective Treatment

 

With the on-site clinic, the medical care is provided at the work site, which is convenient for employees who otherwise would have to leave work for care.  Injuries and illnesses are evaluated by the clinic staff; many cases can be treated on site.  Employees are referred to off-site medical facilities only if the injury or illness is beyond the scope of the medical professionals in the on-site clinic.

 

On-site clinics often use a variety of staffing models, including RNs, nurse practitioners, and physician assistants – with physician collaboration and direction as needed.  Depending on the employer’s needs, on-site clinics can be staffed with a doctor.  When properly managed, on-site medical practitioners can provide high quality medical care while reducing overall costs.  They can also provide other health services such as wellness, and regulatory exams, etc. On-site clinics can include x-ray machines and pharmacy services, though costs and state regulations affect the feasibility of those services.  Good providers of on-site medical clinics will tailor the services provided to the employer’s needs.

 

 

Benefits to Employees

 

The benefits to the employee injured on the job include:

 

  • Medical services available when the typical doctor’s office is closed – evenings, weekends and holidays

 

  • No appointment is necessary

 

  • Immediate medical care following an injury

 

In addition to the workers’ compensation benefits, the employee also enjoys easy access to medical care, assistance with chronic medical problems and healthy living guidance.

 

 

Benefits to Employers

 

The benefits to the employer of the injured worker include:

 

  • Evaluate and treat employee injuries immediately

 

  • Avoids unnecessary and off-site medical treatment

 

  • Referral to appropriate and screened preferred medical providers when off-site care is needed

 

  • Improved outcomes and faster return to work, increasing productivity

 

  • Assist in keeping all workers healthy and productive

 

  • Reduces absenteeism

 

  • Significantly lower cost for medical services for workers’ compensation claims

 

  • Can provide physicals

 

  • Drug screening

 

  • Improved general health of employees

 

  • Improved employee morale

 

  • Increases employee retention

 

  • Can coordinate pharmacy usage with your Pharmacy Benefits Manager

 

  • Timely reporting of the injury and medical information to relevant parties.

 

  • The First Report of Injury form is completed and filed with both the state and claims office.

 

 

Treat Workers Comp and Health Care

 

On the workers’ compensation side, the on-site clinics can treat lacerations, strains, sprains, other minor orthopedic injuries, abscess drainage, minor skin infections and other routine acute medical conditions.  On the health care side, the on-site clinics can treat the whole gamut of minor medical conditions that causes employees to lose time from work including strep throats, colds, ear and eye infections, skin lesion removal and vaccinations.

 

 

 

Clinics Used For Any Site with 1,000+ Employees

 

On-site clinics are not just for industrial sites like factories, and mines or large office centers.  On-site clinics can be operated for just about any industry where there are 1,000 or more employees in one location.  Mobile and temporary clinics are used  for large construction projects such asskyscrapers, power plants, and highways.  All clinics need to be equipped with the necessary furniture, supplies, equipment, and medications.

 

The cost of drug testing for both employee applicants and existing employees can be significantly reduced by using an on-site clinic.  Drug testing due to reasonable suspicion, random testing and post-accident screening can be completed by the on-site clinic.  In many states the timely completion of a post-accident drug testing can be used to deny workers’ compensation benefits to employees under the influence of a drug at the time of their injury.  A positive drug test result can be sent to a certified lab for further confirmation.

 

 

Be Sure to Select Quality On-Site Medical Provider

 

When an employer is selecting the on-site medical provider, select a medical provider who provides an on-going review of the quality of service they are providing.  The service quality can be evaluated by patient reviews and comments, by clinic audits and by staff performance evaluations.

 

On-site clinics do carry costs and risks as well.  To be successful, the staff needs to be trained for on-site work, and be supported with appropriate software, operating systems, supplies, medical direction, protocols, QA, and other infrastructure.  The medical practice needs to carry malpractice insurance coverings the employer and be compliant with HIPAA, GINA, HITECH and other privacy regulations.  In addition, some on-site providers may introduce conflicts of interest if they are financially tied to the off-site hospitals, clinics and pharmacies that  they refer to.

 

For further information about on-site clinics, please contact us.

 

 

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

 


WORKERS COMP MANAGEMENT MANUAL:  www.WCManual.com

VIEW SAMPLES PAGES

MODIFIED DUTY CALCULATOR:  www.LowerWC.com/transitional-duty-cost-calculator.php

 

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

 

©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.

 

How to Manage Independent Medical Examinations to Control Costs

 

Independent Medical Examinations (IME) [also known as Independent Medical Evaluations in some jurisdictions] is a major tool used by workers compensation adjusters and defense attorneys to control medical treatment cost. An IME is the utilization of a medical specialist to examine the employee, to review the employee’s medical history, to provide a diagnosis, and to provide a prognosis. The medical specialist will give an unbiased opinion as to the nature and extent of the employee’s injury. An IME will establish the true level of the employee’s disability and permanency level. This makes the IME an important method of controlling medical treatment cost as well as a way to limit unnecessary lost time.
 
 
The states vary in the number and type of IMEs that can be had. In some jurisdictions, the employer/insurer is limited to one IME throughout the entire course of the claim. In other jurisdictions, the employer/insurer can have as many IMEs as they are willing to pay for. With an IME costing $500 to $1500 depending on the location and the specialty, the employer or insurer does not want to waste money having needless IMEs performed. [WCx]
 
 
The IME doctor will need all the available information on the medical condition of the employee. The IME doctor needs to be provided all medical reports from prior medical providers, all diagnostic testing results (MRIs, CT scans, EMG studies, x-rays, etc.), a complete job description of the employee’s duties including all physical requirements, and the employer’s first report of injury stating exactly how the employee was injured. If the employee has aggravated a preexisting condition, all medical records for treatment of the preexisting condition should be obtained prior to the IME and provided to the IME doctor.
 
 
The adjuster, employer, or defense attorney requesting the IME should draft a letter to the IME doctor stating the concerns about the employee’s medical situation, and outlining the medical questions that need to be answered. The letter should be kept objective, clear, and to the point, as in some jurisdictions it can become a part of the evidence in the claim.
 
 
The various industrial commissions, workers compensation boards, departments of labor, and bureaus give different levels of credence to the opinion of the IME. In some jurisdictions the opinions expressed in the IME hold equal weight with the medical opinion of the primary treating physician.  Other jurisdictions consider the IME but normally give greater credence to the primary treating physician, as the primary medical provider has normally seen the employee many more times than the IME doctor has.
 
 
Overcoming the bias of the commission / board / labor department / bureau requires the selection of a highly skilled and well respected doctor. Many adjusters (and employers on self-insured programs) make the mistake of using the same conservative doctor over and over for every IME. The opinions of these well qualified, conservative doctors, while often are accurate, are discounted by the hearing official because the hearing official knows the reputation of both the plaintiff attorney’s favorite doctors as well as the reputation of the adjuster’s/employer’s favorite doctor.
 
 
To be successful in the use of IME, the employer or adjuster should select a doctor in the appropriate specialty that has a reputation for telling it exactly the way it is. The hearing official will pay closer attention to the medical opinions of the doctors known to be unbiased.
 
 
As an employer, if the reputation of the possible IME doctors is not known, ask an experienced workers compensation defense attorney who has attended hundreds of hearings for IME doctor recommendations. Stress to the defense attorney that you are not looking for the most conservative doctor around, but for the doctor that has the reputation for being the most objective.
 
 
Of course, there are exceptions to the rule on finding the most objective IME doctor. In some jurisdictions like Georgia and New York, the administrative official hearing a contested disability rating will normally split the difference between the disability rating the claimant has been given by his chosen doctor and the disability rating given by the employer’s IME doctor. In those situations, where it is assumed the employee’s doctor will be providing a high rating and the IME doctor will be providing a lower rating, the use of a conservative IME is the better approach. Therefore, it is very beneficial to know how the system works in your state. (See our state by state guide for Laws and Regulations Here.)
 
 
After the IME, if there are still questions about the employee’s medical condition that have not been answered, it can be beneficial to follow-up with the IME doctor and ask those questions. Also, the IME doctor may be able to direct you to research on the particular medical condition of the employee that can be used at the administrative hearing.[WCx]
 
 
In order for the IME to be used as evidence in the claim, you must share it with the employee and/or employee’s attorney. Consult with your defense attorney as to the best time to share the IME information.
 
See also our Insurance Dictionary of Terms and Abbreviations Here

 

 

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 at Amaxx Risk Solutions, Inc. is an expert in employer communication systems and a part of the Amaxx team helping companies successfully reduce Workers Compensation Costs by 20% – 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com   Contact:mstack@reduceyourworkerscomp.com

 



WORKERS COMP MANAGEMENT MANUAL:  www.WCManual.com

VIEW SAMPLES PAGES

MODIFIED DUTY CALCULATOR:  www.LowerWC.com/transitional-duty-cost-calculator.php

 

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

 

©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.

How to Handle the Worst News in Company History

 

There are fire extinguishers in case a fire starts. We hope one never does, yet the fire extinguishers are kept in good working order and hung in many appropriate places. As well, we keep first aid items available in case of injuries, and we hope we never put them to use.  This is proper planning. At its base is the most elementary of risk management processes. It is on this premise that I write this article. [WCx]
 
 
Today I want to take a short walk with you into the possible outcomes of having employees work in most any environment. Take, for example the office, a very low risk workplace, but none the less there is that potential for serious injury or even a fatality.  I will leave this to you, the reader, to add to this any other potentially increased risk that may occur at a particular place of employment.
 
 
Have you thought about what would happen in the event you, the owner, or CEO, ever gets that dreaded call? The call no one ever wants to hear.  It is from your site or plant foreman and the person can barely get out the words. There is a  worker or workers severely injured or killed at the worksite or plant.
 
 
WHAT DO YOU DO RIGHT NOW? The next actions taken may well mean the very survival of a company decades in the making. As well, with current case law regulatory requirements and court precedents, there may as well be criminal charges at hand.  Am I being theatrical? NO, Unfortunately I deal with just these events several times a year and have seen things go from bad to worse just for the lack of proper action being taken in the beginning.
 
 
What you do, how you do it, and how you respond to those around you is critical at this point. What words you choose and the actions you take at this critical time can make all the difference.  It is difficult to use an example here. Literally thousands of variables exist due to business type and the individual details that would make any real or example based case just a story. [WCx]
 
 
The point is your firm is unique and the situation will be as well. I can offer no checklist other than the basics.
 
 
This is where planning and forethought to your exposures is critical. Every owner or CEO should have a plan that has been thought out before hand and reinforced down the lines of responsibility. Just like the annual fire extinguisher or emergency drill, there has to be a plan. A well conceived plan that is communicated and reinforced with all down line supervisors and management often.  If I were to give you a scenario of an event at a competitor’s firm and ask you what they would need to do (or not do) in the event of a serious situation, you could do a relatively decent job with the details.
 
 
However, this is YOUR firm, it involves YOUR employees. The injured or killed are possibly your close friends or even a family member in the case of many firms.
 
 
 As well as having frank talks with all front line management, you also must have a relationship with a labor law firm and consultant that you can call to action with a single phone call. You likely will be in shock at this time and prone to distracting emotions in a situation that is critical.  For this reason the first action in the plan should be to call the labor law firm with whom there is a prearranged relationship. The firm can handle, and you can refer, any questions requiring immediate answers to them.
 
 
Most likely media will be on site right behind the emergency responders. As part of the action plan the law firm will assist in creating an initial statement that can be drilled into the supervisors and employees. All must be instructed on what to say. A standard that works is: “We have encountered a tragedy, details are not yet available, and I will get with you as soon as I have any answers Nothing more.  Your labor law firm, due to your individual circumstances, may have something different in mind. If so, rely on them.
 
 
Non-management employees must also be given rules. All must understand that company policy is quite strict concerning the importance that they do not say anything to the media. This must be included in your initial new hire training, written in company policy, and reinforced regularly
 
 
I do hope this information will convince all senior management to initiate this kind of planning into your existing emergency procedures. The time to prepare is before you get that call no one wants to get. I do hope that your plan remains just that a plan. [WCx]
 
 
A few reminders:
 
  • Gather senior management and discuss what kinds of incidents your industry is vulnerable to.
     
  • Prepare a written policy for serious incidents.
     
  • Communicate and train all senior management.
     
  • Notify all non-management employees that they are not authorized to speak with media after an event.
     
  • Retain a labor law firm to assist and review procedures.
     
  • If there is an incident, immediately call on the law firm to direct you through any incident. Follow the instructions, remember emotions will be high. A trusted advisor is chosen. Listen to them at this time.
 
Also see our article on Immediate Injury Response for further information.  
 
 
Brian Hill is owner of OshaSure in Birmingham Alabama and has over 20 years as a workplace safety and risk consultant. Brian was previously a pilot for a major US airline and member of the company’s interdepartmental safety committee. He found his new career in safety after the closing of the airline in 1991. Brian has found the same passion he had for flying in assisting companies with safety, heath and risk issues.
For more information click on www.oshasure.com

 


WORKERS COMP MANAGEMENT MANUAL:  www.WCManual.com
MODIFIED DUTY CALCULATOR:  www.LowerWC.com/transitional-duty-cost-calculator.php

 

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

 

©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.

Valuable Techniques to Control Medical Costs

Employers who let the injured employees control their own medical care have higher workers compensation medical costs then the employers who are actively involved in the medical care of the injured workers.  There are numerous techniques an employer can use to properly control and direct the medical care provided to injured employees.

 

The states are about even divided between states where employers select the medical provider(s) and the states where the employee chooses the medical provider. Some states even try to give both the employer and the employee a voice in the selection of the medical providers by the use of doctor panels.  In the states that use a doctor panel, the employer selects a group of doctors, and the employee then selects a doctor from the employer’s group of doctors (panel).

 

The first action an employer should take is to identify the reputable, conservative doctors in their area.  Both the nurse case management team and the defense counsel can provide you with valuable information on which doctors you can trust, and which doctor’s rely on referrals from plaintiff attorneys for their income.  Start with having defense counsel provide you with a list of recommended emergency clinics, general practice doctors and orthopedics, then have the nurse case management team cull the list to remove any doctors that are difficult to get along with and/or keep the employees off longer than necessary.   Defense counsel can also tell you if you are in one of the few states that allow absolutely no input by the employer in the selection of the medical provider.

 

 

There are additional important considerations in determining the doctor that should be considered.  You want the doctor(s) to be and do the following.

  •       responsive to the employee’s medical needs
  •      spend the necessary time with the injured employees
  •         have flexibility in scheduling appointments for the employees
  •      review the job descriptions in order to provide light duty work as soon as feasible
  •      have a professional and pleasant manner

 

Post the list of preferred medical providers on the bulletin board for everyone to see.  (Some states require a particular format or poster design for the posting of workers comp doctors; check the specific state requirements for formatting the list of medical providers).  In the states where the employer has the right to designate the medical provider or is required to post a panel of doctors, the list should be titled “Required Medical Provider(s)”.   In the states where the employee selects the medical provider the list should be title “Recommended Medical Providers”. Some networks have exceptional doctors noted, so if these doctors are available consider including them in the panel.  [WCx]

 

 

Establish rapport and dialogue with the medical providers (they will be glad you do as it makes their jobs easier) before the injuries occur.  The medical providers will remember you, as way too many employers have no interaction at all with them.  The medical providers will understand that you care about the general welfare of the employees and you care about getting the employees back to work.  When you show an interest in the employee’s medical care several positive things occur including.

 

  •      medical reports are provided to you timely
  •      you gain cooperation with the return-to-work program
  •       phone calls are returned
  •      any forms or documents you need completed get done

 

There are many other steps the employer should take to control and direct the medical care of injured workers. The new 2012 edition of Manage Workers Compensation Program, Reduced Costs 20-50% has an entire chapter on directing medical care.  The book includes both Ten Considerations for Your Company Doctor and Eleven Reasons NOT to Select a Doctor.  Please contact us for your copy.

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 website 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, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.comContact: RShafer@ReduceYourWorkersComp.com.

 

Our WORKERS COMP BOOK:  www.WCManual.com

 

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SUBSCRIBE:  Workers Comp Resource Center Newsletter

 

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

 

©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact info@reduceyourworkerscomp.com

 

Post-Accident Response Steps to Ensure Win-Win for Employer & Employee

The actions of the employer in the minutes after an injury accident occurs can have a major impact on the overall outcome of the workers compensation claim.  The proper actions and following the proper procedures in the post-accident response will have a definite impact on the overall outcome of the claim.

 

Unfortunately, the standard post-accident response is to drive the injured employee to the doctor and to send in the claim report to the insurance company or third party claims administrator.  If that is the total response to an injury, you can expect to have more than your share of negative outcomes. (WCxKit)

 

 

The proper management of the post-accident response entails having a defined role and established procedures for the employee, the employee’s supervisor and the workers compensation coordinator to follow in every claim.  The training of the staff on the steps they should take is important to a post-accident response.

 

 

The role of each person and the procedures they follow should be in a written format to ensure uniformity in the application and effectiveness.  A standardized response will result in better-cost containment and maintain a higher level of employee appreciation for the immediate post-accident response.

 

 

Prior to the accident occurring, the employer should be prepared with all the appropriate forms.  In addition to the First Report of Injury form used in your state, the employer should have the following documents.

 

  • An employee brochure “What to Do If You Are Injured on the Job”
  • Employee Report of Accident
  • Supervisor Report of Accident
  • Witness Report Form
  • Work Ability Form
  • Transitional Assignment Form

 

 

Each of these forms will assist in gathering the necessary information for the claims adjuster to make the appropriate determination of the compensability of the claim, and for the employee supervisor or workers comp coordinator to arrange for the employee to return to work.

 

 

When an accident does happen, the supervisor should not look around to see which other employee can drive the injured employee to the doctor.  The supervisor should accompany the employee to the pre-selected medical provider.  The supervisor should then provide the employee with the Work Ability Form to give to the doctor. The Work Ability Form provides the format for the doctor to convey the employee’s work restrictions.

 

 

The employee returns the Work Ability Form to the supervisor.  The supervisor reviews the Work Ability Form to see if the employee can return to her/his regular job and it allows the supervisor to comply with any work restrictions the medical provider has given to the injured employee. This ensures the employer understands the job restrictions and allows the employer to arrange for the appropriate transitional duty job.

 

 

In the case of a severe injury where the employee cannot return to work on a modified duty job, the Work Ability Form should be faxed to the workers compensation coordinator.  The workers comp coordinator can review the injury restrictions with the nurse case manager to learn the approximate length of time the injured employee will be totally unable to perform work.  It will allow the workers comp coordinator to know about when to expect the injured employee to be able to start a transitional duty job.

 

 

If the injured employee is unable to return to work either full duty or in a transitional duty job, the supervisor or the workers comp coordinator should keep in touch with the employee.  This will allow you to know the medical progress the employee is making, it will keep the employee feeling connected to the company, and it will allow for the proper transition to a modified duty job. (WCxKit)

 

 

This has been a very brief overview of proper post-accident response.  To obtain the appropriate forms for a post-accident response, please contact us. You can learn more about the proper post-injury response procedure in our new 2012 edition of Manage Your Workers Compensation Program, Reduce Cost 20-50%.

 

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 website 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, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.comContact: RShafer@ReduceYourWorkersComp.com.

 

 

Our WORKERS COMP BOOK:  www.WCManual.com

 

WORK COMP CALCULATOR:  www.LowerWC.com/calculator.php

MODIFIED DUTY CALCULATOR:  www.LowerWC.com/transitional-duty-cost-calculator.php

WC GROUP:   www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE:  Workers Comp Resource Center Newsletter

 

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

 

©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact
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Conservative Primary Care in Chiropractic Practice

By David C. Radford, DC
David R. Seaman, DC
James F. Winterstein, DC
Robert C. Jones, DC
 
 
In Part I of this three-part series, we discussed the history of the chiropractic profession and the issue of primary care, both past and present (see ACA News, January 2012, Page 29). In Part II, we discussed the implementation of conservative primary care, the clinical methods we can use in daily practice to address co-morbidities and how to move our patients toward preventive medicine and wellness based upon the elements of a good patient history (see ACA News, February 2012, Page 28).
 
 
In Part III, we look at the physical examination in light of the patient’s history and expand on implementation of conservative primary care services that we can provide within our current scope of practice. The utilization of doctors of chiropractic (DCs) to coordinate patient care should help reduce our nation’s health care costs by preventing and managing chronic illness1. The importance of the interview process during the subjective history taking comes to light at the first encounter. The specific details we ferret out during the subjective history taking help us start to make a mental checklist of differential diagnoses and what we will need to consider so we may narrow the diagnosis into a rational hypothesis. This mental triage process helps direct us through the patient’s examination and to plan the diagnostic procedures we may want to perform or order. Let’s use the example of a fairly comprehensive office visit as a review exercise. [WCx]
 
 
The Office Visit
Every new patient encounter, change in condition or break in care should include the vital statistics in the office visit. These objective measurements include the height, weight, body mass index (BMI), heart rate or pulse, respiratory rate, blood pressure and pulse oximeter measurement of oxygen saturation. If any of the vital signs are not within normal limits, they should be tracked on a regular basis to determine if a specialist consultation and/or further medical intervention is needed, as this is part of our role. The health-promoting influence of primary care has been accumulating and holds true in both cross-national and within-national studies2. In some situations, we may be the only physician seeing the patient on a regular basis, making it even more important that we track abnormal vitals, direct our care to reduce illness, and prevent end-organ damage and premature death. Obesity, adult-onset diabetes, vitamin D deficiency, hyperlipidemia, hypertension, tobacco, alcohol, drugs, and use of excessive medications are co-morbidities that we see every day. Following the patient encounter, we should be able to describe the patient in detail, including his or her emotional state. It is helpful to note if the patient appeared to be pleasant and cooperative, if he or she was well groomed and what his or her mood was like: good, somber, anxious or depressed. Patients frequently present to a DC in pain, and are often seeking manual medicine. The understanding of the patient’s emotional state gleaned through the history and examination helps us grasp mental health in relationship to pain, which aids in our biopsychosocial approach to care of the patient.3 Assessing the mental health of our patients also gives indications of whether there may be symptom amplification, symptom modification due to mental overlay (i.e., depression often increases pain and creates avoidance patterns), co-dependence on a practitioner and the overall likelihood of whether the patients will engage successfully in our treatment plan.
 
 
Trauma
If there was trauma, did the patient hit his or her head? If there was head trauma, was there a loss of consciousness, blurred or double vision, an associated headache or changes in the ability to remember things or difficulty with concentration? Furthering the discussion, has there been any loss of sleep or sleep disturbance? Have there been unusual emotional changes or mood swings? Is the patient clearly oriented to time, place and person, and is the patient a good historian? Are short- and long-term memory, cognition and general fund of knowledge good? Are the attention span and concentration good? At this point, do you need to set aside time for a mini-mental status examination? Does examination of the head and cranial nerves suggest a need for imaging of the head or perhaps a neurological consult?
 
 
Cardiac/Thoracic
In general, can you describe the patient as being well developed and well nourished? If not, what is the patient’s appearance? A patient who is not nutritionally sound does not have the nutrient building blocks to respond to the physical changes your treatment plan may require. This is an opportunity to discuss diet and lifestyle changes. Based on the patient history, risk factors, vital statistics, appearance of the skin, color of the membranes and body build, do you suspect any cardiovascular problems or chest disease? When you listen, is the chest clear to auscultation in all lobes? Is there any tactile fremitus? Does the cardiac exam demonstrate normal S1 and S2 heart sounds? Are there S3 or S4 sounds? Are the heart rate and rhythm unremarkable, or are there murmurs, rubs or gallops? Is there any peripheral edema? If so, we need to describe the extent and severity in our notes. Based on the auscultation of the heart and lungs, do we need further testing or a specialty consultation? If the female patient is seen regularly by a gynecologist or internist, the breast examination can be discussed as being up to date, and charted as being deferred. Continuing with the thoracic/chest examination, is the trachea in midline? Is there thyroid enlargement or a palpable nodule? Is there hoarseness? Does the patient need an EENT consult? Does auscultation of the carotid arteries reveal good up strokes, and are they negative for bruit? Is there any jugular vein distention? Is there any indication that the patient would be at increased risk for spinal manipulation of the neck?
 
 
Abdomen
Before we palpate the abdomen of the patient, we should have determined through the history if there were any reported bowel, bladder, liver, gallbladder, spleen or pancreatic concerns? It is not at all uncommon for pathology of the abdomen to refer pain to the flank and back. Are the bowel sounds normal, or is there an absence of normal bowel sounds that could suggest an obstruction? Are the superficial reflexes present at the four quadrants? Is the abdomen non-tender or tender to palpation, and if tender, where? Is the liver or spleen enlarged? Are there any abnormal pulses or masses on abdominal palpation? If there is flank or chronic back pain, should we order a routine urinalysis, a CBC and ESR or imaging studies? If the patient is seen regularly by a family practice doctor or an internist, the male’s prostate and for both sexes the rectal examination, can be discussed and charted as being deferred, or the exam can be performed if necessary based upon the chief complaint. [WCx]
 
 
Gastrointestinal
A wide variety of abnormalities contribute to indigestion and to the development of gastrointestinal complaints. This is sometimes a complex issue, and the role of testing for H. pylori infection in GERD remains controversial. The implications of test results with false positive and false negative results remain incompletely understood. Patients with chronic digestive problems may have had diagnostic testing, including endoscopy and colonoscopy with biopsy. If these studies have been done, do we know that life-threatening pathologies have been ruled out? We suggest looking at the role of obesity, diet and lifestyle in our patients with gastrointestinal complaints, and refer the reader to the relevant patient education resources provided at eMedicine’s website for heartburn, GERD and reflux disease. In difficult cases that are non-responsive to conservative care, a referral to a gastroenterologist for co-management is most appropriate.
 
 
Pain/Posture
On your intake paperwork, did the patient complete a pain drawing? Was the severity of the pain indicated on the 11-point 0 to 10 centimeter pain scale, or did you simply ask the patient to rate the pain on a 0 to 10 scale for you? It is important to chart the description as to the nature and character of the pain problem, either using a key to types of pain on the pain diagram, or simply ask the patient to describe the nature and character of the pain. As you watched the patient move, did facial expressions during testing suggest pain; did he or she grimace, or show a facial expression of distress? As the patient sat still or moved, did he or she moan or cry out in pain? It is important to chart how pain was characterized by the patient for our record. Is the patient’s pain drawing anatomical; is it free from signs of embellishment? Do we see or suspect Waddell signs; are there any issues of secondary gain? Describe the patient’s standing or sitting posture and movement from sitting to standing. Is it normal or is there a Tripod or Minor’s sign? Is the stance and gait normal/abnormally wide, stable or unstable? Do we want our patient to do a tandem walk to better assess balance? Is he or she able to walk on his or her heels and toes and squat with good strength? To test proximal muscle strength, is the patient able to duck walk? Is Patrick’s figure four sign negative for hip disease? Palpate the area of concern for tenderness with appropriate pressure and percussion. Does the patient have a facial expression of distress with this type of provocative testing? Note the patient’s skin color and turgor. Are they normal? Is any lymphadenopathy noted? Is there any palpable mass or tenderness in the supraclavicular fossa, axilla or groin? It is helpful as a starting point in care to record all abnormal spine or joint motions using the appropriate measuring device, goniometer for joints and the inclinometer for the various regions of the spine. Based on the history and red flags, is imaging indicated? Are there signs of inflammation? Is the problem unilateral and focal, or is it bilateral and symmetrical, involving multiple joints and tissues? Is there an indication to look at the serum biomarkers for inflammation or autoimmune disease? The medications routinely used should be discussed, and while botanicals and more natural alternatives may be useful, we realize they are not all entirely free from side effects and they can interact with prescription medications and represent a good topic for further discussion.
 
 
Motor/Sensory
For the motor and sensory examination, we record muscle strength by the Medical Research or Kendall Scales (graded 0 to 5) (R/L). In the assessment, are the limbs symmetrical in bulk, strength and tone? If you record the grip strength by dynamometer, always indicate if the patient is right- or left-handed. Are the muscle stretch reflexes symmetrical at the deltoid, biceps, triceps, brachioradialis, wrist, patella, hamstring and ankle? Is the radioperiosteal reflex normal? Is side-to-side evaluation of sensation over the dermatomes using pinprick and light touch intact or altered? Are good joint position and vibratory sense observed distally at the great toes? Do the patient’s feet look healthy? Is there an indication for further testing, metabolic laboratory or electrodiagnosis? If these are abnormal, is an internal medicine consultation indicated? The number of specialist consultations has doubled over the past decade, from 4.8 percent in 1999 to 9.3 percent in 2009. While some policymakers are concerned about this added cost of specialization, many physicians in ambulatory primary care4,like chiropractic physicians, understand our expertise is primarily musculoskeletal medicine and manual therapies, and while we recognize our limits, we also understand our responsibilities as physicians. If there is a spine problem, is the Valsalva maneuver provocative for disc occlusion pain in the cervical, thoracic or lumbar spine? Is there evidence of nerve root tension in the arm or leg? The list of orthopedic and neurological tests can be long, and all examination findings help paint a picture that tells the patient’s story. If plain films or advanced imaging were deemed clinically necessary, how do they correlate with the chief complaint? If a trial of manual therapy and spinal manipulation is indicated, is the patient responsive? If it is essential to the examination, do the patient’s cranial nerves appear to be grossly intact? Are the sclera anicteric, and are the conjunctiva normal? Are the pupils equal and active? Are they reactive to light and accommodation? Is visual acuity corrected? Are the visual fields full? If a funduscopic examination was not performed, was it because there was no complaint to suggest increased intracranial pressure? If it was performed, was the funduscopic examination benign with no exudates? Is there hemorrhage or papilledema to suggest increased intracranial pressure? Are the teeth in good repair? Is a consultation needed with an eye specialist or a dentist? Are there any Long Tract signs? Is the plantar response flexor or extensor, and is Oppenheim’s sign negative? Is there any clonus, or a Hoffman’s sign? Are the finger- to-nose, finger-to-finger and heel-to-shin tests normal? Is there any evidence of downward drift? Is Romberg’s sign absent? Is the patient safe at home? Is the patient at risk of falling at home? If so, does the family know, and is further testing or assistance indicated? Are pulses present at the wrists, ankles and dorsum of the feet? Are the hands and feet warm and dry? Do you observe any cyanosis or clubbing of the distal digits? Do the nails appear smooth with good color and capillary refill? Are there any bruises or cutaneous rashes? Does the bruising reflect a trauma or a clotting problem? If present, does the rash represent a focal response, or is it a more generalized process? [WCx]
 
 
Plan Appropriate Care
You have given this patient a comprehensive physical examination, and based upon the patient’s history, your findings and any special tests, you should be able to plan appropriate care and make necessary referrals for secondary or tertiary care. Of course, not every patient being seen in chiropractic medicine needs a comprehensive evaluation, but if we happen to be the first-choice physician, we have an obligation in our role of primary care physicians to triage the patient and provide not only the best possible care, but make appropriate referrals when necessary. This obligation occurs not only at the point of an initial office visit but also when there is a change in symptoms, an additional chief complaint or an office return after a break in care. The accessibility of the nation’s chiropractic physicians for conservative primary care of non-institutional patients5 using the primary care model should enable the DC to become more involved in the discussion of cost-effective health care policy. It has been found that provider continuity is one of the most important explanatory variables related to the total health care cost.6
 
 
Dr. Radford is the director of the Chiropractic Clinic of Solon, Dr. Winterstein is the president of National University of Health Sciences, Dr. Jones is the president of New Mexico Chiropractic Association and ACA’s delegate to New Mexico and Dr. Seaman is a professor of clinical sciences at National University of Health Sciences’ Florida campus. Drs. James Lehman and Michael Taylor also contributed to this article. Contact for more information at DCR8888@aol.com or phone: (440)-248-8888; www.acatoday.org.
 
 
References
1) Kravet SJ, Shore AD, Miller R, Green GB, Kolodner K, and Wright SM. Health care utilization and the proportion of primary care physicians. American Journal of Medicine, 2008 Feb; 121(2): 148-6.
2) Starfield B, Shi l, Machiko J. Contribution of Primary Care to Health Systems and Health. Milbank Quarterly, 2005, 83: 457-502.
3) Lumley MA, Cohen JL, Borszcz GS, Cano A, Radcliffe AM, Porter LS, Schubner H, and Keefe FJ. Pain and Emotion: A Biopsychosocial Review of Recent Research. Journal of Clinical Psychology, 2011 September: 67: 942-968.
4) Barnett ML, Song Z, and Landon BE. Trends in Physician Referrals in the United States, 1999-2009. Annals of Internal Medicine. 2012;172 (2): 163-170.
5) Shi L, Starfield B, Politzer R, and Regan J. Primary care, self-rated health, and reductions in social disparities in health. Health Services Research. 2002 June; 37(2): 529-50.
6) De Maeseneer JM, De Prinis L, Gosset C, and Heyerick J. Provider continuity in family medicine: does it make a difference for total health care costs? American Family Medicine. 2003 Sep-Oct; 1(3): 144-8. 

 


WORKERS COMP MANAGEMENT MANUAL:  www.WCManual.com

VIEW SAMPLES PAGES

MODIFIED DUTY CALCULATOR:  www.LowerWC.com/transitional-duty-cost-calculator.php

 

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

 

©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.

Amaxx Details 2012 Workers Compensation Management Program Updates

Workers’  Compensation Costs Can Be Reduced by Implementing Operational Best Practices: Learn How With This New Guidebook.
 
A company that wants to implement a new workers compensation program or revamp an existing system will find this book helpful. Maybe your company has recently expanded and you realize the need to train a workers compensation manager or regional coordinators how to hold down compensation costs. Whatever your need, here is the answer: Workers Compensation Management Program: Reduce Workers’ Comp Costs 20%-50%.
 
 
Used by more than 150 firms across the country, this is THE book to help every employer develop a more effective workers compensation program to reduce workers compensation costs. It is based on field research and decades of experience in workers compensation from all aspects of the business. Best practices are described in detail for each person in the injury process.
 
 
This easy-to-read manual has been updated for 2012. It now includes:
 
An index for quick topic look-up so you can view a term or a procedure and see all relevant references.
 
NEW – Workers Compensation Basics
Purpose of Workers Compensation
Who Pays for Workers Compensation?
Parties Involved in Workers Compensation
Benefits for the Employer
Independent Contractors
Benefits for the Employee
Injuries Covered
Types of Workers Compensation
How Losses are Categorized
How Losses are Reported
Calculating Your Premium
How Mod Effects Your Premium
Good/Bad Mod Example
Five Ways to Reduce Your Mod
 
NEW – Fundamentals of Cost Containment
Reasons Workers Compensation Costs are High
Who is in Charge?
Work Ability Form Properties
Who is Responsible for Managing Workers Compensation Claims?
Who is Responsible for Managing Workers Compensation Process?
Hidden (Indirect) Costs of Workers Compensation
Additional Costs
Calculating WC Costs
External Obstacles to Cost Control
Internal Obstacles to Cost Control
 
NEW – Working with Your Adjusters or TPA
Account Handling Instructions
MD Participation
 
NEW- Reporting a Claim
Critical Issues
Essential Intake Considerations
Nurse Triage
 
NEW- Directing Medical Care
Occupational Health Clinics
Remote Health Services
Directing Medical Care in California
 
NEW- Return to Work
What to Include in a Transitional Duty Policy
Non-Profit, Volunteer or Charitable Positions
Employees Who Never Return to Work
Coordinating WC with Federal and State Leave Statutes
 
NEW – Other Indemnity Cost Containment Services
Telephonic Disability Intervention
 
NEW – Medical Cost Containment
URAC Certification
Mental Health RNs
Chronic Pain Programs
An Aging Workforce
At Home Recovery Services
Medical Fee Schedules
Fee Schedule Coding
ICD-9 and CPT Codes
 

NEW- Physical Therapy and Physical Rehabilitation

Differences between Physical Rehabilitation Programs
Pharmacy Benefits Management Program
Authorized Drug Formulary
Toxicology Screening
 
NEW – Fighting Fraud and Abuse
Medical Terminology Used to Identify Malingering
Reviewing Investigation Reports and Videos
Avoid good Day/Bad Day Syndrome
 
NEW – Claims Resolution and Settlements
Conditional Payment and Final Demand
Pharmacy Component of MSA
California Settlement Process
 
 
A 183-page guide covering how to assess your workers compensation program, design program materials, roll out a program to the organization, and monitor and manage the program once implemented.
 
 
Written by a national expert on workers compensation cost containment with over 25 years experience helping companies reduce their losses 20% to 50%.
 
 
T. Ronca, a workers’ compensation defense attorney from Long Island, NY, said the book is an invaluable desk reference. “It is one of the tools that should never be out of reach for a risk manager. Direct employer involvement with claims in the first weeks is the difference between success and failure. This manual will guide the conscientious employer through the pitfalls,” Ronca said.
 
 
What’s more, the book can be delivered with your company logo on the cover and a full-color ad for your company on the back cover. 

Take it out to the field. Text tabs are available to put on each chapter and it is ready to go as your company training manual. All you will have to do is customize the Training Agenda that is in Part I of the book.

 
 
Included in the manual are topics such as: Return to work and transitional duty, claim reporting, employee communications, controlling fraud and abuse, directing medical care, medical cost containment solutions, post injury response procedures, reporting procedures, working with your carrier and third party administrator. There is information about physical therapy, pharmacy benefits management programs, training supervisors and gaining management commitment. It also contains concepts of claim settlement and resolution as well as safety and loss control. New areas are identified above.
 
 
There are 5 sample worksheets in the manual to help organize an efficient workers’ compensation program. These include: timetable for implementation, the injury coordinator job description, and several sample roll-out letters. We recently received a terrific phone call from a third-party administration firm saying how the manual provided an organized way to train clients at loss prevention and has helped their clients put "layers of better WC management" in place. Everyone benefited.
 
 
One large distribution firm wrote to us to say the chapter on safety and loss control led to a company-wide safety change that only cost a few hundred dollars but prevented a specific type of injury that had been draining its budget, says Rebecca Shafer, Esq., President of Amaxx Risk Solution, Inc. who authors the book. Shafer is a national expert on workers’ compensation cost containment with more than 25 years of industry experience helping many companies reduce their losses 20-50%.
 
 
When you order your copy of Manage your Workers’ Compensation Program from Advisen at http://corner.advisen.com/wcbooks, the 183-page guidebook shows how to assess your program, design program materials, roll-out a program to the organization, and monitor and manage the program once implemented.
 
 
The workbook is also available with a customized front and back cover for bulk purchases. Discounted rates apply to bulk orders.
 
 
One company said, "After reading the manual, we took a look at past workers comp practices and saw that every department did things differently. Manage Your Workers’' Compensation Program 2012 gave us the guidance we needed to standardize our workers’ compensation programs across the country. It was like a pre-prepared lesson plan," according to the risk manager.
 
 
A regional hospital in North Dakota wrote that, "Our small company expanded rapidly and we actually didn’t have any official workers’ compensation program in place. This manual gave us step-by-step procedures from the first meetings with management to monitoring the final program. Buying and reading the book was almost like hiring another employee – one who was an expert in workers’ compensation."
 
 
Who Uses the Workers’ Compensation Book?
Risk Managers and Workers’ Comp Managers find it useful learning about the cost containment niche and use it for themselves and to bringing new team members up to speed very quickly. The book becomes a “lesson plan” tool.
 
 
Safety Directors use the book to train supervisors in workers’ compensation claims management. They learn more about their area of responsibility — post loss cost containment — adding to their overall knowledge. They also learn what to do after an injury and what steps are supposed to take place during the first 24 hours.
 
 
Brokers use it for prospects, as well as, to learn about specific aspects of cost containment, passing their knowledge on to their clients. For example, when discussing how to develop a return-to-work program and a client asks about, “off-site return-to-work programs,” the broker quickly finds the relevant section in the book, reviews it and passes the answer on to the client, along with a copy of the cost containment book with the broker’s logo.
 
 
Adjusters use the book to gain a better understanding of the employer’s perspective. Adjusters also want to learn more about cost containment to add to their overall workers’ compensation knowledge in order to grow their careers and stay abreast of new services.
 
 
Account Producers give the book to prospects during formal presentations to illustrate their company is on top of the workers’ compensation industry. The book makes an excellent client gift.
 
 
Vendors such as doctors, physical therapy networks, occupational clinics and medical management firms learn how their service might fit into the workers’ compensation marketplace, what is important to employers, and what they look for in medical services to enable the vendors to enter the workers’ compensation marketplace.
 
 
The manual is a cost-cutting tool to learn more about systematic and operational techniques for reducing workers compensation costs.

 
 
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.
 
 
2012 NEW WORKERS COMP MANAGEMENT GUIDEBOOK:  www.WCManual.com
 
WORK COMP CALCULATOR:  www.LowerWC.com/calculator.php
 
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
 
©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.

What to Tell Employees Who Are Injured On The Job

We are always writing articles to assist the employer in dealing with the complexities of the workers compensation system. We thought for a change of pace we would provide an article to assist the employees in dealing with the tangled web of workers compensation.  

 
The following suggestions will make the workers compensation claim go smoother and alleviate the angst that naturally occurs when an employee is injured on the job. (WCxKit)
 
 
1. Report your workers compensation claim immediately, even if you do not need medical care at the moment. What may feel like a pulled muscle today may be a major problem next week. It is better to have a record of your injury when it occurs rather than trying to explain why you are reporting the injury late.
 
 
2. Ask your supervisor to prepare a written report of the incident. Your supervisor should willingly do so, but if for any reason the supervisor does not act immediately, submit your own written report providing all the details of what you were doing when you got hurt. Be sure the details of your incident are accurate, as the fastest way to lose credibility is to allow inaccurate information to be reported.
 
 
3. Select a medical provider from the list posted. If you do not understand the different specialties, ask for guidance. A medical provider close to work or close to your home is often the easiest one to reach.
 
 
4. All the medical care related to your injury will be provided until you have recovered from the injury.
 
 
5. If you have a pre-existing medical condition, which can be anything from a prior back injury to diabetes, do not try to hide that fact. To get the appropriate medical care you need, all medical conditions or issues should be disclosed to the medical provider.
 
 
6. Keep track of your mileage to and from every medical appointment and to/from the pharmacy. Your mileage can be reimbursed in most states, but only if you have a record of it. Keep a copy of all mileage logs turned into the adjuster.
 
 
7. Obtain a written copy of the report your employer submits to the insurance claims office. If anything is incorrect on the report, now is the time to correct it, not later.
 
 
8. Attend all doctor appointments and all diagnostic testing. If you do not think you are hurt enough to attend the medical appointments, neither will the adjuster.
 
 
9. Provide a copy of all off-work (disability) slips to your employer and to the insurance adjuster, and keep a copy for yourself. Ask your employer if they have a more complete form to use, often called an Injury Treatment Form or Accident Report Form that gathers enough information about your injury so your employer can locate a transitional duty job for you.
 
 
10. Keep in touch with the employer and the insurance adjuster. After each doctor's visit, call both the employer and the insurance adjuster and give them an update on what the doctor said about your medical progress and when you may be able to return to work. If you are on transitional duty and your capability increases (it should) let your employer and insurance adjuster know about this.
 
 
11. Every work place has co-workers that will want to give you unsolicited advice on your workers comp claim. Follow the real doctor's medical guidance not your friends and co-workers.
 
 
12. Every state has a waiting period before lost wage compensation can be paid. Ask the claims adjuster what the waiting period is in your state. If you are out of work longer than the waiting period, you will be paid a percentage (often 66.67%) of your average weekly wage.
 
 
13. Ask about your employer's return to work program while your doctor has you off work with restrictions. Often your employer can modify your current job duties so that you can return to work sooner.
 
 
14. Do not violate the work restrictions placed on you by your doctor while working light duty. You will most likely end up aggravating your prior injury and extending the period of time it will take for you to recover from your injury.
 
 
15. If a nurse case manager is assigned to your claim, keep the nurse informed as to your medical progress and understand he/she is there to make sure you obtain the appropriate medical care. (WCxKit)
 
 
Your employer hopes you will never get hurt, but if you do, keep the workers comp claim suggestions in mind to improve the claim experience and the overall outcome of your claim. 
 
If you are an employer reading this, the above items can be included in an employee brochure.

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 website 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. Rebecca is the author of Workers Compensation Management Program: Reduce Costs 20-50%. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.

 
 
NEW! 2012 WORKERS COMP BOOK:  www.WCManual.com
WORK COMP CALCULATOR:  www.LowerWC.com/calculator.php

 
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.

5 Ways a Pharmacy Benefit Manager can Control Prescription Costs

 
 
The cost of prescribed drugs, especially narcotic pain medications, is rising in the world of workers' compensation. This cost increase is due to the fact that a drug company is like any other company: When the demand for your product is high, supply lessens, and costs have to increase. And, these medications are not exactly cheap to manufacture. In fact I saw a news report that some cancer fighting drugs are in short supply due to overwhelming demand.
 
 
Think about going to your personal physician for a knee strain you had over the weekend playing football with your family. You probably went to your doctor, and you probably left with a prescription for Motrin buddied up with a short-term prescription for a narcotic pain reliever — even if a cold pack or hot pack and rest would have taken care of the problem. This is the world in which we live. In the past, these pain medications were for extremely acute trauma, such as a car accident or bone fracture. But more and more, medications such as Vicodin, Percocet, Oxycodone, etc are being prescribed for the slightly-above-average diagnosis of lumbar or shoulder strain. (WCxKit)
 
 
Below we discuss five ways you can try to control these associated drug costs when it comes to your workers compensation claims. By no means is this an exact science, but it is certainly one you should look into for help controlling your bottom line.
 
1. Come up with your game plan.

Whether you have five claims a year, or five claims per week, medication cost will be a significant expense of the claim. Many carrier/TPAs are partnering with a Pharmacy Benefit Manager (PBM) to review prescription history and also to provide a reduced cost for medications. These outside vendors attract carrier/TPAs by offering them a discount cost for medications, in exchange for their guaranteed business.

 

Adjusters set claimants up with a drug card from these vendors, and they are widely accepted at many pharmacies nationwide. Furthermore, the PBM will review the injury and the claimant’s individual medication history. They can recommend medications based on the injury type and location. This is an attempt to stop every John Doe back pain sufferer from walking out of his doctor’s office with an RX for Percocet, when he really does not meet the criteria for needing that strong of a medication to begin with. Most strains can resolve by taking a stronger dose of Motrin, an anti-inflammatory medication similar to Advil or Ibuprofen. The PBM will also monitor duration of medication use and quantity limits. Why pay for 90 pills when John Doe should only need 30? Medication costs are associated with dosage as well, so it doesn’t make sense to pay for 90 pills unless they are needed.

 

2.  Start being aggressive at the first prescribed RX.

When a new claim is filed and the adjuster sets the drug card up to be mailed out to the employee, it may already be too late. This is when proper communication is handy. If you have a worse-than-average claim, you can phone your adjuster with the info, and they can get the PBM info right to the claimant.

 

This way they are not getting medication from an occupational clinic or hospital, where the costs are typically the highest. Right off the bat they can use the PBM card, and that reduces cost right from the beginning. This also helps manage future spending on RXs, since they already have the card and should be using it for any medication the claimant is prescribed. Sure, not using the card for your first medication fill is no big deal if you only have one or two claims per year, but if you have one or two claims per week, over the course of a year this can lead to a dramatic savings in medication cost. Every little bit of savings will help in the long run, and it is important not to overlook the small savings that you can implement right away.

 

3. Can you do bulk home delivery?

For those injuries lasting longer than a month, it is worth it to look into home delivery of medications. This increases the discount, because you buy more of the medication at one time, and you do not have to pay the pharmacy overhead for a short-term 30 day fill. Injured workers will appreciate having one less errand to run, especially those who do not have easy transportation readily at hand. At the same point, the PBM will monitor dosage and quantity. Why should you continue to get a medication if it is not helping? Or, if the injured worker is not taking the medication at all? These are leakage costs, and expensive ones at that. The adjuster will ultimately decide if a claim is worthy of needing home delivery, and the delivery will not last forever. If a person has a bad fracture and will need a long-term supply of Motrin, this is a perfect scenario.

 

Adjusters do frown on home delivery of narcotic pain meds. This gives the claimant a large supply of potentially strong medication, which carries the risk of addiction. Home delivery meds are generally milder. Again, even though these drugs may not cost the most, any sort of savings is better than no savings at all.

 

4. Are you using prescription utilization review?

PBM companies use a panel of clinical pharmacists to examine prescription data and injury type to make sure appropriate medication is dispensed. This helps control unnecessary costs due to prescribing incorrect medication. Also, PBM utilization review will help to control fraud by monitoring the date and location of refills. Red flags indicating abuse include early refills, a doctor shopping around to get new prescriptions, or a patient changing pharmacies to get refills. Clinical pharmacists also are useful at catching new medication trends, proper quantities of medications, and future costs/needs for ongoing medications. 
 
By using prospective utilization review, done before the product is used, to avoid the cost, consider prior authorization program. By having an MD on the TPA's staff review the file, many of the medication concerns are addressed proactively. The utilization review company you use, should be URAC certified to ensure quality, credentials and training. A good TPA might even have a chronic pain program to discuss pain issues with an interdisciplinary team of experts. 
 
 
 
 
5. Use a Pharmacy Benefit Manager or vendor to help with repeat offenders and duplicate prescription medications.
 
This use of an outside PBM is effective for many reasons, including catching a doctor prescribing both a short-term and long-term narcotic pain medication, duplicate or similar prescriptions being unnecessarily prescribed, and implementing the use of generics whenever possible. The PBM will also participate in state-wide reporting, which will catch if a claimant has other narcotic pain medication fills before the date of injury. This can show the worker may have a history of requesting certain narcotics — a red flag for abuse.
 
 
Surveillance companies usually have a service that can do a background check of pharmacies, to see if your claimant has had fills of certain medications aside from the meds needed for your specific injury. This fights fraud, and can expose someone that may have a prescription drug problem. An easy way to get strong medication is to file a comp claim, and any weapons you have to fight fraudulent claims are worth it.(WCxKit)
 
 
In summary, a third-party PBM is a useful tool not only for cost-savings but also for catching the many forms of prescription abuse out there. Doctors get lazy when it comes to prescribing medications. Sometimes the answer to every injury is a prescription of Vicodin, Percocet, or some other narcotic when none are needed. Not only are these medications expensive, but they can carry long-term health problems including addiction, which only increase the overall cost of the claim. Using a PBM is another way of being proactive when it comes to handling your claims, and your carrier/TPA will have more information on what you can do to implement a PBM program for use on all of your claims that require prescription medication.
 

Ask your TPA what programs they offer.
 


Author Rebecca Shafer
, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website 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, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.com. Contact: RShafer@ReduceYourWorkersComp.com.
 
 

Our WORKERS COMP BOOK:  www.WCManual.com
 
WORK COMP CALCULATOR:  www.LowerWC.com/calculator.php

 
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact

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