Article originally published in On the Frontline Magazine

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

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

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

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

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

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

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

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

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

Joining the Dots

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

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

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

Danielle Lisenbey, President and CEO, Broadspire^®

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

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

Modern Day Nursing

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

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

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

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

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

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

What is Vocational Rehabilitation?

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

Rehabilitation Eligibility and Initial Consultations

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

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

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

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

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

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

• Notice and statute of limitations;

• Intoxication;

• Prohibited Acts;

• Self-inflicted injuries; and

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

Development of Rehabilitation Plans

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

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

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

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

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

Moving Injured Workers Back to Work

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

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

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

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

Conclusions

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

Author Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center.

Contact: mstack@reduceyourworkerscomp.com.

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

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

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

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

Hierarchy of Scientific Evidence

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

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

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

Critical Evaluation by Expert Panel

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

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

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

Free Resource for Published Guidelines

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

• https://www.guidelines.gov/

Evidence-Based Medicine Guidelines for Workers’ Compensation

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

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

The guidelines below are available electronically via paid subscriptions.

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

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

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

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

Summary

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

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

What do you call the person who graduates at the very bottom of his class in medical school? That question was posed to me by a friend of mine in college, particularly after he didn’t do so well on one of his exams. But he would say Mike, you call that person doctor.

All Doctors Are Not Created Equal

Hello, I’m Michael Stack, CEO of AMAXX and while it’s somewhat of a funny question, the answer is one 100% true. It doesn’t mean that I want to go see that doctor, doesn’t mean that you want to go see that doctor, it doesn’t mean that you want your injured employees to go see that doctor either. There’s a common misconception, particularly among American consumers, that all doctors are created equal. We know with complete certainty that that statement is just not true. The message and the doctors that you’re working with can make or break the success of your work comp program. While there are some states that are employer directed states, other states that are employee directed states, and even now there’s others that are a blend of the two. You need to have this physician relationship that can help drive the success of your program. Drive the success of your return to work program and create those better outcomes for your injured workers, thus costing you significantly less in work comp costs.

Characteristics of Ideal Company Physician

I want to go over some of the characteristics that you want to be looking for in that company physician relationship and also some of the ones that if you currently have them, that you need to think about getting a new physician relationship. Let’s talk about what these characteristics are. First you want that physician to be responsive. You want him or her to be caring, willing to spend extra time with your injured employees, with some of the additional paperwork that’s required in work comp, and of course, you want that person to be highly qualified and versed in the best practices of evidence-based medicine.

Let’s unravel these a little bit. Talk about the extra time that’s required in Workers’ Comp as compared to group health. There’s some physicians that are just not interested in that. You need to find the ones that are. You need to find the ones that are specialized in occupational medicine and willing to have this responsive and caring attitude towards your injured workers. We know how important trust is, in order to predict the outcome for your injured workers. That’s true with the employer’s site, that’s true at the medical provider level as well. You want that doctor to be able to come out to your employer site. Hold a health fair. Get to know your employees. Build that relationship, build that trust, and also understand those job descriptions.

What are the functional requirements of the job, so when that employee goes to see that physician, you can get those medical restrictions and you can make them very specific in order to feed that person right into your transitional duty program, which is so key to the success in the recovery of that injured worker.

What NOT to Look for in Company Physician

Let’s talk about the other side of this coin. One caution that I often see. If you get this highly qualified doctor, well versed in evidence-based medicine, big reputation in the industry, you’re often also going to get an arrogance from that particular doctor. That person will be unresponsive because him or her will have no time and no interest in working with you in your program, providing you the restrictions. Filling out your workability forms, feeding into your return-to-work program and just unwilling to come out to get to know your employees and your organization. It’s such a symptom of this arrogance. They also may have a biased approach and be inflexible in being creative in getting those restrictions and helping your employees get back to work in a timely fashion.

This type of physician, and this bias is also a big one, either from the employee side or the employer side as well, because this is how you get the reputation of, “Oh, I’ve got to go see the company doctor and I’m just not going to be treated fairly.” You’ve got that going against you right out of the gate. But if you have that doctor that has that caring attitude, is willing to spend that extra time, you are going to be putting your program on the path to work comp success.

Again, I’m Michael Stack, CEO of AMAXX. Remember your work today, and Workers’ Compensation can have a dramatic impact on your company’s bottom line, but it will have a dramatic impact on someone’s life. Be great.

Author Michael Stack, CEO Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center. .

Contact: mstack@reduceyourworkerscomp.com.

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

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

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

Hey there, Michael Stack here CEO of Amaxx. So I’m not a doctor, right, I have no medical training. I’ve never even particularly liked science very much; biology, chemistry, those classes in high school, just not my thing. I was much better at math, I was always good at math and I was always very interested in business.

Medical Component Significant in Workers’ Compensation

So, fast forward over 20 years later and now I’m in an industry where the medical component of it is a huge piece to what we do in creating these best outcomes. The costs are only continuing to rise and the complexity of the health care system is following right along with it.

So, while I’m not a doctor and you might not be either, I do know how to read. I also know how to use a phone and I even know how to use email and if you have these three skills as well, there is no reason that you should not be following the best practices of evidence based medicine on every single one of your medical injuries, which are your worker compensation claims.

Simple System to Follow Evidence Based Medicine

Now let me lay out a very simple system for you to ensure that that happens. You start with reading the evidence based guidelines for that injury. John Smith’s injury, which has a rotator cuff injury, these are published in MD guidelines, also published in ODG guidelines, both of those are paid subscriptions. You can also use a free resource at guidelines.gov.

So either you yourself or someone else on your claims handling team, read the guideline on what it says for rotator cuff injuries for that particular ICD9 or ICD10 code. You then have a weekly meeting with your claims handling team, your risk manager, your adjuster, maybe your account representative, case manager, possibly, possibly an attorney if it made sense on that particular day.

Compare Injury to Evidence Based Guidelines

You talk about John’s injury, where is he now, where is he going, what has happened, how does it compare to those evidence based guidelines and you’re holding this meeting on the phone. If it starts to look like he’s going off the track or there’s some elements that when you compare them to the guidelines, it’s outside of what’s recommended or outside of what’s typical.

Now, that might be relevant, that might be right, based on John’s scenario but you don’t know that because you’re not medically trained and your adjuster isn’t either. So the next thing you do is, you send an email to your medical advisor and you say doctor medical advisor, can you take a look at this case based on John’s history, based on John’s circumstances, based on the comparison to those evidence based best practice guidelines for what should be expected in this case. Is that right or is there something else we should be doing, some different interventions, maybe it’s an IME, maybe it’s a UR, maybe it’s further case management, maybe it’s something else that your medical advisor would recommend.

Following this simple system, in a systematic way will ensure that every one of your medical injuries, which are your worker compensation’s claims do follow the best practices of evidence based guidelines.

Again, I’m Michael Stack with Amaxx and remember your work today cannot only have a dramatic impact on your company’s bottom line but it will have a dramatic impact on someone’s life. So, be great.

Learn more: HOW TO USE EVIDENCE BASED MEDICINE TO CREATE BETTER WORKERS’ COMP CLAIM OUTCOMES

Author Michael Stack, CEO Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center. .

Contact: mstack@reduceyourworkerscomp.com.

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

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

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

Workers’ compensation is a complex system with varying laws in each jurisdiction and a changing American workforce. While there are many things that change, the fundamentals of a best in class workers’ compensation management program generally stay the same.  One of those elements is the need for effective Medical Cost Management.

What is Medical Cost Management?

“Medical Cost Management” is a term that describes various operations carried out by a workers’ compensation third-party administrator or insurance carrier to reduce the cost of medical claims.  It includes a number of different features that meets the needs of the employer that considers the nature of their industry, the workforce population it employs, injuries common to the work the employees perform and trends in health care that reduces the number of visits to health care professionals.  It also must provide the medical care and treatment injured parties are entitled to as the result of a workplace injury.

Common features of a medical cost management program include, but are not limited to:

• Preferred Provider Organizations (PPOs);
• Nurse case management, including web-based and telephonic hotlines and access;
• Injury case management, including medical and vocational experts;
• Utilization review of medical care and treatment. Given the dangers and overuse of prescription drugs, a complete review of prescription drug usage is essential;
• Independent Medical Exams (IME) & Peer Review;
• Pharmacy / Opioid Management
• In-Home healthcare services; and
• Medical billing review.

Implementing Medical Cost Management in Your Program

The implementation of an effective medical cost management program requires buy-in from a number of interested stakeholders.  This includes an employer concerned about providing quality care and benefit delivery to injured workers.  It also requires a third-party administrator or workers’ compensation insurer that cares about the service it provides to the employer/client and the workers served under the program.  It also includes the effective implementation of the following program components.

• Prompt Reporting of Work Injuries: Any cost-effective program must include a number of different methods for employees to report a work injury.  Advances in technology have moved the industry beyond paper forms that confuse even a trained claims professional.  The use of web-based portals or smartphone apps can assist employees and their supervisors in prompt reporting of all workplace injuries.  It can also include features that allow impacted parties and potential witnesses to preserve evidence related to the injury.  One of the most important features of any injury reporting system needs to include access to immediate and appropriate medical care and treatment.

• Expedited Medical Care and Treatment: Beyond the issue of compensability, all workers are entitled to immediate and effective medical care and treatment following any work related injury.  It should also include steps to monitor and manage the care so that drivers in healthcare (including fraud, waste and abuse) can be eliminated without sacrificing quality.

• Return-to-Work. Return-to-work is an often overlooked component of medical cost containment.  Sadly, interested stakeholders who do not include effective return to work in their cost containment programs are doing a complete disservice to all interested parties involved in a claim.  Implementation of a return to work program should be something that is re-evaluated frequently to meet the needs of each individual client and employee.  It should also include an industry specific review of all processes and options.

Conclusions

Medical cost management in workers’ compensation is an important part of running an effective program focused on compliance with the law and supporting the needs of all interested stakeholders.  A multi-pronged approach requires buy-in from the employer and execution by the third party administrator or insurance carrier.  When done correctly, it will reduce costs and promote program efficiency.

Author Michael Stack, CEO Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center. .

Contact: mstack@reduceyourworkerscomp.com.

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

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

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

A majority of states have some type of medical treatment guidelines in their workers’ compensation systems. They are generally intended to get the highest quality care to injured workers with an eye toward reigning in costs. Unnecessary treatments and medications can often be avoided when guidelines are followed.

But just as the workers’ compensation system is different in every jurisdiction, Medical Treatment Guidelines can vary widely from state to state. Organizations that operate in multiple locations may find it confusing to keep up with each jurisdiction’s guidelines; they may also get pushback from medical providers or others involved in the claims process. Understanding some of the challenges and following a few steps can help get the most benefits from guidelines.

What They Are

Medical Treatment Guidelines are written from a clinical perspective to help lend consistency and best practices in determining medical care for injured workers. They are a set of procedures, pre-appraised resources and tools intended to be the gold standard in medical treatment.

There are a variety of Medical Treatment Guidelines in workers’ compensation. The American College of Occupational and Environmental Medicine and the Official Disability Guidelines from the Work Loss Data Institute are the most prevalent, although many jurisdictions use just portions of each. Several states have developed their own, either based on either of the two national guidelines or developed in-house.

Some are intended to be educational tools for medical providers, while others are used as criteria to approve or deny treatment. Some are created via a strict scientific regimen. Others are approved by physicians on more of a consensual basis.

Proponents say properly written and followed guidelines can prevent inappropriate treatments and get injured workers back to function and work quicker. They point to the overprescribing of opioids as an example of a consequence for the failure to have guidelines. Better safety, clinical outcomes, shorter treatment, and improved return-to-work rates are among the benefits.

Challenges

While the Medical Treatment Guidelines may be the rule of the land in some jurisdictions, they are not cast in stone. That can be a positive factor, in that it allows for exceptions; however it can be a problem if medical providers either don’t understand the guidelines or refuse to adhere to them.

There are additional challenges posed by Medical Treatment Guidelines.

• Some are published online, while others are put manually into a system.
• Some jurisdictions struggle with keeping their guidelines current according to the latest medical research.
• Lack of info. Some of the more common occupational injuries have no associated Medical Treatment Guidelines.
• Everyone involved in a claim — the claims adjuster, nurse case manager, physician, UR and bill payment personnel must know and understand them for maximum effectiveness.
• Dispute resolution. Some states have a dispute resolution process focused on evidence-based medicine, while others do not.
• Decision makers. The treating physician has the final say in some jurisdictions, while payers can direct care in others.
• Approval/denial process. In some instances, the best treatment for a particular injured worker goes against the Medical Treatment Guidelines, but the provider fails to adequately explain the rationale.

Solutions

Understanding, consistency and common sense are key to getting the most out of Medical Treatment Guidelines. Here are steps to do that.

1. Organizations need to understand the guidelines of each jurisdiction in which they operate. They need to pass on that information to their claims handlers, nurse case managers, physicians and all others involved.
2. Coordinate. In addition to understanding the Medical Treatment Guidelines, those involved in the claims process must be consistent in their application.
3. Work with doctors. Medical providers need to be on board with the guidelines for them to be effective. In cases where physicians may be leery of guidelines dictating the treatment, organizations should explain that exceptions are allowed.
4. Where an injured worker has comorbidities, psychosocial issues or other extenuating circumstances, the guidelines may not offer the best hope for a positive outcome. Organizations must be willing to take a holistic approach to each injured worker and encourage those involved in the claims process to fully evaluate medical treatment requests that run counter to the guidelines.
5. Overcoming denials. In situations where the best treatment does not concur with the guidelines, there should be a smooth process to review and decide on them quickly. For example, physicians working with the organization need to understand how to properly document exceptions to the guidelines and explain why recommended treatment can improve function.
6. Communicate. Keeping stakeholders in the loop is critical. Any changes in guidelines must be passed on as soon as possible.

Summary

Medical Treatment Guidelines are not a panacea or ‘the silver bullet’ to quickly resolving claims. But where they exist, they are based on scientific evidence.

At the same time, treatment dictated by guidelines is not always right for each injured worker. Common sense and individual medical diagnosis of cases must also play a part in the decision making process.

Author Michael Stack, Principal, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center. .

Contact: mstack@reduceyourworkerscomp.com.

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

©2017 Amaxx LLC. All rights reserved under International Copyright Law.

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

Chiropractic care has been a mainstay in workers’ compensation systems for some time.  While there are many benefits to this form of care, members of the claims management team should use caution when managing claims involving a chiropractor.

Are Chiropractors Real Doctors?

Chiropractic care is an alternative form of mainstream medicine used to treat a variety of disorders impacting the musculoskeletal system.  By using the spinal cord as a reference point, chiropractors use various manipulations in order to treat not only neck and back pain, but also other conditions that have their origins in the central nervous system.

The requirements to become a chiropractor vary in every state.  In some instances, a chiropractor receives more medical based training than the average medical doctor (MD).  The main difference in training is chiropractors concentrate their focus of study in physiology and body mechanics.

Areas of Concern for the Work Comp Professional

Chiropractors should be treated with the same professionalism as any other health care professional.  Like anyone else who provides medical care and treatment, a majority of chiropractors are professionals in every sense of the word.

Claims handlers do need to educate themselves on how chiropractors operate.  Unlike most medical doctors who work in or associate with larger groups, many chiropractors operate in a solo practitioner setting.  They also offer additional services such as massage and aromatherapy.  When managing claims involving chiropractors, claims professional should employ the following techniques to ensure the injured worker is receiving quality medical care and treatment:

• Review of Billing Practices: Every claims professional should review all medical bills submitted for payment with integrity.  When an employee sustains a work injury and is seen and examined by a chiropractor, it is important to review it under the same standards one would from a medical doctor specializing in orthopedic and neurological care.  This will include identifying billing codes that are consistent with an initial examination.

• History of Chiropractic Care: It is important for every member of the claims management team to obtain a complete set of medical records for a claimant.  This can be difficult when a person has received previous chiropractic care.  Any billing statement from an injured worker’s initial visit should indicate if they are an existing patient, have received chiropractic care in the past or are new to this form of treatment.

• Reviewing Treatment History: While chiropractors use medical terminology in their records, it does differ from what you would typically find in reports generated from a traditional medical doctor.  It is important to note the frequency of care and how long it is recommended.  One should also take note of “flare-ups” listed in medical records and determine if they coincide with the employee’s recollection.  It is also important to scrutinize any medical care with applicable state medical treatment parameters.

Managing Claim Costs

Members of the claims management team will need to take additional steps to address out of control treatment with a chiropractor.  There are steps that can be taken to address this form of medical mismanagement.

• Independent Medical Examination: The IME is the easiest, but sometimes most expensive cost containment method in claims involving chiropractic care.  Given the restrictions most states place on such exams, it is a decision that cannot be taken lightly.

• Record-Only Medical Review: This is also known as a “paper review.”  From a cost perspective, this is an excellent method to obtain an expert opinion regarding the reasonableness and necessity of care.  They can also address whether the chiropractic care is consistent with medical treatment parameters.  A paper review is also less expensive when compared to a full-blown IME.

Conclusions

Members of the claims management team and other interested stakeholders need to understand the benefits and dangers of chiropractic care.  Part of this includes methods and techniques to analyze the care received and making sure it is consistent with workers’ compensation guidelines.  It should also be care to treat the effects of a work injury and make the employee whole.

Author Michael Stack, Principal, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center. .

Contact: mstack@reduceyourworkerscomp.com.

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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.