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.

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.

Medical treatment has comprised the bulk of workers’ comp claim costs in recent years, and the trend seems to have no end in sight. Where indemnity used to be the main expense, medical now represents 60% or more.

There are a variety of tools to help manage medical costs; medical bill review, utilization review, provider networks, nurse case management, nurse triage, Medicare Set-asides, and the list goes on. While any of these tools can be effective, they might actually be costing you more than they are saving. You need to look at your return on investment and make sure the medical management services you are using are truly helping your organization save money on medical.

1. The Doctors: Costs vs. Outcomes

Low-cost medical networks were all the rage in the workers’ comp system for a while. But in recent years, there’s been more and more evidence to show that going cheap on medical providers may come back to bite you.

The latest indication comes from a study in which a 63-year-old woman with low back pain was sent for MRIs at 10 facilities in the New York area to see what, if any differences there would be. Sure enough, not a single diagnostic finding out of 49 distinct findings reported was identified by all 10. The woman’s actual diagnosis was stenosis; she was given physical therapy and education and is said to be doing just fine. But had one of the 10 interpretations of her MRI been used, she might have been sent for unnecessary surgery and/or drugs — big expenses with a poor outcome.

The adage ‘you get what you pay for’ is as true of medical providers as it is for anything. Try to partner with area providers that A: understand the world of workers’ comp — and if there are none, start educating area physicians; and B: have low litigation rates and high return-to-work outcomes.

Likewise for other medical providers, such as physical therapists. Look at the number of treatments, their average cost, and the outcomes.

Once you’ve identified the best providers, partner with them and direct injured workers to them where possible. In states where the employer cannot direct care, you can still provide information that lets the injured worker know who the top providers are.

2. Pharmacy Benefit Managers

Pharmacy benefit managers with good track records can be invaluable to a workers’ comp program. But again, you need to make sure you’re getting one that adds value to your company.

Where PBMs initially added value through lower prices, many have implemented clinical management programs to lower costs further and improve outcomes. It’s important to look at a PBM’s overall program to make sure you’re getting the best for your money.

Consider such things as pharmacy charges vs. pharmacy costs; the percentage reductions below the state’s fee schedule; the PBM penetration rate; cost per script; percentage of medications dispensed by pharmacies vs. physicians; and first fill rate.

3. Involvement of Nurses

Nurses can be brought in to help with a claim — nurse case managers; or they can be the initial source to help determine medical treatment — nurse triage.

NCMs are the point person for the injured worker and medical providers. Those who do it in-office are telephonic case managers, whereas those who go out of the office are field case managers. Evaluating the effectiveness of NCMs is easiest with a large database, to compare things like the cost of claims and number of lost workdays with and without a NCM. Your insurer and/or third-party administrator may be able to help.

To find the value of nurse case triage, you can look at the number of calls divided by the number of claims actually reported for workers’ comp, to get the number of claims avoided by percentage.  It’s also important to look at the training and experience of the nurses involved. One thing to be aware of is how invested the triage nurse is involved in the claim. Triaging is at the initial stage of the claim, not manage the claim — which is the job of the NCM, if there is one.

4. Bill Review

Medical Bill Review fees can be hidden and pricey, so it’s important to look for transparency from the claims administrator. There are many claim service providers now that have modified their BR fee structures so the costs are more obvious. Ideally you want a lower administrative cost for BR, combined with maximized savings.

You can find the net savings of your BR service by taking the gross savings (total charges minus total paid) and subtracting the BR service fees. Additional things you can measure to ensure you’re getting value are the percentage of net savings, the turnaround time, and the denied bill rate.

Conclusion

Price alone should not be the deciding factor for medical management tools; a holistic view of your services is best. However, you also want to make sure you aren’t shelling out more money than you are saving. Whether you are evaluating your current tools or looking for new ones, just make sure they lead to improved outcomes and lower costs, to get the best from your investment.

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

Author Michael Stack, Principal, COMPClub, 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 of COMPClub, an exclusive member training program on workers compensation cost containment best practices.

Contact: mstack@reduceyourworkerscomp.com.

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

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

©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.