Spot Over-Treatment from Medical Providers

medical over-treatmentMembers of the claim management team need to take control of their files to reduce workers’ compensation costs by spot unscrupulous practices by medical providers.  While a vast majority of providers are ethical, never let down your guard, and be proactive in identifying red flags when it comes to over-treatment by medical providers.

 

 

  1. The medical records are “template” style or barely exist at all.

 

A careful review is required when medical records all look the same.  It is important to note “template” style records that repeat does not mean you are dealing with a shady doctor.  It could just be that the doctor is very poor at note-taking.  Great doctors do great analysis and back up opinions with objective medical facts.  They arrive at this point by walking through the medical records and creating a great conclusive medical report.

 

 

  1. Missing dates of service, or no date labels on the medical notes

 

Missing dates of services are often paired with “template “style medical records.  The doctor uses a fill-in-the-blank system.  Typical examples include: Patient came in with complaints of _______ which they attribute to work causing them _____ pain out of 10, with 10 being the worst pain imaginable.

 

Pay attention to medical records generated by health care providers.  If anyone is watching, a physician will not get far by doing this.  On the other hand, if nobody is paying attention, thousands of dollars could be paid for unnecessary medical care and treatment.  Make sure the notes are clearly labeled, dated, and legible.  If not, you need to contact that physician’s office immediately.

 

 

  1. Different handwriting or inks on the same dates of service.

 

Some medical providers are not fully digital when it comes to the preparation of medical records.  A nurse or the medical assistant may make notes in a medical record before the doctor attends to the injured employee.  However, in some instances, this could mean notes are being manufactured.  Carefully review these records.

 

 

  1. The medical provider will not send medical records or state that they do not keep medical “records.”

 

All legitimate medical providers should keep records of patient interactions, including telephone calls and messages.  Even the most trivial of companies store records of some sort.  As a matter of best practice, refuse to pay any bill ever without a medical record.

 

 

  1. The medical notes showed continued high levels of pain.

 

All legitimate medical care and treatment should provide some relief to an injured employee.  If it is two months post-injury and the employee reports a pain level of “10 out of 10,” questions need to be raised as to what care is being provided, and why the injured employee is still suffering from the effects of the injury.  If the physician is not doing anything about it, or the person is no better, then you must find out what is going on medically and get that person to a specialist or set up an Independent Medical Exam(IME) to address these ongoing complaints.

 

 

  1. Conflicting medical reports or conflicting subjective complaints.

 

Take the following example:  You are reviewing a stack of medical records on a claim.  The injured employee states they are in very bad pain, 8/10.  It is hard to bend and walk.  The next day they show up for therapy, and they tell the therapist they are doing great, and they think treatment is really helping them.  Two days later they go back to the doctor and say they feel the same, about 7-8/10 pain. Then the same day they have therapy and tell the therapist they feel great, and are looking back to getting back to work.

 

Therapy can flare pain up a bit, but over a few weeks, the pain should be gradually lessened.  If you start to notice inconsistent pain complaints, and pain out of proportion to the injury, think about getting an IME to better understand what is going on.

 

 

Conclusions

 

All health care providers should have consistent billing practices.  They should be using standard billing forms such as a CMS/HCFA-1500 form so the bill can be processed and paid in a timely manner.  All medical bills should conform to the medical record that is often required to be attached to the bill.  If not, ask immediate questions. It is also important to ask questions if red flags are raised when reviewing medical records.  Failure to do so can result in excessive money being spent.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2019 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.

Reducing Work Comp Costs With Field Nurse Case Managers

Field Nurse Case ManagerInterested stakeholders in the workers’ compensation claims process should seek creative methods to reduce workers’ compensation program costs without cutting corners.  When looking for ways to reduce costs, the well being of the injured employee is paramount.  One step that can be taken is to use field nurse case managers to better direct care, and do so in a cost-effective manner.

 

 

It All Starts with the Claim Handler

 

When a claim handler is faced with a new and severe claim, it requires immediate attention. The injured worker may have a life-altering injury at work requiring emergency surgery before the adjuster even sees the claim. These injuries are crush injuries, severe fractures, spinal injuries, or closed-head injuries.  The claim handler should also ask the following questions:

 

  • Does the injured employee require an extended hospital stay?

 

  • Does the injured employee have adequate in-home medical care or is an outside service provider recommended?

 

  • Will the injured employee require more surgery?

 

These are questions that must be answered, and if the claim handler is unavailable, a Field Nurse Case Manager can be very useful.

 

 

What is a Field Nurse Case Manager?

 

Field Nurse Case Managers are typically a registered nurse who specializes in the coordination of medical care of injured employees in workers compensation cases.  They are aware of a variety of resources that manage the claim and bring a high level of medical care to the employee and ensure the proper utilization of services and resources.  They can serve as a “go-between” for the various other interested stakeholders – multiple medical facilities, doctors and other specialists, and vocational rehabilitation consultants.  They can also serve as a resource for friends and family members of the injured employee by ensuring the injured party receives a high quality of medical care when they are off work for an extended period.

 

 

Benefits of Field Nurse Case Managers

 

There are many benefits to using a Field Nurse Case Manager.  Here are some examples of how an employee can receive best in class service, while not requiring the insurance carrier to spend significant amounts of money on a claim.

 

 

  1. Help ease the transition from hospital to home and beyond.

 

Insurance carriers sometimes look at short-term costs, but forget the long-term risks.  It can be easily forgotten that employees who sustain serious trauma have virtually every aspect of their life impacted.  A Field Nurse Case Manager can assist in the transition by monitoring medical care and educating family members on the needs of the injured employee.

 

 

  1. Secure medical records faster than the claim handler.

 

A claim handler is often burdened with several important tasks that are time-sensitive, and requesting medical records is often a low priority that causes delays.  An experienced Field Nurse Case Manager will know where to go in the hospital, and who to speak with to get this much needed information.

 

 

 

  1. Help make a discharge from hospital to home easier.

 

 

Employees with severe injuries can receive medical care and treatment in-home.  By using a Field Nurse Case Manager, this care can be coordinated to take place by ensuring it is provided correctly, and assist with issues concerning transportation to/from appointments.

 

 

  1. Will stay on the case until the injured worker is stabilized.

 

The Field Nurse Case Manager assists the injured employee’s initial needs of moving from the hospital to home, ongoing medical care, and other issues.  They also serve as a point of contact regarding pressing medical concerns and can attend medical appointments with the employee.  There is also a benefit to working with a FNCM when it comes to chronic pain or mental health concerns.

 

 

  1. Provides the injured worker resources of care.

 

The Field Nurse Case Manager provides the injured employee a resource with all interested stakeholders.  By assigning a FCNM, the employee can better understand what care is best, provide answers to questions, durable medical equipment assistance, arrange in-home medical care, and seek to improve the employee’s daily life.

 

 

Conclusions

 

Field Nurse Case Manager workers have a special job coming to a severely injured worker needing help. They aid in many areas, not only to the injured party but also to the family. The Field Nurse Case Manager helps the carrier by obtaining much needed information about the injury, while at the same time assist the employer by providing updates on the injured employee’s status.  Most importantly, the worker gets help to focus on healing with quality service that only a nurse can provide.

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2019 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.

Weeding Out The Truth About Medical Marijuana

Medical MarijuanaMarijuana is illegal under federal law. But workers’ compensation stakeholders who think that gives them license to ignore the issue are making a huge mistake, according to experts.

 

The cannabis industry is growing by leaps and bounds and shows no signs of slowing. Most states now allow the drug in some form. Judges are increasingly siding with injured workers who want to be reimbursed for the drug.

 

Employers, especially those who do business in multiple states, need to know how to ensure a safe workplace, be fair to all employees and protect themselves from litigation. Staying abreast of the latest developments is key.

 

 

Some Basics

 

Terminology. Keeping up with the lingo can be exhausting, but payers who do have an edge when it comes to addressing the issue. Some important terms include:

 

  • THC: A cannabinoid that produces the ‘high’ that users experience
  • CBD: A molecule touted as having potential medical benefits without the psychoactive properties of THC.
  • Hemp: A strain derived from the species cannabis sativa, as is marijuana, but with lower concentrations of THC and more CBD. The Agricultural Improvement Act signed into law recently removed hemp from the list of Schedule I controlled substances and made it an ordinary agricultural commodity. CBD derived from hemp has recently become widely available.
  • Strains: There are hundreds of combinations, mainly from three strains:
  1. Indica — produces a more relaxing effect
  2. Sativa — is more energizing
  3. Ruderalis — has low levels of both THC and CBD.
  • Budtender: The person at a ‘dispensary’ who gives advice about which varieties may be more helpful to the user

 

 

Physical Effects

 

Whether and to what extent marijuana helps with various physical or mental conditions is a matter of debate, since the federal prohibition of the drug stymies research on it. But there is some evidence it may help alleviate chronic and neuropathic pain, cancer pain, and spasticity. Some people claim it can also help with anxiety, post-traumatic stress disorder, traumatic brain injury, depression or acute pain. There are conflicting studies about whether marijuana can serve as a viable substitute for opioids, but the most recent study suggests it does not.

 

High doses of marijuana, especially when it’s ingested as an edible, can have serious repercussions. Some users have gone to emergency rooms believing they are having a heart attack. In addition to the potentially positive impacts, the drug can also cause a variety of unpleasant symptoms, including:

 

  • Rapid, irregular heart rate
  • Anxiety
  • Lung irritation
  • Coughing, wheezing
  • Nausea, vomiting
  • Various exacerbations of serious psychiatric conditions such as depressions, bipolar illness, schizophrenia and other psychotic disorders.

 

 

Problems for Employers, Payers

 

Drug testing to identify marijuana users high on the job may be counterproductive. Since the drug stays in the body long after its effects have worn off, the tests can’t really determine if a person is impaired. Workers in safety-sensitive jobs are another story, as they are prohibited from performing their jobs if there is any sign of drug use identified.

 

However, for other workers, employers may notice certain signs that could indicate an employee is under the effects of marijuana:

 

  • Slowed responses and reflexes
  • Lethargy, drowsiness
  • Slowed perception of time; appearing in an almost dreamlike state
  • Unfocused
  • Impaired memory function
  • Red eyes or dilated pupils

 

Employers who suspect their workers of being high on the job must be careful about how they respond. Unless they have clear-cut policies that allow for drug testing when they suspect impairment, organizations can be accused of discriminating against certain employees. Working with an attorney and developing a solid policy that is communicated to all employees is imperative.

 

Another major concern for payers concerns the logistics for reimbursement. It’s not like other, FDA-approved drugs, where a physician prescribes a certain dose, number of pills per day and timeframe for use. Physicians in medical marijuana states can only recommend using the drug. It’s then up to the user, working with the budtender, to determine what might help.

 

The many different strains mean one purchase may be different from another. There are many inconsistencies in terms of the quality and purity as well as labeling — within states and even within communities.

 

However, as the pharmaceutical companies begin to derive purer and more targeted compounds from marijuana, we will likely see more employees using prescribed, rather than marijuana dispensary, formats which will reduce the rationale for using the latter, and will provide safer, efficacious and accurately dosed drugs.

 

The best advice from experts is to work closely with all stakeholders involved, including the injured worker. Working with the physician, for example, might persuade her to prescribe a treatment or medication other than marijuana. At the very least, it could help determine how much and for how long the drug will be used. Having more and better communication with the injured worker can provide insight into whether and why he believes marijuana is the best option and help determine the anticipated expense.

 

 

Conclusion

 

The issue of medical marijuana is not an easy one for workers’ compensation stakeholders right now, but it should not be ignored. Regardless of personal feelings about the issue, organizations are increasingly being forced to deal with it. Those who understand their states’ laws and the various nuances involved, and work with other stakeholders will be best prepared when it arises.

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2019 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.

NCCI Report Highlights Early Identification of Prescription Drug Abuse

Prescription Drug AbusePrescription drugs continue to contribute to a significant portion of medical costs in workers’ compensation claims nationwide.  This is due in part to opioid addiction and its negative impact.  Gains are being made, which means proactive members of the claim management team need to be continually engaged and implement best practices to avoid addiction and reduce the portion of claims consumed literally by prescription drugs.

 

 

NCCI Report Highlights the Problem

 

The National Council on Compensation Insurance (NCCI) recently released a report regarding prescription drug costs in workers’ compensation case.  The report sets forth the following encouraging conclusions:

 

 

  • While the prescription drug share of medical costs in workers’ compensation cases is at 13.7%, this amount declined by 2% in 2015, and 4% in 2016; and

 

  • Main drivers in prescription drug usage include Lyrica, OxyContin, and Gabapentin, which account for more than 15% of prescription drug costs in 2016.

 

While some of these trends are positive, it should still be understood that more can be done by proactive claim handlers to control the costs of prescription drugs in workers’ compensation claims and run a more effective program.

 

 

Early Identification of Prescription Drug Abuse

 

All interested stakeholders should be on the look-out of for overuse and abuse of prescription drugs.  Signs of misuse include the following:

 

  • Identification of injured employee’s with risk factors that include past/present history of substance abuse, family history of substance abuse, and various psychological and/or psychiatric conditions;

 

  • Injured employees that specifically request prescription medications by their name brand and refuse to accept generics; and

 

  • Instances where someone regularly claims to lose their prescription drugs and is requesting a refill.

 

The existence of a pain management agreement is a common feature in most workers’ compensation laws in instances where an employee is using opioid-based drugs.  This agreement should be strictly followed.  There should also be a renewed effort on the part of everyone to direct an injured employee back to work, even if it is in a light-duty/sedentary capacity.  Studies suggest strong return-to-work efforts significantly reduce the medical spend on any type of personal injury claim.

 

 

Multi-Faceted Approach to Reducing Prescription Medical Expenses

 

Proactive stakeholders in the workers’ compensation system can advocate for change to reduce the cost and human toll prescription drugs – mainly opioid-based – take on injured employees.  This includes an effective three-pronged approach.

 

  1. Prevent new cases of opioid-based prescription medication abuse from occurring: This all starts with the use of a pain management agreement – and making sure it is strictly enforced.  This zero-tolerance approach will ensure powerful pain medications are not misused or abused.  Terms within the agreement should include exactly how the medications are to be used, random drug testing and consequences for false/positives, failed tests and missed testing, how replacement medications are to be dispensed and where all prescriptions are to be filled – avoiding physician dispensing protocols.

 

  1. Treat people who are addicted with compassion: No process is foolproof, and anyone can become addicted.  It is important to treat individuals who suffer from this consequence are treated with respect and dignity.  All reasonable and necessary forms of treatment should be made available; and

 

  1. Use drug utilization measures to better target prevention and treatment: This is one of the most effective tools available to members of the claim management team in combating the abuse and overuse of opioid-based prescription medications.  Drug utilization review (DUR) is the process of reviewing all aspects of prescription drug usage – prescribing, dispensing, and use of medication.  It examines the individual usage of someone against predetermined criteria based on evidence-based medicine to ensure an effective and efficient result.  The recent NCCI report also credited the effective use of DUR in driving down the amount of money spent on prescription drugs in workers’ compensation claims.

 

 

Conclusions

 

There are many negative consequences of prescription drug abuse and misuse in workers’ compensation cases.  Steps are being taken to hold these adverse effects in check and also reducing workers’ compensation program costs.  This can be accomplished by implementing an effective approach that includes drug utilization review in your program.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2019 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.

11 Tips for Safe Use of NSAIDS to Treat Pain in Workers’ Compensation

NSAIDs in Workers' CompensationThere’s good news about the latest drug usage in the workers’ compensation, although it comes with a word of caution. The good news, according to the latest Drug Trend Report from myMatrixx is that the use and spend on opioids have once against decreased. Alternative medications treatments are being used more often to treat pain. While that’s good in the effort to prevent unnecessary use of opioids, one class of medications need to be taken with caution.

 

NSAIDs — nonsteroidal anti-inflammatory drugs— have become one of the medications of choice to treat pain. These can be very effective and don’t carry the risks of addiction or dependence of opioids. However, the problem is the potential negative effects on the cardiovascular system. Care needs to be taken when prescribing them, especially to older workers.

 

The situation is something of a Catch-22; older injured workers often have pain, but they are typically more vulnerable to problems of the cardiovascular system. Payers can help protect injured workers who are prescribed these medications by understanding the risks, educating patients and exercising caution.

 

 

NSAIDs and Cardiovascular Issues

 

NSAIDs are often used to treat mild to moderate pain. They are especially helpful for pain caused by inflammation, such as arthritis or a sports-type injury.

 

NSAIDs are drugs with analgesic, anti-inflammatory, and antipyretic activity. Some of the commonly used over-the-counter varieties are ibuprofen, such as Motrin and Advil; and naproxen sodium, or Aleve and Anaprox. Prescription NSAIDs include Celecoxib, or Celebrex; and diclofenac, known as Cataflam and Voltaren. Aspirin, which is an NSAID, does not pose a risk of heart attack or stroke and is commonly used to prevent those conditions.

 

Gastrointestinal problems associated with NSAIDs are well known. But researchers have also found that these medications can increase blood pressure and lead to congestive heart failure, as well as acute myocardial infarction.

 

The Food and Drug Administration warned of the potential risks of heart attack or stroke from NSAIDs in 2005. Ten years later the agency strengthened its warning, based on the advice of an expert panel that had reviewed additional information.

 

The risk was especially noted when the drug rofecoxib, or Vioxx, was on the market. It was removed in 2004, after being associated with as many as 140,000 heart attacks in the U.S. during the five years it was sold. It prompted further research about the risks of heart attack and stroke from NSAIDs in general.

 

According to the FDA:

 

  • The risks of heart attacks and strokes increase even with short-term use of NSAIDs and may begin within a few weeks of taking the medications.
  • The higher the dose of NSAID, the higher the risk. Also increasing the risk is the length of time the medications are taken.
  • People most at risk are those who already have heart disease, although others can also be at risk.

 

Patients taking diuretics may be at the highest risk of heart attack or stroke, especially during the first few weeks of taking NSAIDs.

 

 

Preventing NSAID Risks

 

Taking NSAIDs for a few days to relieve pain generally carries just a small risk, for most people. Employers and payers can help ensure injured workers are less at risk of developing heart attacks or strokes from the medications through the following strategies:

 

  1. Monitor for signs and symptoms of adverse effects.
  2. Educate injured workers and family members on the risks, especially those more at risk.
  3. Prescribe the lowest dosage possible.
  4. Prescribing taking the drugs for only a limited period of time.
  5. Try alternative remedies for people who have heart disease, if at all possible.
  6. Do not take more than one type of NSAID at a time.
  7. Try alternative medications, such as acetaminophen. Be aware, however, that this drug can cause liver damage if the daily limit exceeds 4,000 milligrams or if the person drinks more than three alcoholic beverages a day.
  8. Suggest week-long NSAID ‘holidays’ on occasion.
  9. Advise the injured worker to get medical attention immediately if he experiences chest pain, shortness of breath or sudden weakness or difficulty speaking.
  10. For muscle or joint pain, suggest hot or cold packs or physical therapy before NSAIDS, for those more at risk.
  11. Injured workers already taking aspirin to prevent a heart attack should talk with their physician first, as some NSAIDs may hamper the aspirin’s effectiveness.

 

Conclusion

 

The workers’ compensation industry has made inroads in curbing the unnecessary use of opioids. However, care needs to be exercised before giving an injured worker a blanket recommendation or prescription for NSAIDS, especially for people who have pre-existing heart-related conditions. As with all medications, moderation is key.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2019 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.

Keeping Up With Clinical Trends – Use Of Hepatitis C Medications In Workers’ Compensation

Kathy-Tiemeier myMatrixxHepatitis C, a viral infection of the liver caused by the hepatitis C virus (HCV), can be spread through contaminated blood and other body fluids. The infection can range in duration from a few weeks (acute) to a life-long illness (chronic). Between 75% and 85% of the people who become infected with hepatitis C will develop the chronic form1, CHC, which now affects more than 3 million people in the U.S.2 CHC may lead to chronic liver diseases, including cirrhosis and liver cancer. With the 2011 arrival of newer therapies to treat HCV (specifically direct-acting antiviral therapies, or DAAs), alcohol-related liver disease now has surpassed HCV as the leading cause of liver transplantation in the U.S., and HCV as an indication for liver transplantation is expected to continue its decline.3

 

 

I have received a request for a medication to treat hepatitis C. Will you please tell me why hepatitis C drugs might be needed to treat an occupational injury?

 

While we don’t see a lot of hepatitis C patients in workers’ compensation, it may be appropriate for claims under certain situations. Occupational exposure to hepatitis C could result from needlesticks in some injured worker populations, such as healthcare personnel, first responders and other municipal workers. The risk of HCV infection following a needlestick or sharps exposure to HCV positive blood is approximately 0.1%.1Injured patients who received blood or organs from an HCV-positive donor also could be infected.

 

Unlike for hepatitis A and hepatitis B, no vaccine currently is available for hepatitis C.1 Further, not enough evidence is available to support the effectiveness of post exposure prophylaxis, or PEP, after potentially being exposed to HCV.4

 

 

Recommendations from the Centers for Disease Control and Prevention (CDC)5:

 

  • PEP is not recommended for hepatitis C.
  • PEP following an occupational needlestick does include antiviral drugs for human immunodeficiency virus (HIV) and vaccination for hepatitis B, however.
  • Pre-existing chronic infection:
    • The occupationally exposed worker should be tested within 48 hours of exposure to determine the presence of antibodies to the hepatitis C virus (anti-HCV).
    • Anti-HCV will be present if the exposed worker has previously been infected with hepatitis C. If positive, further testing and referral to care for pre-existing CHC infection may be needed.
  • Infection as a result of the occupational exposure:
    • Those who test negative within the first 48 hours should be tested for HCV RNA three or more weeks after exposure to determine whether HCV then exists in the exposed worker’s bloodstream, with referral for care for a positive test as a result of the occupational exposure.6
    • Patients may spontaneously clear an acute infection up to six months after exposure. Therefore, all exposed workers who test positive in less than six months should be tested again at least six months after exposure to determine existing infection status.

 

 

Are the newer hepatitis C drugs much different from the older ones and why are they so expensive?

 

In addition to the cost of treatment, the choice of medication treatment protocol should take into account the genetic makeup, which is known as the “genotype”, of the virus. Hepatitis C has seven recognized viral genotypes1. Knowing the genotype is important to determine the most appropriate medications once a person has been diagnosed with CHC. In the U.S., about 70% of CHC cases are genotype 11, which has a lower response rate to older hepatitis drugs like ribavirin and injectable pegylated interferon, than other genotypes.7

 

DAAs, the newer treatment options for CHC, are available in oral form, so they are more convenient to use. They are much more expensive than earlier drugs; but they produce substantially higher cure rates than the older medications, more than 90% for many patients in as little as eight weeks. Before DAAs were introduced, the success rate for previous HCV therapies was only about 41% and severe side effects often were associated with using them.8

 

Curing an exposed worker of the HCV infection prevents chronic liver disease and possible liver cancer or transplantation. In addition, DAA medications are effective for most patients without requiring multiple courses of therapy. Even at their high initial cost compared to other drugs, they typically cost much less than managing liver cancer or undergoing a transplant along with their corresponding follow-up treatments.

 

 

I have heard some of the newer hepatitis C drugs have generics. Can you provide details?

 

Yes. Authorized generics to Harvoni® (ledipasvir 90mg/sofosbuvir 400mg tablets) and Epclusa® (sofosbuvir 400mg/velpatasvir 100mg tablets) became available early 2019. Gilead Sciences, Inc., the manufacturer of both medications, made them accessible through a newly created subsidiary, Asegua Therapeutics LLC. The Average Wholesale Prices (AWP) for the generics are significantly less than the brand name medications.

 

 

Do DAAs have any drawbacks?

 

Treatment for CHC is evolving quickly, and so are treatment guidelines. The promising news is the DAAs that cure hepatitis C offer hope of eliminating it in the near future. Unfortunately, however, data from the CDC indicate the number of new HCV infections is on the rise. From 2010 to 2015 the number of acute hepatitis C cases reported to the CDC nearly tripled – mainly from increased injection-drug abuse. Improved case detection contributed to this increase as well, but to a much lesser degree. 9 Symptoms are often mild and vague in acute cases, making diagnoses difficult.

 

Not every patient is cured after one course of DAA treatment. A small percentage fail the initial therapy and need another round, usually with a different set of drugs. Hepatitis C will recur for some treated patients and others may be re-infected after CHC has been cured.

 

Another major concern related to the development of new HCV therapies is the emergence of resistance to DAA drugs. Drug resistance occurs when the hepatitis C virus no longer responds to treatment. This challenge to chronic HCV treatment is developing rapidly and it already has shown clinical impact on available DAA regimens. Drug-resistant viruses most frequently develop when drug doses are below therapeutic levels. However, they can also emerge when DAA therapy fails.10,11

 

 

CONCLUSION

 

As stated previously, within workers’ compensation, the prevalence of hepatitis C is rare. However, the higher cost of new drug therapies can make a significant impact on workers’ compensation payers even if only used by a small portion of their injured worker population. Curing the infection is important, though, to prevent progressive liver damage that can result in debilitating and costly outcomes.

 

 

  1. Centers for Disease Control and Prevention. Hepatitis C questions and answers for health professionals. https://www.cdc.gov/hepatitis/hcv/hcvfaq.htm#section1. Last updated April 30, 2018. Accessed Dec. 7, 2018.
  2. U.S. Department of Health and Human Services. Office of Population Affairs. Hepatitis C. https://www.hhs.gov/opa/reproductive-health/fact-sheets/sexually-transmitted-diseases/hepatitis-c/index.html. Last reviewed April 10, 2018. Accessed Dec. 7, 2018.
  3. Cholankeril G, Ahmed A. Alcoholic liver disease replaces hepatitis C virus infection as the leading indication for liver transplantation in the United States. Clin Gastroenterol Hepatol. 2018;16(8):1356-1358. doi: 10.1016/j.cgh.2017.11.045.
  4. Hughes HY, Henderson DK. Postexposure prophylaxis after hepatitis C occupational exposure in the interferon-free era. Curr Opin Infect Dis. 2016;29(4):373-380. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5527758/. Accessed Dec. 7, 2018.
  5. Centers for Disease Control and Prevention. Information for healthcare personnel potentially exposed to hepatitis C virus (HCV). https://www.cdc.gov/hepatitis/pdfs/testing-followup-exposed-hc-personnel.pdf. April 2018. Accessed Dec.7, 2018.
  6. American Association for the Study of Liver Diseases and Infectious Diseases Society of America. HCV testing and linkage to care. https://www.hcvguidelines.org/evaluate/testing-and-linkage. Last updated May 24, 2018. Accessed Dec. 7, 2018.
  7. NIH Consensus Statement on Management of Hepatitis C: 2002. NIH Consens State Sci Statements. 2002;19(3):1-46. https://consensus.nih.gov/2002/2002HepatitisC2002116html.htm. Archived. Accessed Dec. 7, 2018.
  8. Pharmaceutical Research and Manufacturers of America. Twenty-five years of progress against hepatitis C: setbacks and stepping stones. http://phrma-docs.phrma.org/sites/default/files/pdf/Hep-C-Report-2014-Stepping-Stones.pdf. December 2014. Accessed Dec. 7, 2018.
  9. Centers for Disease Control and Prevention. Viral hepatitis. https://www.cdc.gov/hepatitis/statistics/2015surveillance/commentary.htm. Last updated June 19, 2017. Accessed Dec. 7, 2018.
  10. American Association for the Study of Liver Diseases and Infectious Diseases Society of America. HCV resistance primer. https://www.hcvguidelines.org/evaluate/resistance. Last updated May 24, 2018. Accessed Dec. 7, 2018.
  11. Downward E. Drug resistance. HepatitisC.net. https://hepatitisc.net/treatment/drug-resistance/. Last reviewed March 2018. Accessed Dec. 7, 2018.

 

Kathy-Tiemeier myMatrixxAuthor Kathy Tiemeier, RPh, DAIPM, myMatrixx, Senior Clinical Account Executive. myMatrixx, an Express Scripts company, offers best-in-class pharmacy services for workers’ compensation programs that include: formulary and network management, utilization management, claims processing, home deliver and specialty pharmacy care and physician outreach programs. Working with the financial and risk management leaders of organizations, myMatrixx helps reduce the pharmacy cost associated with injured workers through innovative programs, business analytics and robust clinical protocols and expertise.

 

To learn more about our Clinical programs, email Clinical@myMatrixx.com.

Fentanyl in Workers’ Compensation – 4 Ways to Keep Injured Workers’ Safe

Fentanyl in Workers' CompensationFentanyl is 100x stronger than morphine. Carfentanil is 100x stronger than fentanyl. For injured workers who become addicted to prescribed opioids, that can be a death sentence.

 

Armed with information about the latest illicit drugs and a willingness to adopt certain strategies, payers can ensure their injured workers get the most appropriate treatment and avoid becoming victims of the latest drug nightmare.

 

 

Heroin, Fentanyl, and Analogues

 

The dangers of unnecessary opioid use have been well documented and publicized for several years. To its credit, the workers’ compensation has been at the forefront of efforts to stem what has become a national crisis. But often overlooked are injured workers who already are, or become addicted to these prescription drugs and turn to the illicit drug market for relief.

 

Opioid prescribing dropped by nearly 9 percent in 2017, according to some accounts. However, some injured workers who were already addicted turned to heroin, leading to fatal overdoses from that drug. More recently, additional drugs have taken over the market, many of which are far more potent than opioids.

 

As described in It’s Not Just Heroin Anymore, a white paper from myMatrixx, synthetic opioids such as fentanyl have risen on the black market, mainly due to economics. Where heroine requires growing the opium poppy plant, harvesting the resin and processing it into the final product, fentanyl is purely synthetic, meaning it can be made easily and cheaply.

 

“Fentanyl is 50 times more potent than heroin and 100 times more potent than morphine,” according to the research paper. “Even more alarming, however, is the fact that there are compounds with molecular structures closely similar to fentanyl (analogues) that are drastically more potent and these are now making their way into the hands of drug addicts.”

 

Illicit makers of fentanyl have found in analogues a way to circumvent the regulations of the Controlled Substances Act. The CSA classifies substances based on their chemical identity. Since the fentanyl analogues are not on the list as identified controlled substances, they, technically, are not illegal substances.

 

There are 4 fentanyl analogues that are legal for medical use, including:

  • Carfentanil, only for veterinary use, it is normally dispensed as an elephant tranquilizer. It is 100 x stronger than fentanyl. myMatrixx notes it has been linked to increases in overdoses in the Midwest in particular.
  • Sufentanil
  • Alfentanil

 

 

Other analogues of fentanyl are Schedule I under the Controlled Substances Act.

 

 

What to Do

 

Most people prescribed opioids do not become addicts; however, anyone can develop an addiction. That is why it is imperative for workers’ compensation stakeholders to take every precaution to prevent addiction and address it appropriately in injured workers affected.

 

Here are ways payers can keep their injured workers safe:

 

  1. Educate providers. Despite their good intentions, some treating physicians are not trained in dealing with pain and/or opioid prescribing. They may also not follow evidence-based guidelines. Payers who develop solid relationships with network and/or area physicians can work with them and make sure they understand how to mitigate the risks.

 

For example, providers should know to:

 

  • Avoid prescribing opioids as a first line therapy
  • Screen patients for addiction before starting opioid therapy and continuously throughout treatment
  • Conduct urine drug screenings to monitor compliance
  • Be aware of, and adhere to formulary restrictions
  • Watch for, and address aberrant behavior
  • De-escalate or discontinue opioid therapy when necessary

 

  1. Provide strong clinical oversight, of physicians and pharmacies. Working with a pharmacy benefit manager and/or carrier is a place to start.
  2. Ensure providers are aware of alternative therapies to opioids and encouraged using them
  3. Intervene when there are concerns of opioid overprescribing. Having another physician talk with the provider can be effective. Insurers and/or third-party administrators often have medical personnel available to help.

 

 

Summary

 

The opioid crisis within the workers’ compensation system has improved in recent years. However, it is far from over. Stakeholders should stay up-to-date on the latest issues surrounding the problem and take steps to protect their injured workers.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2019 Amaxx LLC. All rights reserved under International Copyright Law.

 

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

6 Triggers for When, And When NOT to Use Nurse Case Managers

when to use nurse case managementNurse case managers are a hot topic in workers’ compensation, and with good reason. Used properly, they can generate great results for organizations in getting injured workers back to work as soon as possible and saving precious dollars for organizations. But there is often misunderstanding about how and when to use Nurse Case Managers. For example:

 

  • Should you use a Nurse Case Manager on every workers’ compensation claim?
    • No
  • If a Nurse Case Manager is used, should it be for the entire duration of the claims process?
    • No
  • Is there a difference in telephonic vs. field Nurse Case Managers?
    • Yes

 

Nurse Case Managers can reduce litigation rates, foster patient engagement in the recovery process, and provide vital communication among all stakeholders. They can also be a waste of money and add little value.

 

Understanding when and how to use Nurse Case Managers is key to getting the best bang for the buck.

 

 

What They Can Do

 

Research showing the potential value of Nurse Case Managers has resulted in some companies using them on every single claim from beginning to end. Many of these companies then wonder why they are spending so much money without seeing a return on investment, so they discontinue using Nurse Case Managers altogether. Both are a mistake.

 

Here are some of the many ways Nurse Case Managers can help on a workers’ compensation claim:

 

  • Advocate and educate. The best reason to use a NCM is to help an injured worker who is frightened, confused and angry — often a recipe for litigation. The NCM can educate and advocate for the injured worker and guide him through the entire process, so he knows what to expect. The NCM can also inform employers on how the injured worker is progressing, and work with the treating physician to make sure the worker is getting appropriate care.

 

  • Flag potential problems. If the injured worker has psychosocial or pain management issues or needs durable medical equipment, the NCM can spot that early in the claims process and help coordinate the necessary treatment.

 

  • Communicate with all stakeholders. The NCM can keep everyone in the loop, so necessary details don’t fall through the cracks.

 

 

When to Use Nurse Case Managers

 

Simple, medical-only, and claims where the injured worker is highly engaged and anxious to return to full duty as quickly as possible do not signal the need for a NCM. On these and other cases the addition of a case manager is unnecessary and a waste of money.

 

More complex claims are where Nurse Case Managers can have a significant impact. Certain claims should trigger involvement from a NCM, including:

 

  1. Lost time. Workers who are off the job for more than a couple of days can benefit from extra involvement. A NCM can answer the injured worker’s questions and ensure he is complying with the treatment plan.

 

  1. Surgery is needed. Even if it is a medical-only claim, the need for surgery should be a red flag to get a NCM on the claim. There will be many things going on, such as preparing at home, the need for and type of pain medications after, and any DME that might be temporarily needed. The NCM can coordinate the various moving parts.

 

  1. Failing to attend scheduled medical appointments. Whether the worker is off the job or working in some capacity, failing to see treating physicians, physical therapists and other providers is a sign there may be a problem. A NCM can contact the injured worker and either get the person to comply or find out if there is an underlying problem that should be addressed.

 

  1. Comorbid Conditions. An injured worker with diabetes, obesity, hypertension or other comorbid conditions is prime for a more complicated claim. A NCM can help keep the claim on track.

 

  1. Uncooperative treating physician. If the injured worker’s primary physician continues to say the patient needs to stay out of work entirely, a NCM can intervene, find out why the person is not recovering, and explain return-to-work principles — such as light duty and employer accommodations.

 

  1. Catastrophic and/or multiple injuries. These claims involve many people and moving parts. A NCM can be the go-to person for all parties involved, including the injured worker and his family. The NCM can also make any arrangements needed, and keep costs down by selecting the most appropriate equipment.

 

 

When to End NCM Involvement

 

Putting a NCM on a claim doesn’t need to be a long-term prospect. These can be short assignments — even just one or two visits or calls. Depending on the complexity of the claim and ongoing issues, the NCM may need to contact the injured one time to keep him on track and in compliance with medical appointments; or may need to reach out to the treating physician for something simple; or discuss accommodation possibilities with the employer. The earlier a NCM intervenes in a claim, the shorter the assignment typically is.

 

You can gauge when the NCM is no longer needed, for example:

 

  • The injured worker is back to work in at least a light duty capacity
  • Stakeholders are communicating well with one another
  • Restrictions are decreased, and the worker is progressing well

 

 

Conclusion

 

Nurse Case Managers can add tremendous value to a claim, generating optimal outcomes for injured workers and lower costs for payers. But it is not a black and white issue; meaning they don’t need to intervene in every single case, and they don’t need to be involved indefinitely. Thinking through a strategy for using Nurse Case Managers can have a significant impact on claims.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

 

Compounded Medications — 6 Solutions to Address a Nagging Issue for WC

Compounded Medications — 6 Solutions to Address a Nagging Issue for WC“There is no such thing as an FDA-approved compound medication.” That statement from myMatrixx Chief Clinical Officer Phil Walls underscores one of the main criticisms of these medications; while the drugs within the mixtures may all be FDA-approved, the specific combinations have not been tested and verified.

 

Safety is just one concern, however. The other is cost; they generally are priced significantly higher than similar, FDA-approved drugs or the sum of their underlying medications.

 

Both the utilization and the average cost of compounded medications in the workers’ compensation system has decreased in recent years. However, there are still pockets of excessive use. Stakeholders need to maintain a steady and continued focus on efforts to curb the unnecessary use of these pharmaceuticals.

 

 

Problems Cited

 

Compounds are a mixture of drugs intended for a specific patient’s use. According to an FDA report, they are beneficial only in limited circumstances; such as when other medications have failed, a patient is allergic to some of the inactive ingredients or has difficulty swallowing.

 

The federal agency inspected compounding facilities and noted the following “troubling conditions” that could lead to widespread harm of patients:

 

  1. Toaster ovens used for sterilization.
  2. Pet beds near sterile compounding areas.
  3. Operators are handling sterile drug products with exposed skin, which sheds particles and bacteria, among many others.

 

 

Latest Stats

 

Compounded medications are not considered first-line therapy for pain or other common conditions of injured workers according to industry guidelines, such as evidence-based medicine guidelines from Work Loss Data Institute, American College of Occupational and Environmental Medicine, and many other state-specific guidelines.

 

Compounds are available in many applications but are used in workers’ compensation most often as topical products for pain management. Usually, compounded medications are excluded from workers’ compensation formularies, and require prior authorization before they are dispensed to an injured worker.

 

State legislatures and organizations within the workers’ compensation system have taken steps in recent years to reduce the overuse of compounds, and they have been largely effective, according to the most recent Drug Trend Report in the workers’ compensation system from myMatrixx:

 

  • Spending on compounded medications declined 37.1 percent in 2017
  • It was the third year in a row that payer spending on compounded drugs has decreased
  • Compounds fell from the top 10 therapy classes
  • Utilization decreased 21.2 percent
  • The average cost of compounded medications decreased 15.9 percent

 

Along with the good news, however, are some disturbing reports.

 

Recent Problems

 

  • Pennsylvania. A recent report found that legislative reforms in the state resulted in cost savings on physician-dispensed drugs; however, they were offset by an increase in pharmacy dispensing of expensive compound drugs.

 

The legislation that took effect in December 2014 capped prices paid for physician-dispensed drugs and restricted physician’s ability to dispense opioids and other drugs to limited timeframes. The Workers Compensation Research Institute found there was an associated decrease in the number of injured workers who received physician-dispensed drugs. But they also found there was a “dramatic” increase in the prescription payments for compound drugs in the same years, which it attributed to the emergence of new pharmacies dispensing expensive drug products, especially compound drug prescriptions.

 

  • Texas. A loophole in the state’s drug formulary allowed compound prescriptions to be filled without obtaining preauthorization to confirm medical necessity. Regulators said the workers’ compensation system saw a 46.4 percent increase in compound prescriptions from 2010 to 2014, with the total cost of an average prescription more than doubling from $356 to $829.

 

 

Solutions

 

A new rule amended the Texas formulary to exclude any prescription drug created through compounding and required preauthorization for all compounded medications. That rule took effect July 1. Several additional states have adopted similar measures, including Arkansas, Oklahoma, Florida, Nevada and Tennessee, and the idea is being considered in other jurisdictions.

 

The National Conference of Insurance Legislators is considering model legislation with clearly established guidelines for the reimbursement of pharmaceutical products in the workers’ compensation system. It includes language that would limit compound medications and require a critical evaluation with a physician documented statement of medical necessity or a utilization review of the compounded pharmaceutical products.

 

Stakeholders can work closely with state regulators and legislators. Additional ways to address the issue of excessive use of compound medications include:

 

  1. Working closely with a pharmacy benefit manager to ensure compounds are used judiciously and only when preauthorized
  2. Payment limits. Placing reimbursement limits per each script or per each ingredient in a compound medication
  3. Limiting the number of ingredients or the total cost per script
  4. Retrospective review. Allowing employers the option to deny coverage for a compound medication that has not been preauthorized
  5. Network pharmacies. Allowing employers to direct injured workers to specific pharmacies
  6. Including compound medications in the list of medications allowed only with preauthorization

 

 

Conclusion

 

The overuse of compound medications has been a troubling area for workers’ compensation stakeholders for several years. Strategies to address the issue are effective but must be continually employed and updated to ensure the problem is appropriately managed.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

How to Use HIPAA to Obtain Timely Medical Records

Members of the claims management team obtain medical records on a frequent basis when investigating workers’ compensation claims.  It is important they do this promptly given the many constraints of workers’ compensation laws.  Given the nature of these requests, state and federal privacy laws come into play.  Failure to understand these laws and their requirements can lead to delay and problems down the road.  Now is the time to better understand these laws and how to incorporate them into your team’s best practices.

 

 

It All Starts with HIPAA

 

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) serves as the basis for healthcare privacy and the dissemination of medical records in the United States.  The law was enacted in 1996 to address the many issues medical providers were facing and to protect the privacy of all individuals.  In essence, it serves as the baseline for standards enacted at the state level for all covered entities.

 

 

Understanding the Basics of HIPAA

 

To understand the law, it is important to understand when it applies and whom it protects.  HIPAA applies to all “covered entities,” which are defined under 45 C.F.R. §160.103, as:

 

  • Health care providers who transmit “protected health information;”

 

  • Entities that process personal health information (healthcare clearinghouses);

 

  • Health plans such as Group Health Plans; and

 

  • Any business partner of a “covered entity.”

 

It is also important to note that the federal law applies to “protected health information,” otherwise known as PHI.  This is information defined under 45 C.F.R. §164.501, which is individually identifiable health information maintained or transmitted in any form, whether electronically, on paper or orally.

 

 

Exceptions to HIPAA in Work Comp

 

Employees at healthcare providers are required to know and understand HIPAA and have a duty to protect a patient’s PHI.  Training is required for these entities as part of their ability to do business.  Problems arise when employees at these facilities do not understand the nuances of HIPAA and how a state workers’ compensation act allows members of the claims management team to obtain PHI without properly executed authorizations.  One such exemption is found under 45 C.F.R. §164.512(l), which states, “A covered entity may disclose protected health information as authorized by and to the extent necessary to comply with laws relating to workers’ compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.”

 

 

Effectively Using the “Work Comp” Exception

 

Although this exception to HIPAA allows for easier access to a patient’s PHI, there are important limitations and requirements one must first understand.  Failure to understand these issues can result is frustration, delay, and sanction.

 

  • The permissible release of PHI is limited to only medical records directly related to the work injury in question. It does not provide for the cart blanche release of “any and all medical records;”

 

  • State workers’ compensation and other privacy laws often require the requesting party to notify the injured worker in writing they are making a request. Additional requirements sometimes require the requesting party also to disclose the medical records obtained from a provider to the injured party; and

 

  • Failure to make the necessary request disclosures may result in a sanction against the requesting entity.

 

It is also important to note that medical providers releasing documents under this exception may charge the requestor reasonable copy and retrieval fees.

 

 

Conclusions

 

It is important for members of the claims management team to obtain medical records in a timely manner.  Part of this can include the request of medical records related to a workers’ compensation claim under HIPAA without obtaining written authorization.  Before making these requests, it is important for claim handlers to know the necessary rules and follow them to avoid problems down the road.

 

 

 

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

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

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

 

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

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