Traumatic Brain Injuries and Effective Workers’ Comp Claims Management

Properly Handling Mental Cases in Workers' CompensationGrowing awareness of traumatic brain injuries (TBI) requires members of the claim management team and other interested stakeholders to learn, and understand more about these complex injuries. This includes having a firm grasp on conditions associated with injuries to the head, common diagnostic testing, signs of injury, and proper investigation techniques.

 

 

What is a Traumatic Brain Injury?

 

Traumatic Brain Injuries do not fit one specific pattern or mechanism.  It can include a variety of physical and psychological effects that result from blows to the head, or whiplash type events.  The signs and symptoms of a TBI can vary, including the onset of symptoms shortly after the event.  Common signs of a TBI include the following:

 

  • Loss of consciousness for a few seconds, up to a few minutes;

 

  • No loss of consciousness, but a state of being dazed, confused, or disoriented;

 

  • Headache;

 

  • Nausea or vomiting; and/or

 

  • Fatigue or drowsiness.

 

A person’s motor skills can also be impacted following a TBI.

 

 

Expected Medical Care and Treatment

 

Medical care required to treat a TBI should not be a “one size fits all” approach.  People react differently, and so is the healing process.  Common medical procedures associated with a TBI include:

 

  • Computerized Tomography (CT scan): This is a scan that uses a series of x-rays to study the brain.  It can uncover evidence of bleeding on the brain, clots, and bruises;

 

  • Functional MRI (FMRI Scan): This is a specialized MRI that helps a medical provider discover and measure brain activity.  I can also uncover areas of the brain suffering an injury;

 

  • Intracranial Pressure Monitor: Bleeding on the brain and swelling of tissue from a TBI causes pressure on the skull.  This instrument measures the pressure inside one’s skull; and

 

  • Neuropsychological Testing: There are various tests medical providers can conduct to study the impact an injury has on the brain.  This testing can be short, or last over the period of several days.  It can also help assess the cognitive, emotional, and behavioral impact of a TBI.

 

This list is not all inclusive.  Members of the claim management team should always question the reasonableness and necessity of medical care, and make sure all treatment advances the injured employee toward a full recovery.

 

 

Common Signs of Traumatic Brain Injuries

 

It is important to remember that not all TBIs are the same.  A TBI can also result from a “minor” incident, and does not require the person to lose consciousness.  A variety of symptoms are associated with a TBI:

 

  • Confusion or amnesia;

 

  • Loss of memory or problems performing basic motor functions; and

 

  • Tiredness, or a loss in appetite.

 

The Glasgow Coma Score is a tool used when a TBI involves the loss in consciousness.  It is a test performed on initial examination to estimate the severity of the injury, and best direct medical care and treatment.  This test is based on special awareness, verbal orientation, and motor response.  The higher the scores, the less severe the injury.  TBIs classified as being “mild” can generally be treated at home.  Lower scoring injuries require hospitalization, and in severe cases immediate surgery to relief pressure on the skull.

 

 

Investigation Tips and Tricks

 

There are many important questions and pieces of information one must gather when investigating a TBI in the context of workers’ compensation.  At a minimum, the following information is essential when investigating these claims:

 

  • Mechanism of injury: Determine if the head struck and object and the force of the strike.  Knowing the object the head struck is also important;

 

  • Severity of injury: Information to receive should include whether there was a loss of consciousness, and if so, for how long.  It is also important to determine the Glasgow Coma Scale information, if applicable; and

 

  • Symptomology: It is important to obtain information on the physical, cognitive, and behavioral/emotion symptoms of the employee immediately following and after the injury.  This information should be documented in medical records.

 

Conclusions

 

Our understanding of Traumatic Brain Injuries is changing the landscape of workers’ compensation.  Members of the claim management team need to investigate this information in order to make proper claim handling determinations.

 

 

 

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.

Compensability of Mental Health Claims in Workers’ Compensation

Properly Handling Mental Cases in Workers' CompensationPsychological and psychiatric injuries in workers’ compensation cases place many demands on members of the claim management team.  These demands include understanding issues of compensability of mental health claims, managing the claims to mitigate exposure, reduce program costs, and ensure the injured employee is paid all benefits they are entitled to receive.

 

 

Compensability of Mental Health Claim

 

Mental health-related workers’ compensation claims can arise in a variety of instances and injuries.  The compensability of the injury is driven by the statutory framework in place as jurisdictions vary on how such claims meet the statutory definition of a “personal injury.”  This requires an understanding of the law and facts of the case.

 

  • Physical/Mental Injuries: This is the most common type of case that jurisdictions accept as being compensable under a workers’ compensation act. This type of claim arises when the employee suffers a physical injury that produces sufficient mental stress or stimulus that results in physical symptoms that meet a threshold of being compensable.  The concept of physical “impact” is required, and mental health claims without such contact to the employee are deemed insufficient.

 

  • Mental/Physical Injuries: These cases are characterized by extraordinary mental stress that manifests, or culminates in a physical work injury.  Legal standards for this type of injury varies, but usually includes instances where the stress from the work injury is beyond the ordinary day-to-day stress from which an ordinary employee is exposed.  In layman’s terms, stress from the work injury culminates in a mental break down and can include stress over a period of time similar to physical workplace exposure cases.

 

  • Mental/Mental Injuries: This type of claim is generally not compensable, but is an emerging area of workers’ compensation law given our growing understanding of mental health and its parity with physical injury claims.  In these claims, there is a required mental stimulus that results in a mental injury.  Common examples of these claims are employees who witness a serious or stressful event such as the death or severe injury or a co-worker or bystander.  A frequent claim made by employees in mental/mental claims are Post-Traumatic Stress Disorder (PTSD).

 

 

Defending Mental/Mental and PTSD Claims

 

Experienced members of the claim management team know that these claims require hard work and a deep understanding of legal and medical issues.  This includes an understanding of the law, and willingness to peel back the layers and understand what is going on in the employee’s past, and present.

 

PTSD is best defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), which is published by the American Psychiatric Association.  Under the DSM-V, a true diagnosis of PTSD requires clinical observations and accurate documentation.  In general terms, the following findings are either required or need to be present in conjunction with other factors:

 

  • Documented stressor by either direct exposure, or second-hand information concerning a significant event;

 

  • Intrusion symptoms such as unwanted upsetting memories, nightmares, flashbacks, etc.;

 

  • Avoidance behaviors;

 

  • Negative alterations in cognitions and mood;

 

  • Alterations in arousal and reactivity;

 

  • Functional significance that creates symptoms of distress or functional impairment (g., social, occupational); and

 

  • Exclusion not due to a medical condition or some form of substance abuse.

 

It is important to investigate claims of mental health and PTSD-related injuries in an aggressive manner.  This includes a complete investigation of the employee’s prior medical history and their socio-economic and familial background.  It will also include the use of a reputable medical expert, preferably a psychiatrist, or neuropsychiatrist with clinical experience.

 

 

Conclusions

 

Work injuries that involve a psychological and/or psychiatric condition challenge members of the claim management team.  It is important they understand the law and complete a thorough investigation.  This includes knowing everything about the injured employee, and a willingness to leave no stone unturned.

 

 

 

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 the 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.

New Federal Guideline Aims To Clarify Safe Opioid Weaning Practices

The Centers for Disease Control and Prevention (CDC) was the first to sound the alarm on the U.S. opioid epidemic. For years, the CDC tracked the epidemic and shared the alarming statistics with the medical community in hopes that it would make an impact, yet opioid overdose deaths continued to rise. In 2016, this prompted the CDC to publish a comprehensive guideline for the use of opioids in chronic pain. The guideline was met with mixed reactions. Those who supported it saw it as a template for appropriate and judicious prescribing. Those who criticized the guideline feared that it would lead to the abandonment of patients who legitimately needed opioid therapy. This issue came to a head in March of 2019 when a group of more than 300 healthcare professionals and patient advocates pinned a letter to the CDC complaining of widespread misapplication of the guideline. The letter blamed the CDC guideline for inciting fundamental policy and practice changes that resulted in patients being subjected to involuntary dose reductions that caused unnecessary suffering and some patients to resort to suicide or illicit drug use.

 

 

Federal Agencies Respond to the Controversy

 

The CDC reacted by issuing a statement recognizing the evidence for misapplication and reemphasizing that the guideline neither supports nor recommends the abrupt discontinuation of opioids in any patient since it may result in harm. Last week, recommendations regarding when and how to discontinue opioids safely were formalized in a guideline published by the U.S. Department of Health and Human Services (HHS). The HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics warns clinicians that abrupt discontinuation can lead to significant opioid withdrawal symptoms, worsening of pain, psychological distress and suicidal thoughts. The guideline also recommends against mandating dose reductions or discontinuation arbitrarily without considering the clinical circumstances. It also stresses to not interpret the CDC’s cautionary threshold of 90 mg morphine equivalence as a de facto limit. While the CDC Guideline does recommend avoiding or carefully justifying increasing dosages above 90 MED/day, it does not recommend abruptly reducing opioids in patients already taking dosages higher than 90 MED/day.

 

Fundamentally, the HHS guideline reemphasizes the message in the CDC guideline: opioids should only be used when the benefits clearly outweigh the risks. Medical care for patients with chronic pain should focus on therapeutic goals and not necessarily on any predefined restrictions. This essentially means that regardless of the dosage or duration of usage, it is appropriate to continue opioid therapy in patients who are progressing toward or have met therapeutic goals including pain relief, improved function and quality of life. So, if these therapeutic goals are not achieved and the risk-benefit ratio is unclear or unfavorable, consideration should be given toward tapering to reduce opioid dosage or discontinuation, says the HHS guideline.

 

 

Compassionate Risk Assessment for Opioid Dosage Reduction

 

Watching this controversy play out in the media, and speaking for the clinical team at myMatrixx, I can say that it all seems like absurd theater in which we are the enlightened audience. The CDC guideline has been under persistent criticism since it was first published — a guideline that was very carefully written and based on clear evidence. Any misinterpretation or misapplication should only be attributed to those who misused it. Nothing in the CDC guideline was wrong per se, just misapplied. The HHS guideline only reemphasizes guidance specific to tapering that was originally in the CDC guideline. We feel that it effectively conveyed the message to clinicians to be more careful with opioids, but not careless.

 

This is the same message and approach we take with clinicians when given the opportunity to collaborate with patient care via our CASE RX program. The majority of the cases we review through this program involve chronic pain patients on long-term, high-dose opioid regimens. In order to determine if the continuation of opioid therapy is appropriate, we perform a thorough risk-benefit assessment in which we compare the level of therapeutic benefit the patient is achieving from opioid therapy to the overall level of risk. When the risks clearly outweigh the benefits, we present the clinician with a recommendation to wean.

 

This type of assessment is consistent with both the previously released CDC guideline and the newly released HHS guideline. We have always promoted gradual dose reductions and provided individualized weaning schedules that clinicians can understand and use as a template for the entire weaning process. The ultimate goal is to gain agreement with the clinician and patient that opioid therapy that does not result in clinically meaningful improvement is only presenting the patient with risk.

 

 

Author Michael Nguyen PharmD, CPh, Director of Clinical Services, myMatrixx.  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.

 

Michael Nguyen’s blog may also be found at: https://www.mymatrixx.com/new-federal-guideline-aims-to-clarify-safe-opioid-weaning-practices/

Vocational Rehabilitation Qualified Rehabilitation Consultant Misconduct

vocational rehabVocational rehabilitation and working with a Qualified Rehabilitation Consultation (QRC) can reduce workers’ compensation costs and get an injured employee back to work in a timely manner.  Problems can arise when the QRC starts acting like an advocate for the injured employee.  Members of the claim management team and other interested stakeholders need to be on the look-out for QRCs gone wild – and ensure they are working for the rehabilitation plan, and not the employee.

 

 

What are QRCs?

 

QRCs are trained vocational rehabilitation consultants than assist employees in post-injury return-to-work and medical management activities.  Requirements for QRC registration are typically governed by administrative rules established by an industrial commission.  They are appointed following a work injury where the employee’s injury is severe enough to require extended time off work.  They should have a solid medical background, and understanding of the labor market and empowering employees to return to suitable gainful employment.

 

 

Acting in the Best Interests of the Rehabilitation Plan

 

QRCs will meet with an injured employee at appointed times set forth in statute or rule and determine the vocational goals.  This includes an assessment of various factors, which can include:

 

  • The nature and extent of the employee’s injury;

 

  • Restrictions and other limitations placed on the employee post-injury;

 

 

  • Ability of the date of injury employer in returning the employee to work, including in a light-duty capacity.

 

QRCs are required to be neutral parties and not an advocate for the employee.  The best interests of all parties need to be carefully balanced and taken into consideration.

 

 

Qualified Rehab Consultant Misconduct

 

QRC misconduct is defined by statute or rule in each jurisdiction.  There are general principles that govern the conduct of a QRC.  Proactive members of the claim management team need to be on the look-out for these factors and take appropriate action against a QRC that steps outside their role.

 

  • Failure to perform rehabilitation services with reasonable skill because of negligence, habits, or other cause. This can include a number of different factors and behaviors.  It can be something as basic as missing meetings or appointments, and consistently not returning telephone calls in a timely manner.  It can also include failing to properly supervise QRC interns and support staff;

 

  • Engaging in conduct that is likely to deceive, defraud, or harm the public;

 

  • Fraudulent billing practices, or failing to properly bill for vocational rehabilitation services; and

 

  • Engaging in adversarial communication or activity. This can include behaviors such as offering opinions on the facts of the case, litigation strategy, requesting information not related to the rehabilitation plan, failing to report all relevant information, and not complying with authorized requests for information.

 

QRCs need to take their responsibilities seriously.  Let the attorneys advocate for their client(s).

 

 

Removing a QRC From the Rehabilitation Plan

 

Each jurisdiction has the mechanisms and standards for removing a QRC from the rehabilitation plan and installing a difference vocational assistant.  Most states look at the “best interests of the parties” when making such changes.  Factors for consideration include the following:

 

  • Loss of trust of the QRC. Claim handlers making this argument should provide concrete evidence on how the QRC has “picked sides” in a dispute – become an advocate for the inquired employee;

 

  • Duplicative time and costs that may be incurred as the result of the removal/change in QRC. This is an argument that can be made when the claim management team opposes the change in QRC;

 

  • Reputation and years of experience and complexity of assignments by the individual; and

 

  • Geographic location of the QRC. In some instances, one QRC may be better than another if the employee relocates.

 

 

Conclusions

 

QRCs play an essential role in vocational rehabilitation and getting an injured employee back to work.  Claim handlers need to be diligent in making sure the QRC is doing their job and being an advocate for the rehabilitation plan, and not a party.  Failure to do so will result in an employee being off work for a longer time, and more money spent on vocational rehabilitation costs.

 

 

 

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.

Closing Down Vocational Rehabilitation Workers’ Comp Cases

vocational rehabVocational rehabilitation is an essential workers’ compensation benefit for employees suffering from the effects of a work injury.  It not only helps the employee understand their medical care and treatment, but provides them with assistance in getting back to work.  This reduces the money spent on a workers’ compensation claim and improves program efficiency.  Members of the claim management team need to examine their files to ensure this benefit is being provided in a responsible manner.  When there is no longer a benefit to the employee, steps must be taken to discontinue services.

 

 

When is Vocational Rehabilitation Appropriate?

 

Vocational rehabilitation services are provided to employees who are qualified under a workers’ compensation law.  This is a benefit that did not come into acceptance in most jurisdictions until the 1970s.  It is generally not available to an employee unless they have been off work for an extended period of time.

 

In order to qualify, a consultation is usually performed by a Qualified Rehabilitation Consultant (QRC), and a recommendation is made regarding the employee’s status.  Factors generally considered include:

 

  • Whether the employee is permanently precluded or is likely to be permanently precluded from engaging in their usual and customary occupation or from engaging in their pre-injury job;

 

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

 

  • Whether the employee can reasonably be expected to return to suitable gainful employment through vocational rehabilitation services by taking into consideration the treating physician’s opinion regarding the employee’s ability to work.

 

 

Vocational Rehabilitation is Being Provided – Now What?

 

During vocational rehabilitation, the QRC will issue regular progress reports.  It is essential that the claim handler monitors vocational rehabilitation once it has been approved.  These reports outline the services being provided and the progress the employee is making in recovering from the work injury.  Important issues to consider when reviewing periodic reports are as follows:

 

  • New or continuing physical limitation that significantly interferes with the completion of the rehabilitation plan;

 

  • Whether the employee is participating fully with the plan; and

 

  • Whether the goals of the plan should change, or be modified.

 

Steps should be taken to termination vocational rehabilitation services if it appears the employee will not benefit from ongoing assistance from the QRC.

 

 

Do Not Pass Go: Shutting Down Vocational Rehabilitation Services

 

Each jurisdiction has the prescribed method one must follow in order to terminate the rehabilitation plan, and discontinue ongoing services from the QRC.  While the process may differ, there are general requirements that are considered when putting an end to vocational rehabilitation serves.

 

  • A new or ongoing physical disability that significantly interferes with the completion of the rehabilitation plan. This is sometimes the case when the employee has a significant setback in their medical care or new injury or disability that is not related to their work injury;

 

  • The employee is not cooperating with the vocational rehabilitation being provided by the employee. Common examples include missing medical and physical therapy appointments, or failing to keep in contact with the employer and/or QRC; and

 

  • The employee is not participating effectively in the implementation of the rehabilitation plan.

 

The focus of the arguments made to terminate ongoing vocational rehabilitation services is whether the employee would benefit from additional vocational rehabilitation assistance.  The party seeking to cease these services has the ultimate burden of proof.  Grounds for stopping these services that are absolute usually include:

 

  • An employee who has returned to work with a negligible wage loss, or without a wage loss. Expectations of near-term future earnings can also be taken into consideration;

 

 

  • The employee is no longer making themselves available for services;

 

  • Death of the employee.

 

The closure of a rehabilitation plan generally requires a form to be filed with the industrial commission.

 

 

Conclusions

 

Members of the claim management team must closely monitor every workers’ compensation benefit being received by an employee.  This includes keeping abreast of the employee’s status and cooperation with vocational rehabilitation benefits.  While this is a useful benefit, steps should be taken to terminate it if evidence supports the conclusion the employee would not likely benefits from ongoing vocational rehabilitation services.

 

 

 

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.

 

 

 

 

 

 

 

 

 

Brand Name and Specialty Drugs Drive Up Workers’ Comp Pharmacy Costs

brand name and specialty drugsThere’s a lot of good news in the latest pharmaceutical reports for the workers’ compensation industry. Prescribing and spending on opioids is down, and compound medications are much less of a factor than they have been in the past.

 

Stakeholders that want to continue seeing positive trends need to keep their eyes on the ball with trends affecting the industry. Many are wondering what’s next? What will be the next development that could unexpectedly drive up pharmaceutical costs among injured workers?

 

“There’s significant concern over the rising cost of prescription drugs,” according to the Drug Trend Report released by myMatrixx earlier this year. And “there is a lack of understanding about the impact specialty medications may have on workers’ compensation insurance.”

 

Stakeholders who are aware of, and take steps to address these two issues will be ahead of the game in holding down pharmaceutical costs.

 

 

Brands vs. Generics

 

Substituting generics for brand-name drugs where possible is one of the most effective and easiest ways to reduce drug costs in the workers’ compensation system. And yet, there are still many providers who prescribe brand name drugs unnecessarily. These prescribers and their injured-worker patients may be unaware of the cost differences involved.

 

“Over the past five years, the most commonly used brand-name traditional drugs among injured workers experienced list price inflation of 65.5%, but prices for the most commonly used generic medications declined 35.0%,” according to the myMatrixx report. “In contrast, a market basket of commonly used goods (e.g., milk, bread, etc.) rose only 7.4%.”

 

As Phil Walls, chief Clinical Office of myMatrixx explained, a generic version of a drug may cost 20 percent of the price of the brand name drug, on average. Spending $100 for a drug that could be purchased for $20 can have a significant impact on costs. But cost is not the only issue.

 

Many providers and injured workers believe brand name drugs are inherently of better quality than the generic versions. However, they have the same active ingredients and work the same way as brand name drugs.

 

“A generic medicine is the same as a brand-name medicine in dosage, safety, effectiveness, strength, stability, and quality, as well as in the way it is taken and should be used,” per the Food and Drug Administration.

 

To gain FDA approval, a generic medication must be ‘bioequivalent’ to the brand name version. That means they are chemically nearly the same, although generic drug makers are allowed 20 percent variation in the active ingredient from the original formula. But according to Harvard researchers, “while the FDA does allow for up to 20 percent wiggle room, in reality, the observed variation is much smaller, 4 percent.”

 

Several brand name drugs that are widely used among injured workers have patents that have recently expired, such as Lyrica. That’s good news, in that less expensive generic versions will likely come on the market soon. However, stakeholders are advised to ask their pharmacists if the generic may be substituted for the form of a drug that their injured worker is receiving.

 

For example, some drug makers issue a long-acting version of a medication that is set to expire and set the cost at a lower amount than it would be for 2x the original drug. Providers and patients would be inclined to seek the long-acting version since it would essentially cost less than taking two pills of the original version. However, once the patent expires, patients who are taking the long-acting version won’t be eligible to receive the generic version, which would only be a substitute for the original version.

 

Some additional drugs with patents expiring this year are Amrix®, Fentora®, Flector®, and Vivlodex®.

 

 

Specialty Meds

 

The vast majority of workers’ compensation payers will likely never encounter a claim that involves specialty drugs. But for those that do, it can be a shock. These drugs comprise just 1.7 percent of claims, yet they drive 7.1 percent of spend. That number represents an increase of 18.5 percent over the prior year.

 

“On average, payers spent $5,130.57 per injured worker on a specialty medication,” according to the myMatrixx report. “Specialty medications cost four times as much, or more, as traditional medications for payers.”

 

While those numbers might cause payers to shy away from footing the bill for these medications, that strategy will drive up costs even more. “The maxim that the most expensive specialty drug is the one not taken means that poor adherence on the part of the patient may render even the best therapy ineffective,” the report said. “Compliance is vital; if the patient is not compliant, the course of therapy has to be repeated,” Walls added.

 

Paying for, and ensuring that injured workers take specialty medications when warranted is, therefore, imperative to achieving the best outcomes and containing costs.

 

Specialty medications are used for conditions that have not traditionally been associated with injured workers. However, that is changing.

 

The proliferation of new cancer-presumption laws for firefighters means more cancer drugs will be seen in workers’ compensation claims. Needlestick injuries to healthcare workers and first responders may warrant specialty drugs for HIV and Hepatitis. Specialty drugs for hepatitis C can cost $100,000 for a 90-day supply.

 

Workers most likely to receive a specialty drug include:

 

  • Emergency first responders
  • Public safety personnel
  • Law enforcement officers
  • Correctional officers
  • Healthcare workers
  • Certain defined workers in states with cancer presumption laws

 

 

Conclusion

 

Drug spend in the workers’ compensation system can be astronomical, but the costs can be controlled. Staying on top of issues such as generic vs. brand name drugs, and the increased use of specialty medications will help. Working closely with providers, pharmacists, and PBMs is the best way to ensure injured workers get the medications they need without payers spending unnecessarily.

 

 

 

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.

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.

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