Maximize the Value of Your Pharmacy Benefits Manager

 

PBMs Can Be More Than Discounted Prescriptions
 
Insurers and self-insured employers often utilize Pharmacy Benefit Managers (PBM) to manage the cost of prescription medications in their workers’ compensation claims.  The contracts that PBMs have with the national drug store chains reduce the cost of each individual prescription given to an injured employee. Unfortunately, that is where many insurers and self-insured employers stop utilizing their PBM.  Often more, or even much more, can be done by insurers and self-insured employers to control the cost of medications.
 
 
Most Doctors Disconnected From Cost of Workers Comp Claim
 
Most doctors treating injured employees have little or no direct contact with the employers and adjusters handling the workers’ compensation claim.  The doctor’s office staff will handle all telephone calls, emails or faxes from employers, nurse case managers or adjusters. The limited contact the doctors have with anyone besides the employee will be brief discussions with the nurse case manager. For the most part, doctors work absent of any input from other parties involved in the workers’ compensation claim and are oblivious to the cost control activities on the claim.
 
The goal of the treating doctor is to assist the injured employee in regaining as much functionality as possible.  The treating doctor will normally prescribe all necessary diagnostic testing, medical treatment and medications without concern for the cost. 
 
 
Lack of Involvement Leads to Higher Costs
 
This lack of involvement in the cost of medications often leads the doctor to make medication choices that cost more, but are no more beneficial to the injured employee than alternative choices.  For instance – doctors will often write a prescription with the notation “DAW”.   DAW stands for ‘dispense as written’ which tells the pharmacist not to substitute a generic drug for the name brand drug.   As many drugs have a generic version that is biochemically and therapeutically equivalent, the DAW adds additional cost to the prescription, but does not provide any additional benefit to the injured employee.
 
The PBM should contact the medical provider’s office and inquire why the DAW is needed when there is a generic equivalent.  If your PBM is not doing this when the medical provider writes the prescription for the name brand drug, you should request they start doing so.  Also, a follow up letter should be sent by the PBM to the medical provider asking for all future prescriptions to be for the generic version of the medication.  If your PBM is not doing this, again you should request they do so.
 
 
PBM Should Push for Generics
 
If the medical provider continues to write prescriptions for the name-brand drugs when generic equivalents are available, a Letter of Medical Necessity should be generated by the PBM and sent to the medical provider before the PBM authorizes the pharmacist to dispense the medication.  The Letter of Medical Necessity will ask the doctor to provide documentation as to why the name brand drug must be used and not the generic equivalent.  Often there is no reason for the name brand drug other than that is what the doctor has always prescribed for the particular medical need.  When the doctor has to respond to the Letter of Medical Necessity, the prescription usually gets changed to the generic version.  This is not to say that there are no situations where the name brand drug is a better option.  The Letter of Medical Necessity does not dispute the use of the name brand drug, but does ask why.
 
If neither an inquiry as to why a prescription is written as DAW nor a Letter of Medical Necessity changes the behavior of the treating doctor, the employer, nurse case manager or adjuster should request a Peer-to-Peer Review, which may make a difference. 
 
 
Your PBM Should Have Medical Opinion to Review All Prescriptions
 
Your PBM should have on-staff, or at least on retainer, a doctor who can discuss with the treating doctor the reason a particular prescription is being written (especially with narcotics and other medications which are utilized on a long-term basis).  The treating doctor may have a valid reason why the more expensive (or most expensive) option is necessary.  The Peer-to-Peer Review will frequently result in the treating doctor recognizing that cost is a factor in the medical treatment, resulting in the treating doctor writing prescriptions that provide the needed medical care while controlling cost.
 
We recommend you confirm with your PBM they are questioning all DAW prescriptions, sending a letter to the doctor asking for future prescriptions to be generic, sending a Letter of Medical Necessity when generics are not used, and utilizing Peer-to-Peer Reviews when needed to control the cost of medications.
 
 

Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: RShafer@ReduceYourWorkersComp.com.

 

Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com Contact mstack@reduceyourworkerscomp.com

 


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

 

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

Massachusetts Employer Fined for Improper Removal and Disposal of Asbestos

A Methuen, Massachusetts-based developer has been ordered to pay a $20,000 fine and serve probation after pleading guilty for the improper removal and disposal of asbestos for work performed on a multi-family residence in Lawrence, Attorney General Martha Coakley announced recently.
 
 
Robert A. Norcross, 51, pleaded guilty in Essex Superior Court to three charges of violating the Massachusetts Clean Air Act: failure to file a notice of asbestos removal with the Massachusetts Department of Environmental Protection (MassDEP), improper removal of asbestos-containing material, and improper disposal of asbestos waste.  The asbestos containing material was pipe insulation in a multi-family residential property in Lawrence owned in trust by Norcross. (WCxKit)
 
 
After the plea was entered, Superior Court Judge John T. Lu sentenced Norcross to 18 months’ probation.  Under the terms of probation, and an administrative consent order with Mass DEP, Norcross must pay a fine of $20,000, with $10,000 suspended during the period of probation.  Norcross is also required to participate in asbestos training and have all of his properties inspected and properly abated of asbestos containing materials.
 
 
Asbestos is a hazardous material that must be reported, removed, and disposed of properly to ensure the health and safety of the public at large,” AG Coakley said.  “The defendant ordered unlicensed workers to remove and dispose of asbestos containing materials without taking the proper precautions, putting people at risk.”
 
 
The Massachusetts Environmental Strike Force received information that Norcross had ordered the improper removal of asbestos containing insulation from one of his residential properties.  Norcross engaged workers in the removal process without the required notification to MassDEP.  Further investigation revealed that the insulation had been removed by untrained workers in an area of the property used by tenants to wash laundry.
 
 
The workers failed to do the work in a properly contained space to prevent the release of asbestos fibers within the building, and did not adhere to air filtering or other protective measures while removing the asbestos containing materials.  Pursuant to Mass DEP regulations, the removal of asbestos must be performed by a licensed contractor with notification as to when the removal will occur and requires certain methods and standards for the safe removal, storage, and disposal of the asbestos throughout the abatement process.
 
 
After the illegal removal process had occurred, one of the workers transported bags of the asbestos debris to an unlicensed facility in New Hampshire for disposal. (WCxKit)
 
 
A grand jury returned indictments against Norcross and he  was arraigned in Essex Superior Court at which time he entered a plea of not guilty and was released on personal recognizance.  Norcross pleaded guilty recently and was sentenced.
 

Author Robert Elliott, executive vice president, Amaxx Risk Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. See www.LowerWC.com for more information. Contact: Info@ReduceYourWorkersComp.com.

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

Chronic Pain Management Causes Long and Costly Payouts

In a recent claims audit of workers’ compensation claims for a Texas municipal pool, the claims auditor was astonished by the number of lifetime medical claims.  The indemnity benefits had been paid out, sometimes years ago, but the former employees were still treating on a regular basis.  In most of the claims the reason the employee had been seeing the medical provider for years was due to chronic pain.

 

Chronic pain refers to the medical condition where the injured party continues to suffer pain from the injury six or more months after the injury occurred and the pain is not relieved by medical or surgical care.  For the treating physician, a patient’s chronic pain and the management of it can be a difficult process.  Chronic pain can be hard to detect which makes it a difficult diagnosis for the physician.

 

The condition of chronic pain can continue for years or even the lifetime of the employee.  In some cases the injured employee can return to work with the pain and ‘live with it.’   However, often the pain can be severe enough to be debilitating, preventing the injured employee from returning to work.

 

Chronic pain is often associated with Reflex Sympathetic Disorder (RSD) but can be present without RSD.  When an employee develops RSD pain is often describe as a severe burning pain.  While pain is very difficult to measure, there are physical symptoms of RSD the physician can see and measure including skin temperature changes (warmer or cooler than other parts of the body), skin color changes, stiffness and swelling in affected limbs, and decreased ability to move an affected extremity.

 

It is the work comp claims where the employee develops chronic pain without a RSD diagnosis that create a difficult situation for the work comp adjuster.  Chronic pain can develop from various types of injuries including herniated and/or ruptured disc, amputation of a body part, joint injuries like carpal tunnel syndrome, torn ligaments and torn cartilage injuries and even traumatic brain injuries.

 

As chronic pain cannot be seen and is very difficult to measure, it is sometimes used as an excuse to stay off work by unscrupulous employees.  The employee, who had a valid injury,  becomes adjusted to receiving compensation without working and finds the claim of chronic pain to be the path to long-term benefits.  The adjuster becomes suspicious of the employee’s delayed recovery due to chronic pain, sends out surveillance and finds the employee playing golf or performing strenuous work (away from the job).   It is these fraudulent claims that give chronic pain a negative connotation.

 

Of course there are many totally legitimate injury claims with chronic pain. The challenge for the adjuster then becomes separating the valid chronic pain claims from the bogus claims, and then providing chronic pain management for those employees who truly need it.

 

Usually the first step the work comp adjuster takes to verify the employee’s chronic pain is to have an independent medical examination (IME).  In some situations the IME doctor can verify the existence of chronic pain, but often the IME doctor cannot state with certainty whether or not the employee has a chronic pain condition.

 

After the IME, the next step for the adjuster is often to have a nurse case manager (NCM) assigned to the chronic pain claim, if a NCM has not already been working with the employee.  Chronic pain management can become very expensive and take a considerable amount of medical knowledge to properly control.  The NCM can discuss with the treating physician and the employee the best course of chronic pain management.  The NCM should remain involved in the chronic pain claim until the employee is able to return to work or it is determined the employee will never return to work.

 

In most claims the treating physician initiates the use of pain medications, usually opioids (narcotics), to control the chronic pain.   There are several problems with using opioids to control pain.  The first one faced by the treating physician is to established the proper dosage for the employee.  If the dosage is too low, the employee continues to suffer the pain.  If the dosage is too high, the employee can become addicted to the pain medication.

 

Addiction is a problem with opioids for chronic pain management.  The employee who started taking the opioids for the chronic pain likes ‘feeling no pain’ and become addicted to the opioids.  With the addiction the employee becomes accustomed to having the narcotics in his body, and to continue to achieve the same effect, the dosage has to be increased.  This leads to dependency on the drugs.  It also creates withdrawal symptoms when the opioids are reduced or stopped.

 

The NCM must work with the physician to go beyond the use of narcotics to control the chronic pain.  Instead of the narcotics the physician may consider electrotherapy with a transcutaneous electrical nerve stimulation (TENS) unit.  Similar in effect to the TENS unit are pain pacemakers that can be implanted in the body to deliver low-level electrical stimulation to the spinal cord.

 

Another method to control chronic pain is the use of trigger point injections.  A local anesthetic sometime with a steroid is injected into the painful area to relieve the pain.  In some cases in only takes a few injections to resolve the chronic pain.  Trigger point injections are often combined with physical therapy to recondition the muscles while the pain is being alleviated.

 

In the last few years some doctors have turned to anticonvulsants to control chronic pain. How anticonvulsants reduce pain is unclear but appears to be effective in some types of chronic pain control.  Another recent approach being used to control pain is low dosage antidepressants which influence the level of certain chemicals in the brain.

 

Also, as there appears to be a mind-body connection when it comes to chronic pain, alternative treatments like psychotherapy and relaxation techniques are being tried with some success.

 

A pain management specialist/clinic can be utilized to assist the employee.  The NCM can coordinate the treating physician, the pain management specialist, and any other medical providers including orthopedists, anesthesiologists, psychologists, and physiatrists.  The NCM will review the medical and psychological aspects of the employee’s case with the pain management specialist to determine the best course of action.   (workersxzcompxzkit)

 

Fortunately chronic pain workers’ compensation claims are infrequent, but when they do occur, they tend to be very expensive and can last for years.   Learning how chronic pain claims should be managed will save the insurer or self-insurer significantly on these large dollar claims.  The experienced work comp adjuster working with a dedicated NCM can control these claims for the benefit of both the employer and the employee.

 

Author Rebecca Shafer, J.D., Consultant,  has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, healthcare, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. She can be contacted at:  RShafer@ ReduceYourWorkersComp.com or 860-553-6604.

Podcast: KNOW the New OSHA Recordkeeping Rules — OR Risk Fines and Criminal Penalties. Click Here:
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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers’ comp issues.

 

©2009 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com

 

Independent Medical Exam Uncovers Workers Compensation Fraud

A Florida man  pled guilty in Suffolk Superior Court to charges he schemed to collect falsely workers’ compensation benefits and lied under oath. The defendant, formerly from Massachusetts, pled guilty to two charges of charges of workers’ compensation and perjury. The defendant collected a total of $3,960 in workers’ comp benefits to which he was not entitled. 

The man was injured  while working as an asbestos technician in Massachusetts. He applied for and received receiving total disability benefits from his employer’s insurance company from December 2003 through March 2004. During part of this time, he was employed full-time with a new employer.

The man’s total disability  benefits were terminated in April 2004 as a result of an  Independent Medical Examination (IME), which cleared him to work without restriction. In an attempt to obtain partial disability benefits for his December 2003 injuries, he reopened his claim in March 2005 and was subjected to a second IME, at which time he underreported his work hours despite being employed full-time with a new employer. 

As the result  of a modification hearing held by the Massachusetts Department of Industrial Accidents (DIA) in May 2005, ordered the original employer’s insurance company to provide partial disability benefits to the individual while he was working full-time. At this hearing before the DIA, the man gave false testimony regarding his work hours and duties with this new employer.

The insurance company  conducted an investigation and found multiple discrepancies between the Employee Earnings Report (EER) submitted by the individual in June 2005 and records of his employment at the second employer, including his dates of employment, hours worked and job classification. (workersxzcompxzkit)

Following a guilty plea, the court sentenced the defendant to one year in the House of Correction on the fraud count, with the three-year perjury sentence suspended. On the two counts of workers’ compensation fraud, he was sentenced to three years probation and was ordered to pay $3,960 in restitution.

“FRAUD PREVENTION” PODCAST click here: http://www.workerscompkit.com/gallagher/mp3
By: Private investigator with 25 years experience.

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

©2009 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact
Info@ReduceYourWorkersComp.com

Knowing When and How to Settle a Workers Compensation Claim

Include Future Medical Exposure in the Settlement While many claims  settle with the payment of statutory benefits, there are claims needing further consideration.  In the states where the medical portion of the workers' compensation claim cannot be closed, the adjuster needs to evaluate possible future medical exposure and take the appropriate steps to conclude the medical where appropriate at the same time the disability claim is concluded, even if it involves payment for estimated future medical expense.  If the medical  portion of the claim is not settled, in most states the employee will have the right to unlimited future medical coverage (with actively treating time restrictions in some states).  For example, if the employee has a disability rating to their lumbar spine and you leave the medical open, your company may be paying for the chiropractor bills for rest of the employee's life, or even worse, paying for surgery possibly unrelated to your work comp claim.   (Note:  Most plaintiff attorneys will want to resolve the future medical, especially if they are entitled to a portion of the medical settlement in their fee).  To establish the  value of the open medical, the adjuster will need to rely on the insurance company's/TPA's medical director for the amount of future medical care needed.  In most cases, the adjuster can multiply the number of future doctor visits by the cost per visit to get an estimate of the value of the future medical expense.  When the employee's future medical cost cannot be determined or future medical care is expected to be minimal, the adjuster should still make a nominal payment (large enough to satisfy the workers' compensation board/industrial commission) to settle the future medical.   The adjuster will need to obtain the employee's signature on the appropriate release or settlement form(s) used in their state to document the resolution of the future medical claim. Determine the Disability Rating/Permanency Rating In about half  of the states, the employer can select the treating physician for the employee.  As part of your risk management plan, a list of approved conservative physicians selected by their area of expertise should be established before an injury ever occurs.  The employee can then be directed to the approved physician who provides the necessary medical care without keeping the employee out of work any longer than necessary.  Employer-selected  and approved physicians less likely to overstate the disability rating as a plaintiff's attorney-selected physician might be inclined to do.   In these states as soon as the employee reaches MMI, the adjuster needs to take the doctor's permanency rating and apply it to the disability schedule utilized in that state.  In the states  where employees can select their own doctor to treat them for their injury, the adjuster needs to be ready to immediately refer the employee for an Independent Medical Exam (IME) or Peer Review when the treating physicians states the estimated disability.  If the disability rating given by the employee's physician is low or acceptable to the adjuster, a referral for an IME may not be needed.   If the adjuster,  medical director or nurse case manager questions about the validity of the permanency rating given by the employee's physician, then proceeding with a prompt IME is essential to controlling the settlement value of the claim.  In those states  where the workers' compensation board/industrial commission often splits the difference between the permanency rating given by the employee's physician and the permanency rating given by the employer's physician, the IME is absolutely necessary for a fair settlement of the claim. The area of the  claim where the plaintiff attorneys or the employee most often try to capitalize is in establishing the permanency rating.   Plaintiff attorneys will try to send the injured employee to a doctor with a reputation for being generous with (overstating) the disability ratings, not to the doctor who will provide the best medical care to the employee.   The reason the plaintiff attorneys do this is to maximize their earnings, because they are paid a percentage of what the employee receives.   Resource:  http://reduceyourworkerscomp.com//documents/Doc-List-by-Module.pdf Superior Employee Communication The best way  to prevent the involvement of an employee's attorney is proper on-going contact with the employee.  While there will always be some employees who are very claims conscious and will obtain an attorney despite the best efforts of the adjuster, most employees get an attorney when they don't know what to expect or they do not feel the adjuster is helpful.  When both the employer and the adjuster maintain good rapport with the employee throughout the medical recovery, the involvement of the plaintiff attorney is often eliminated.  The adjuster should always direct the employee to a physician, where doing so is not barred by statute, who will provide prompt, complete medical care and provide an accurate permanency rating. In states where  the employee has the right to select the physician and the employee's attorney sends them to a medical provider who provides the highest medical rating, the adjuster should continuously press the treating physician for current medical reports.  In addition, all allowable examinations by an Independent Medical Examiner should be completed at the appropriate time(s) to provide an accurate permanency rating.  (workersxzcompxzkit) If the employee's  physician gives a high rating and the employee's attorney is unwilling to settle for the IME rating, then the timely use of defense counsel becomes necessary to adjudicate the differences in the permanency rating. Impairment Rating Firms are often used to evaluate the correct rating according to the edition of the AMA guidelines, or ODG, used in your state. One such firm is Impairment Resources at www.Impairment.com. These are MD's who research then write an report based on objective evidence, not a physical exam of the claimant, specifying the correct impairment rating. If you use such a firm, remember to include it in your account handling instructions.  According to www.Impairment.com, the average error rare of impairment ratings is over 70%, and the vast majority of those errors are over (not under) rated. TO DOWNLOAD OR LISTEN TO FREE AUDIO PODCAST click here: http://www.workerscompkit.com/gallagher/mp3 By: Anthony Van Gorp, private investigator with 25 years experience.

 
 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers' comp issues. ©2009 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com

A Doctor Tells Us How To Make Workers Compensation IMEs More Useful

A Look at Today and a Quick View to Tomorrow

Today
Most of us  are aware at the macro level an Independent Medical Exam (IME) is a medical exam meant to deliver an independent medical opinion for the purpose of determining, if possible, root causation of a given condition and the necessity along with appropriate level of any further treatment.  The IME should be performed by a physician with credentials and training necessary to deliver the opinion and with no connection to the current patient treatment.  The independent physician will first review the case medical file with all associated films and medical history, then, if not just simply doing a Record Review, see the patient for an exam.  The physician will dictate notes from the exam and a final report will be delivered back to the IME requestor.    

Several factors play into a well delivered IME. 

1.  First and foremost,   a qualified physician must be found to execute the exam.  Qualifications vary by state in terms of Workers’ Compensation certification, but in all cases an IME is best executed by a State Board Certified physician.  In a very close second, validation must be made that the physician has never had a loss of license to practice, never had a loss of drug license and is currently seeing patients with no more than 20% of patient load being devoted to IME work.  If a physician has been reported to a medical review board, records should be fully reviewed to determine if the incident could have any negative impact down the road should the physician need to go to deposition or take the stand.  The above precautions on physician selection all play a part to lowering workers’ compensation costs by making sure only well-qualified physicians are handling these cases.  IMEs performed by physicians not meeting the above conditions will most likely be thrown out under cross in court and new IME’s will have to be ordered. 

2.  The requester’s   part in this process should be to deliver to the physician a set of questions outlining exactly what needs to be answered by the exam.  The number of questions is generally less than 10 but in some very complicated cases can be as many as 15 – 20.  By committing every time to taking this step, the requester draws a firm line around what should be discussed by the physician.  This is the one step where the requester can take a forward leadership role versus having tangents or introducing elements that were of no concern.  This in no way means that there is influence over the unbiased nature of the opinion, but it does mean the requester offers guidelines to what needs to be discussed.

3.  Once a competent  physician is found,  the goal is to deliver an IME report that answers the requester’s questions in an unbiased, medically sound manner based on current accepted literature within a given medical specialty.  Preferably, the IME report will give a brief synopsis of medical history and how it relates to the current condition followed by answers to the questions, and ‘only’ the questions, in order, using language similar to that posed by the requester.  This method of reporting provides clarity while following the requester’s direction. 

The following items  of concern are controlled differently in almost every state and include the allowance of videotaping during an IME, attendance by court reporters, and audio only recording.  These concerns will not be elaborated on here as this is a whole discussion in and of itself.  Next, fees for executing an IME may also be predefined under a given state’s laws or may have no boundaries at all.  The key here is to be well versed in the laws of each state where one must request an IME as they directly affect process, level of effort and cost.

IME Companies
Digging a bit deeper,  as most are aware, the process around delivering an IME has many more moving parts and several of which are highly time consuming, hence costly.  IME companies began with the idea to not only connect physicians with requesters, but also to take over many of the time-consuming processes to offer requesters savings in personnel, level of effort and of course financials.  Most IME companies have a panel of physicians they offer their clients.  IME company physician panels vary greatly in number of physicians, geographic scope and specialties covered.  Some IME companies will offer to search out physicians for a requester for a fee or for free.  A good IME company’s physician panel should already be prescreened for the physician conditions noted earlier. 

Additional services  offered by IME companies can include some or all of the following: collecting medical records, scanning paper records into electronic format, using medically trained personnel to thin and organize medical records, setting up patient appointments, offering dictation and transcription services for physicians, and offering requesters standard report formatting.  Some IME companies offer medical/legal review by nurse paralegals who make sure the medical opinions fulfill all of a requester’s questions and do so in a legally meaningful way.  This quality control check acts as a large cost saver by reducing the need for addendums and reducing the number of additional IMEs.

In addition  to offering the full range of services, there are several other key points to factor in when searching for a good IME company:

1.  Make sure  the company follows the three main areas of a well delivered IME from above.

2.  A requester  should have a list of physicians to select from within one (1) business day if no physician search is required.  If a search is required, a list should be delivered within five (5) business days of a request.

3.  Creating an  appointment should happen within 24 hours of selecting a physician with most within a few hours.  Specialty does not matter to make an appointment.

4.  The actual  appointment, pending on specialty, should be set generally within two weeks (10 business days) of selecting the physician.  One note, it is not uncommon for ‘highly specialized’ physicians to take up to 25 business days to work in an appointment.

5.  The best fee  structures are typically “all-in” fees.  This means whatever has to occur to get the report delivered for the IME is covered.  Just think the spaghetti sauce motto – “it’s in there.”  A la carte pricing may look good on the face, but time has generally proven  this scenario ends up costing more to the requester in the long run. 

6.  Web access  in a HIPAA compliant environment to review case files and check status has begun to be a bigger part of the process.  This can be a plus and, in larger customers, may be a requirement.

Tomorrow 

As we move  toward the current administration’s healthcare reform, the amount of oversight and influence of laws being set up by the federal government will play in this field is still unclear.  The one thing that is certain is more influence is surely coming. 

Almost as a preemptive  move, the trend at the top end of IME delivery is rapidly moving to consolidation of IME companies into larger national IME provider networks.  The insurance industry at the very top end has also started to pick up on this trend by eliminating regional IME companies and building central processes to utilize only a handful of national IME provider networks.  The move is stated by the carriers as a cost saving effort.  In their defense, the point of safety in numbers because of uncertainty must be considered.  The concern in this move for the carriers and IME providers will be in taking greater effort with quality control and patient care.

 More workers  re-entering or moving to litigation because of a lack of proper care in the system does not save anyone.  Unfortunately, in the short-term, most of the level of effort of quality control and problem solving will be placed on the shoulders of already stretched front line claims adjusters.  Ultimately this trend toward  consolidation will need to be watched to see if it is truly in the best interest of the patients and actually supports the purported cost savings. 

In the middle  portion of the market and for the foreseeable future, regional IME companies are still strong and viable choices for assisting with this type of work and many times offer similar or more services for similar costs.  These regional companies are motivated to earn a requester’s business and should be more responsive to a requester’s needs in order to secure longer term relationships.  The service relationships should bare additional cost savings for requesters coupled with an ease on the constraints of requester’s own work force.  (workersxzcompxzkit)

At all levels,  the industry will be keeping a watchful eye as to the final direction of the federal government and its reform efforts.  This legislation will surely make changes for all of us.  Until then, smarter IME companies will find a way to continue to improve and put themselves into the best position possible to take necessary advantage of whatever the administration finally delivers and use that for the continued service of requesters.

Author:  Dr. Jared Salinsky, D.O.   We welcome as a guest writer, Dr. Jared Salinsky, DO, Chief Medical Officer with InMedEx.  Contact him at email:  JSalinsky@inmedex.net; www.InMedEx.com or by phone: 727-514-2259.

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

©2009 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com

 

When NOT to Request an Independent Medical Examination (IME)

MYTH: To get a slow claim “moving,” the best thing to do is request an IME (Independent Medical Evaluation).

REALITY: If a claim is “stalled,” it’s quite common for the adjuster to request an IME to get the status of the injury/recovery. In some cases this may be effective and warranted, but sometimes that makes it worse. It makes is worse in these 3 circumstances:

1 – when the timing is not right,
2- when inadequate medical records are included with the IME packet,
3- or, when inadequate medical questions are asked of the doctor who is performing the IME.

You might want to consider a Functional Capacity Evaluation instead. Or, you might want to get a brief surveillance to “see” what capability (or lack of) the claimant has. Before a claim is sent for an IME, have your Medical Advisor review the claim.

Robert Elliott, Senior Vice President, Amaxx Risks Solutions, Inc. is an attorney who has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, health care, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality. Contact him at: Robert_Elliott@reduceyourworkerscomp.com or 860-553-6604

For more cost-saving tips go to WC Cost Reduction Tips.
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Workers’ Comp Kit® is a web-based online Assessment, Benchmarking and Cost Containment system for employers. It provides all the materials needed to reduce your costs significantly in 85% less time than if you designed a program from scratch.

Do not use this information without independent verification. All state laws are different. Consult with your corporate legal counsel before implementing any cost containment programs.

©2008 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com

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