How to Manage Independent Medical Examinations to Control Costs

May 24, 2012 by Leave a Comment

 

Independent Medical Examinations (IME) [also known as Independent Medical Evaluations in some jurisdictions] is a major tool used by workers compensation adjusters and defense attorneys to control medical treatment cost. An IME is the utilization of a medical specialist to examine the employee, to review the employee’s medical history, to provide a diagnosis, and to provide a prognosis. The medical specialist will give an unbiased opinion as to the nature and extent of the employee’s injury. An IME will establish the true level of the employee’s disability and permanency level. This makes the IME an important method of controlling medical treatment cost as well as a way to limit unnecessary lost time.
 
 
The states vary in the number and type of IMEs that can be had. In some jurisdictions, the employer/insurer is limited to one IME throughout the entire course of the claim. In other jurisdictions, the employer/insurer can have as many IMEs as they are willing to pay for. With an IME costing $500 to $1500 depending on the location and the specialty, the employer or insurer does not want to waste money having needless IMEs performed. [WCx]
 
 
The IME doctor will need all the available information on the medical condition of the employee. The IME doctor needs to be provided all medical reports from prior medical providers, all diagnostic testing results (MRIs, CT scans, EMG studies, x-rays, etc.), a complete job description of the employee’s duties including all physical requirements, and the employer’s first report of injury stating exactly how the employee was injured. If the employee has aggravated a preexisting condition, all medical records for treatment of the preexisting condition should be obtained prior to the IME and provided to the IME doctor.
 
 
The adjuster, employer, or defense attorney requesting the IME should draft a letter to the IME doctor stating the concerns about the employee’s medical situation, and outlining the medical questions that need to be answered. The letter should be kept objective, clear, and to the point, as in some jurisdictions it can become a part of the evidence in the claim.
 
 
The various industrial commissions, workers compensation boards, departments of labor, and bureaus give different levels of credence to the opinion of the IME. In some jurisdictions the opinions expressed in the IME hold equal weight with the medical opinion of the primary treating physician.  Other jurisdictions consider the IME but normally give greater credence to the primary treating physician, as the primary medical provider has normally seen the employee many more times than the IME doctor has.
 
 
Overcoming the bias of the commission / board / labor department / bureau requires the selection of a highly skilled and well respected doctor. Many adjusters (and employers on self-insured programs) make the mistake of using the same conservative doctor over and over for every IME. The opinions of these well qualified, conservative doctors, while often are accurate, are discounted by the hearing official because the hearing official knows the reputation of both the plaintiff attorney’s favorite doctors as well as the reputation of the adjuster’s/employer’s favorite doctor.
 
 
To be successful in the use of IME, the employer or adjuster should select a doctor in the appropriate specialty that has a reputation for telling it exactly the way it is. The hearing official will pay closer attention to the medical opinions of the doctors known to be unbiased.
 
 
As an employer, if the reputation of the possible IME doctors is not known, ask an experienced workers compensation defense attorney who has attended hundreds of hearings for IME doctor recommendations. Stress to the defense attorney that you are not looking for the most conservative doctor around, but for the doctor that has the reputation for being the most objective.
 
 
Of course, there are exceptions to the rule on finding the most objective IME doctor. In some jurisdictions like Georgia and New York, the administrative official hearing a contested disability rating will normally split the difference between the disability rating the claimant has been given by his chosen doctor and the disability rating given by the employer’s IME doctor. In those situations, where it is assumed the employee’s doctor will be providing a high rating and the IME doctor will be providing a lower rating, the use of a conservative IME is the better approach. Therefore, it is very beneficial to know how the system works in your state. (See our state by state guide for Laws and Regulations Here.)
 
 
After the IME, if there are still questions about the employee’s medical condition that have not been answered, it can be beneficial to follow-up with the IME doctor and ask those questions. Also, the IME doctor may be able to direct you to research on the particular medical condition of the employee that can be used at the administrative hearing.[WCx]
 
 
In order for the IME to be used as evidence in the claim, you must share it with the employee and/or employee’s attorney. Consult with your defense attorney as to the best time to share the IME information.
 
See also our Insurance Dictionary of Terms and Abbreviations Here

 

 

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 at Amaxx Risk Solutions, Inc. is an expert in employer communication systems and a part of the Amaxx team helping companies successfully reduce Workers Compensation Costs by 20% – 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com   Contact:mstack@reduceyourworkerscomp.com

 



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VIEW SAMPLES PAGES

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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.

Filed Under: Coordinating Medical Care, Medical Issues Tagged With: , ,

Valuable Techniques to Control Medical Costs

May 8, 2012 by Leave a Comment

Employers who let the injured employees control their own medical care have higher workers compensation medical costs then the employers who are actively involved in the medical care of the injured workers.  There are numerous techniques an employer can use to properly control and direct the medical care provided to injured employees.

 

The states are about even divided between states where employers select the medical provider(s) and the states where the employee chooses the medical provider. Some states even try to give both the employer and the employee a voice in the selection of the medical providers by the use of doctor panels.  In the states that use a doctor panel, the employer selects a group of doctors, and the employee then selects a doctor from the employer’s group of doctors (panel).

 

The first action an employer should take is to identify the reputable, conservative doctors in their area.  Both the nurse case management team and the defense counsel can provide you with valuable information on which doctors you can trust, and which doctor’s rely on referrals from plaintiff attorneys for their income.  Start with having defense counsel provide you with a list of recommended emergency clinics, general practice doctors and orthopedics, then have the nurse case management team cull the list to remove any doctors that are difficult to get along with and/or keep the employees off longer than necessary.   Defense counsel can also tell you if you are in one of the few states that allow absolutely no input by the employer in the selection of the medical provider.

 

 

There are additional important considerations in determining the doctor that should be considered.  You want the doctor(s) to be and do the following.

  •       responsive to the employee’s medical needs
  •      spend the necessary time with the injured employees
  •         have flexibility in scheduling appointments for the employees
  •      review the job descriptions in order to provide light duty work as soon as feasible
  •      have a professional and pleasant manner

 

Post the list of preferred medical providers on the bulletin board for everyone to see.  (Some states require a particular format or poster design for the posting of workers comp doctors; check the specific state requirements for formatting the list of medical providers).  In the states where the employer has the right to designate the medical provider or is required to post a panel of doctors, the list should be titled “Required Medical Provider(s)”.   In the states where the employee selects the medical provider the list should be title “Recommended Medical Providers”. Some networks have exceptional doctors noted, so if these doctors are available consider including them in the panel.  [WCx]

 

 

Establish rapport and dialogue with the medical providers (they will be glad you do as it makes their jobs easier) before the injuries occur.  The medical providers will remember you, as way too many employers have no interaction at all with them.  The medical providers will understand that you care about the general welfare of the employees and you care about getting the employees back to work.  When you show an interest in the employee’s medical care several positive things occur including.

 

  •      medical reports are provided to you timely
  •      you gain cooperation with the return-to-work program
  •       phone calls are returned
  •      any forms or documents you need completed get done

 

There are many other steps the employer should take to control and direct the medical care of injured workers. The new 2012 edition of Manage Workers Compensation Program, Reduced Costs 20-50% has an entire chapter on directing medical care.  The book includes both Ten Considerations for Your Company Doctor and Eleven Reasons NOT to Select a Doctor.  Please contact us for your copy.

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 website 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, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.com. Contact: RShafer@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

 

Filed Under: Coordinating Medical Care, Medical Cost Containment, Medical Issues Tagged With: , ,

Medical Provider Performance Indicators for Workers Compensation

February 26, 2012 by Leave a Comment

By Karen Wolfe, BSN. MA, MBA
President, CEO
MedMetrics, LLC


 
Workers' Comp is Different
While rating providers in group health is a long-practiced endeavor, its elements and parameters have not significantly migrated to workers compensation. Efforts to translate group health provider quality measures to workers’ compensation have fallen short of the mark because they omit several factors crucial to workers’ comp. Quality medical performance indicators in workers’ comp encompass medical treatment, outcome, and cost factors similar to those in general health, but they also include non-medical functions. In workers comp, those non-medical elements can be primary drivers of cost, quality, and outcome.


Return to Work: An Indicator of Performance
A major quality goal in workers' comp is return to full work. Responsibility for achieving that goal rests with the treating physician. Another major quality goal in workers’ comp is return to maximum or full work capacity at the least cost. This article explores the many non-medical functions of treatment that spell quality in workers’ compensation, factors that must be considered in rating doctors’ performance.[WCx]


For instance, multiple and repeated studies have shown that early return to work is a major indicator of better outcomes in workers comp. (Google search:  “Return to Work studies in workers’ compensation.”) The overwhelming take-away from these studies is that the sooner employees return to work after a work-related injury, the sooner they are re-acclimated to the job and the lower the overall cost of the claim. Alternatively, the longer the employee is kept off work, the higher the cost of the claim, with reduced chance of successfully returning to work. Studies show a 1:1 correlation between length of time off work and returning to work — ever. Treating providers are the major driver in returning claimants to work. Therefore, early return to work and reduced overall work loss are key indicators for evaluating medical provider performance.
 

Cost Measures of Performance
Also important to rating provider performance in workers’ compensation is the issue of cost. Two quantifiable generators of unnecessary costs are frequency and duration of medical treatment. Because PPO, MCO, and MPN networks discount each unit of service delivered, the tendency of some providers is to exploit both frequency and duration of treatment to overcome their discounted fees. Individual provider’s frequency and duration of medical treatment for specific injury types should be measured and compared with the performance of their peers treating similar injuries.


Another comparative quality indicator is direct medical costs. Billed costs are not a true performance indicator by themselves. However, assessing billed costs with paid amounts or percentage reduction of charges recommended by bill review is a more accurate measure.

 
Prescriptive Practices
Recent research indicates a problem of opioid misuse or abuse in workers comp. Evaluate prescribing practices of individual physicians by monitoring current data, thereby creating an opportunity to intervene. Prescribing practices are a valid indicator in measuring performance.
 

Outcome
Of critical importance is evaluating providers in terms of outcome like how did things turn out in the claims where they were involved? Is the employee back at work, permanently disabled or somewhere in between? What is the provider’s record? If a provider is associated with a high rate of litigated claims, that should also be considered in the descriptive mix.
 

Create Algorithms to Measure
Providers can be rated specifically for workers' comp by creating a set of algorithms measuring these factors using data. An algorithm is simply a defined process, often mathematical, used to solve a problem or reach a conclusion. Algorithms should be used to compare similar types of providers who have treated like injuries in the same jurisdiction during the same time frame. Consistency is achieved because the computerized algorithms apply the same standards to all medical providers who meet a set of conditions.
 

Analyze Data from Multiple Sources
The data used to evaluate provider performance should be derived from more than one source. Raw billing data or bill review data should be integrated with claim data in order to reach a valid conclusion. Billing and treatment data must be integrated with loss time and outcome information, usually found in different systems, in order to reach legitimate conclusions regarding providers. 

Ratings for medical providers must be transparent, fair, and objective. Fairness and accuracy in developing and measuring provider performance is critical. The indicators can be found in the data. The data must be integrated and evaluated using computerized algorithms that measure and monitor provider performance based on a combination of workers’ compensation-specific values.[WCx]


Measuring Provider Performance Is a Good Thing
A post was submitted by Joe Paduda last year, “Like it or not, physician ratings are coming”. The title suggests rating doctors is a bad thing. It is actually a good thing, unless you are a poorly performing provider. Using legitimate workers comp-specific rating systems to provide objective evidence for selection and for weeding out the less effective or even fraudulent providers is positive progress. A poorly performing provider guarantees complexity and cost in the claim. Informed decisions about medical providers based on data will replace personal biases and unknown outcomes. Basing provider selection decisions on objective data is imperative.


Author Karen Wolfe, BSN, MA, MBA, is President/CEO, MedMetrics®, LLC. Karen is founder and president of MedMetrics® LLC, an Internet-based Workers’ Compensation medical analytics company. She applies her medical knowledge to gathering, understanding and applying Workers’ Compensation data to the operational process. MedMetrics imports, integrates, and analyzes its clients’ medical billing and claims level data. MedMetrics uses several tools such as Predictive Intelligence Profiling and Medical Provider Performance Assessment to gather and analyze data. Contact: Phone: 541-390-1680; Karenwolfe@medmetrics.org; www.medmetrics.org.

 



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VIEW SAMPLES PAGES

MODIFIED DUTY CALCULATOR:  www.LowerWC.com/transitional-duty-cost-calculator.php

 

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.

Filed Under: Assessment & Diagnostics, Benchmarking & FTE & Operational Comparison, Claim Management, Medical Cost Containment, Medical Issues Tagged With: , , , , ,

Workers Comp Medical Crew Cares for Employees in Amazon Jungle

August 2, 2011 by Leave a Comment
 
Not quite what U.S. professional travelers would call business class in Atalaya, Peru — where Medcor staff stayed befoe starting the wo-day river trip through Boca Manu, Peru and on to the Cocha Cashu research station.
 
Indeed, whether in the Peruvian jungle or at the Mount Everest base camp, Medcor is there for more than 170 worksites, including factories, distribution centers, studios, farms, and mobile or temporary units.
 
 
Founded in 1984 by CEO, Philip Seeger and COO Ben Petersen, Medcor operates many onsite clinics across the United States to support employers who want to control costs, improve outcomes, provide rapid medical response when it is really necessary and avoid claims when they are not necessary – and this means planning ahead even when the worksite is far from the typical office.
 
 
Privately held with 400 full-time and 400 part-time employees, Medcor does $54 million in business per year. The company boasts seasonality and flex work to meet changing client needs – for example, the retail distribution industry during the holiday season. In addition to itson-site clinics, Medcor also serves more than 80,000 worksites with telemedicine.
 
 
Although its core business is focused on providing on-site medical clinics to large worksites and providing injury triage to small worksites across the country, Medcor has a great deal of expertise in the fascinating field of wilderness medicine.
 
 
The company provides on-site medical services at Yellowstone National Park, operates a clinic at the base camp of Mount Everest and has operated clinics on pipelines and windfarms and projects in locations  such as Midway Island, of the northwest Hawaiian islands. Medcor has also has served those affected by hurricanes Katrina and Rita, and provided on-site medical services at the World Trade Center after the events of 9-11. Medcor is currently back on site sat the World Trade Center supporting rebuilding projects.
 

Not your typical day at the office for Medcor team members in Peru where they are setting up a remote clinic to support research scientists. From left, Phillip Seeger, Medcor founder and CEO and Dave Matthias, risk manager for the San Diego Zoological Society.

 
There are also a variety of other similar companies that provide remote medicine services. Many of them are highly specialized, focusing on evacuations, off-shore oil rigs, pipelines or military bases.
 
 
Medcor Executive Vice President Curtis Smith notes there are at least eight benefits of having an onsite clinic for employers with remote locations:
  1. Improved medical outcomes for employees and workers onsite.
  2. Improved morale and confidence for employees and workers onsite (which, in turn supports recruiting and retention at the remote site).
  3. When done properly, remote medical crews reduce costs and liability.
  4. Avoids unnecessary travel costs by resolving cases on site.
  5. Better screening and monitoring of on-site staff, including early intervention of injuries and illness.
  6. For patients who do need evacuation, there is better planning, stabilization, prep, and continuity of care that helps reduce complications. For example, on the Amazon trip, a scout team discovered other river evacuation routes for emergencies before they happen.
  7. There is less litigation because outcomes are better, documentation is better, and the employer is more likely to be in compliance with applicable laws and best practices.
  8. It is morally the right thing to do.
 
 
Benefits may extend further for U.S.-based companies including compliance with U.S.-based workers compensation and other laws which are likely to be claimed as an applicable standard for expat employees and the parity of service/benefits with other employees who are not in remote locations.

Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website 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. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.
 

Our WC Book:  http://www.wcmanual.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.
Filed Under: Medical Cost Containment, Travel and Overseas Employees, WC in Other Countries (International) Tagged With: , , , , , , , ,

Work Comp Provider Helps North Dakota Recover from Floods

July 31, 2011 by Leave a Comment
 
Designated FEMA responder since working with hurricane Katrina, Rita, Ike, and Lili support staff, Medcor, a workers compensation medical care provider, will be providing on-site medical services to support about 360 relief workers in Minot, ND, for the next three months. Relief workers operating from a field operations center help Minot (pronounced “my-not”) residents devastated by flooding. The company has deployed a mobile clinic that includes staff living quarters, office space, and an exam/treatment room.
 
 
Medcor executive vice president Curtis Smith said the deployment took place within 72 hours of being asked. This assignment’s staff includes Brian Schroeder and Jodi Meere, paramedics and U.S. Army veterans from Iraq.
 
Headquarterd in McHenry, Ill, Medcor travels the globe to provide corporations with efficient healthcare. While the company works extensively with off-shore drilling industry, it also provides support to remote scientists in the Amazon jungle, for example. In this latest deployment, Medcor gives flood relief workers in North Dakota appropriate health services which greatly contains their employers workers compensation costs.
 
 
Now that floodwaters have dropped below flood stage for the first time since spring, relief workers are able to assist in cleanup and rebuilding Minot. The city experienced extensive damage after the Souris River broke a 130-year high-water record, cresting nearly 13 feet above flood stage. Approximately 11,000 people were evacuated from the Minot area — flooding damaged 4,100 homes in the hundreds of businesses, Smith said. Minot is a city of just over 40,000 people – the fourth largest in the state. It is also known for a U.S. Air Force base 15 miles north of it.
 
 
“Relief work is physically demanding in unstable environments, so injuries and exposure hazards do occur. Medcor accompanies the relief workers so the workers do not need to rely on local medical resources which were also affected by the floods,” Smith said via press release. “Having Medcor at the field operations center also frees up local medical resources to focus on providing care to local residents.”(WCxKit)
 
About Medcor:
Medcor provides telemedicine services to nearly 90,000 worksites in all 50 states and operates 174 on-site workplace clinics. Medcor’s services are available 24/7 for worksites of any size in many industries. Medcor’s services help employers reduce health care costs while improving access to care and outcomes. Medcor is headquartered in McHenry, IL. For more information, visit www.medcor.com or contact Curtis Smith at csmith@medcor.com.

Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website 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. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.
 
 
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.
Filed Under: Medical Cost Containment, Risk Management, Safety and Loss Control Tagged With: , , , , , , ,

5 Good Reasons to STOP Before Deposing a Doctor

July 12, 2011 by Leave a Comment
When you get a “bad” report from an agreed medical exam (AME) or a panel qualified medical exam (PQME) your first thought might be to depose the doctor. Your second thought should be, maybe not.
 
 
5 reasons not to depose a doctor:
 
 
1.      Doctors rarely change their opinions. Factors such as ego, bias, facts, and law often prevent doctors from changing their opinions. Even in the face of skilled questioning, a doctor will usually not change an opinion of industrial causation to non-industrial, reduce impairment, or increase apportionment in a deposition.
 
 
2.      The doctor might increase exposure. As your defense attorney is trying to reduce exposure, the applicant's attorney is trying to increase it! The applicant's attorney will probably try to rebut the standard AMA Guides rating with an Almaraz rating. And he or she may push for more medical-legal referrals.
 
A sample conversation:
Q: Dr. Ortho, my client completed your questionnaire, correct?
A: Yes.
Q: Did my client indicate complaints on the questionnaire outside your field of expertise?
A: Yes.
Q: What were those complaints, Dr. Ortho?
A: The questionnaire indicated complaints of anxiety, depression, difficulty sleeping, and sexual difficulties.
Q: You also took my client's medical history, personally, correct?
A: I did.
Q: During this interview did my client again complain of anxiety, depression, difficulty sleeping, and sexual difficulties?
A: Yes.
Q: Complaints of anxiety and depression fall within the specialty of psychiatry, correct?
A: Of course.
Q: Sleep problems could indicate neurological issues, correct?
A: Yes, that is correct.
Q: And sexual problems may indicate a disorder regarding internal medicine, correct?
A: Yes.
Q: You just indicated that all of these complaints fall outside the field of your expertise, correct?
A: That is correct, counsel.
Q: Referrals in psychiatry, neurology, and internal medicine would be required to fully address these complaints, correct?
A: Yes, that would seem reasonable.
 
 
Congratulations, you just bought three medical-legal examinations and untold additional exposure!
 
 
3.      If it is broken, why fix it? AMEs and PQMEs often write reports that provide industrial-causation or high-permanent disability but are not substantial medical evidence. There are many reasons why a report is not substantial medical evidence. Expert attorney advice is sometimes needed to reveal these flaws. But once the flaws are revealed, it is important to remember that it is the applicant's burden to prove industrial causation and the extent of impairment (LCS 3202.5). It is not the employer's burden. Hence, if a report is not substantial medical evidence, deposing the doctor may just give applicant's attorney and the doctor a chance to fix a bad report and make it substantial medical evidence.
 
 
4.      Time and money. A doctor deposition will probably cost more than $1,000 in doctor and defense attorney fees. And it will add several months to the life of the case.
 
 
5.      Maybe you can settle the issues. Use your knowledge and skills to negotiate, compromise, and settle the issues you have with the AME or PQME report. However, be careful not to reveal too much. Do not show all your cards. If you do not settle, you want to close discovery and set the case for trial, with the expectation that the judge will not base an award on reports that are not substantial medical evidence. If you tip your cards during negotiations, the applicant's attorney may decide that he needs to depose the doctor so he can fix the report and make it substantial medical evidence.
 
 
Important note: There are cases in which you should depose an AME or Panel QME. Nothing here is intended to imply you never need to. But you should consider the factors above before you set the next AME or PQME deposition.
 

California Attorney: Albert A. Navarra is a practicing lawyer from Newport Beach, CA, a Board Certified Specialist in Workers Compensation law, and a partner at Sapra & Navarra, LLP. Navarra is a frequent speaker about workers compensation issues, and has represented employers in the area of workers compensation for over 10 years. He is also an expert in constitutional law, the author of The Elements of Constitutional Law, and a frequent guest on radio stations across the country. He can be reached at: (866) 384-4891 or Albert@snworkcomp.com.

 
 
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.
Filed Under: California Workers Comp, Legal Doctrines, Medical Cost Containment Tagged With: ,

Ten Medical Cost Containment Strategies To Reduce OVERALL Costs

February 22, 2011 by Leave a Comment
There are many available techniques to control medical cost in workers compensation.
 
A search of the internet for Medical Cost Containment will provide a tremendous amount of information but each website is focused on the product(s) or service(s) provided by the particular company. There are many and varied means of controlling medical cost in workers compensation which span a broader range of services than almost any single company can provide.
 
 
To be truly effective in controlling the medical cost of workers compensation, employers and insurers should not limit their medical cost containment efforts to only one or a few areas. While state statutes may limit or bar the use of some the methods of controlling cost, the employer or the insurer should utilize as many medical cost containment strategies as possible. All of the following medical cost containment strategies have been shown to save money for the employer or the insurer. (WCxKit)  Spend now to achieve overall lower workers compensation costs. This is how to hold costs down over the long term. This is referred to as the TLC (total loss costs).
 
 
Top 10 Medical Cost Containment Strategies
 
 
1.  A SUPERIOR Medical Provider Network is a group of doctors, hospitals and other medical providers with whom an insurer or a self-insured employer has prearranged for medical treatment for employees injured on the job AND provides better results than other providers – lower litigation rates, better medical outcome, faster return to work. 
 
 
2. Nurse Triage  is used as the very first phone call that is made (after the supervisor). The employee calls an RN who discusses the severity of the injury and the probably type of treatment that will be needed. These aren’t just any nurse, but specially trained ones using medical algorithms and overseen by sophisticated protocol to ensure appropriate referrals are made the the Emergency Dept, clinical treatment or self-care. If every injury is called in to Nurse Triage, the number of lost time claims will be reduced by 40%. The ROI is huge! I’ve toured the Medcor operation and was amazed at the efficiency and the training (I sat in the training room to view the type of training the RNs receive.) I was a guest of Broadspire who uses Medcor for their sophisticated medical protocol partner.  
 
 
3. Medical Management is the practice of having an experienced nurse case manager to coordinate and managed the medical care received by the employee. This includes both the senior nurse reviewer who may be dedicated to an account handling all lost time or serious medical claims for that company. They review all care and treatment for injured employees to insure it is appropriate and timely. If additional tests are needed they will advise the doctors. Their priority is getting the employee back to full recover.
 
 
4. Utilization Review is the independent confirmation of the need for a medical service. Utilization review includes precertification reviews before the medical care is provided, concurrent reviews while the employee is in the hospital or during on-going medical care, and retrospective reviews to verify the needs for the medical services already provided.
 
 
5. Medical Bill Reviews are normally done by companies that specialize in reviewing the medical bill to verify the accuracy of the medical bill diagnostic codes and medical bill charges. The medical bill charges are either compared to the state fee bill schedule or with what are reasonable and customary charges for the medical services provided. Medical bill reviews include both the audits of doctor bill and hospital bill auditing.
 
 
6. Pharmacy Benefit Managers are companies that specialize in managing and controlling the cost of medications prescribed for the employee. This includes both obtaining discounts on medications plus providing drug utilization reviews to prevent the excessive use of narcotics and other medications. Using physicians to actively review claims results in proactive pharmacy benefits management, rather than after the fact review of medications already taken, can stop overuse before it occurs.
 
 
7. Independent Medical Examinations occur when the employee is sent to another medical provider for a second opinion. Independent medical examinations are most often used when the employee’s medical recovery progress is slower than normal.
 
 
8.  Peer Reviews is the practice of sending the medical reports and diagnostic reports to another medical provider for a review of the medical information for the purpose of confirming the appropriateness and quality of the medical care being provided. Using physician review is in my opinion one of the most useful tools an employer can use. They can read he medical reports to find what’s NOT there. They look for other possible causes of injury, appropriateness of care and make sure employees go to the correct specialists.  This service may be called Peer-to-Peer.
 
 
9.  The era of computers has created the ability to use technology to obtain information that would not otherwise be available including:
 
1.      Predictive Modeling is used to identify early on those claims that have a high probability of becoming expensive claims so they can be acted upon quickly.
 
2.      Data Mining is used to identify high cost medical providers; medical providers who are slow to return the employee to work and to identify other claim related information that impacts claim cost.
 
3.      Benchmarking is using the known information about your workers’ compensation claims to compare your cost control results against others employers or insurers. (WCxKit)
 
10. Send me your ideas for YOUR favorite Medical Cost Containment Strategy. Let me know if it’s OK to share your ideas. Please write up to 200 words.

Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker and website 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.  Contact:  RShafer@ReduceYourWorkersComp.com.

 
WORK COMP CALCULATOR:   http://www.LowerWC.com/calculator.php
 
WC GROUP:  http://www.linkedin.com/groups?homeNewMember=&gid=1922050/
SUBSCRIBE: Workers Comp Resource Center Newsletter

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.

©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
Filed Under: Medical Cost Containment, Medical Issues, WC 101 Tagged With: , , , , , ,

Nine Questions to Ask When Coordinating Managed Care Providers

February 12, 2011 by Leave a Comment

Coordinated medical care refers injured employees to specific physicians, integrating the protocols and goals of the overall workers compensation management program and coordinates with health insurance, i.e., managed care.

　
It means planning before an injury happens and educating your employees about proper procedures.(WCxKit)
　
Managed care, if set up properly, reduces medical and indemnity costs, fine tunes medical treatment, creates a care-plan, sets a return-to-work date and requires periodic re-evaluation between the physician and case manager.
　
Having a WC coordinator to post checklists and host employee meetings can go a long way to steering your injured employees and on-duty managers to the right physician.
　
Finding the right managed care vendor is another matter. In addition to PPO providers, consider onsite occupational clinics. Yes, set your own clinic, really. I've worked airlines, state parks and other large organizations, including hospitals that have onsite clinics. It offers convenience and quality control.
　
Questions for the Managed Care Vendor
1. Does the managed care vendor have enough providers in its network to deliver prompt service and provide adequate geographic coverage?
　
2. What mechanisms are in place for provider evaluation and other issues related to quality of care?
　
3. How does the managed care program integrate with the claims administrator?
　
4. Are providers willing to visit the facilities and learn about the employers’ corporate culture and needs?
　
5. Do network doctors appear to be caring and concerned, or rushed and rude?
　
6. Are providers return- to-work oriented? Do they provide transitional duty job restricitons so the employee on the FIRST VISIT so employers can quickly place the injured employee is an open position, e.g. in a job pool for instance.
 
7. Does the provider have less litigation than others?
 
8. Do medical costs from this provider compare to other providers — remember you don't always want lower costs per visit, you want employees to return to health and productivity sooner, and sometimes that may cost MORE per visit, but cost less overall.
 
9. What are OVERALL costs of employees treated by this provider — in outcome based provider subsets, cost of the overall claims are lower because employees return to work more quickly and need medical care less often.
　
When your company forms a partnership with the right insurance company or claims administrator, they will appoint a dedicated adjuster who understands investigation.
　
Look to allow a 24-hour turn around time in response to injury reports. Also, be sure your managed care vendor gives the employer the retaining right to choose legal counsel, settlement authority, second injury and subrogation.
　
Your company must maintain control at all levels of workers compensation to be sure your costs do not escalate. There are many steps in the process that could serve as money sieves.
　
Fraud, other money sponge, can also be prevented and detected when all parties involved in workers compensation — supervisors, managers, claim adjusters and medical providers, work as a team.
　
Surveillance by qualified investigators is used to verify the extent of the disability, establish the ability of the employee to do transitional duty work and determine if the worker is working elsewhere may be necessary in some cases.(WCxKit)
　
Knowing when to implement this type of fraud investigation means planning for it ahead of time and being aware of all legal ramifications of investigative work.
　
Five questions to ask when coordinating your medical care and other tips to save your workers compensation department money #WorkersComp.
 

Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker and website 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.  See www.LowerWC.com for more information. Contact:  RShafer@ReduceYourWorkersComp.com or 860-553-6604.

WORK COMP CALCULATOR:   http://www.LowerWC.com/calculator.php
 
WC GROUP:  http://www.linkedin.com/groups?homeNewMember=&gid=1922050/
SUBSCRIBE: Workers Comp Resource Center Newsletter

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.

©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
Filed Under: Medical Cost Containment, Medical Issues Tagged With: ,

Getting the Best Initial Care for Your Injured Workers

January 4, 2011 by Leave a Comment

As an employer, you want your injured employees to get the best care available when they are hurt. You also want to find healthcare providers who understand your company’s specific goals, needs, and possibilities. And you want them focused on the bottom line as well.  A very tricky balancing act –  but a necessary one!

 

 

How can you locate and identify a good initial healthcare provider? Here are a couple of suggestions from a case management nurse who has been around the block a few (million!) times: (WCxKit)

 

 

  1. For your initial evaluation and treatment, a great choice is an experienced Occupational and Environmental Health Physician (OEM). This is a specialty of physicians who evaluate the interaction between work and health. An Occupational Health doctor should be familiar with work operations, return to work procedures, workers compensation laws in your jurisdiction, and many other related topics.   Please note:Just because the local clinic calls itself an “Occupational Health Clinic” don’t assume the doctors are Occupational and Environmental Medicine Physicians!

 

 

  1. As you are selectingor reviewing your panel provider for occupational health, CALL the center and speak to the administrator. Set up a tour. Meet with the doctor(s). Ask about their specialty and experience. You are putting your employees’ health and your money into their hands, so go and check them out. Trust me — if the doctors won’t play nice with you, they certainly won’t play nice with your injured workers.

 

 

  1. If you’re not sure where to find a qualified OEM doctor, check out the website for the American College of Occupational and Environmental Medicine, www.acoem.organd click on “Find a Doctor.”

 

 

  1. If you are in a locationwhere there is no qualified OEM nearby, talk with your nearest occupational health center’s medical director and make sure he or she is familiar with your state workers compensation laws, your company’s policies regarding post-injury care and return-to-work, and that the doctor is willing to keep in close contact with you during treatment of your injured employee. Feel free to send over your own post-accident form for the doctor to complete, if you don’t like the form the center provides. You’re paying for this service – make it work for you!

 

 

  1. PAs and NPs and DOs, oh my!Yes, there are too many initials in medicine. Let’s see try to clear up some you might encounter at your Occupational Health Center.

 

 

PA = Physician Assistant

A PA has completed an educational program lasting approximately 26 months; is state-licensed and certified by examination, and must complete continuing education regularly. A PA can prescribe medications, and must work under the supervision of a physician.

 

 

NP = Nurse Practitioner

An NP has completed graduate education as a Nurse Practitioner beyond the Registered Nurse program, either to the master or doctorate degree level; is state-licensed and nationally certified by examination, and must complete regular continuing education. A NP can prescribe medications and, depending on the regulations of their state may or may not function under a physician’s direction. Some states allow NPs to set up private practices without physician supervision. Other states require some collaborative agreement with a physician. (State Requirements)

 

 

DO = Doctor of Osteopathy

Yes, they are “real doctors.” To generalize greatly, DOs have the same scope of practice as MDs, though there are differences in their training and treatment techniques. DOs are licensed to practice the full scope of medicine throughout the United States.

 

 

Overall, we recommend good old fashion COMMUNICATION! If you or a supervisor, adjuster, or case manager isn’t comfortable calling your healthcare provider to touch base about a tricky case, then you’re using the wrong facility. (WCxKit)

 

 

Remember, if you are in a Employer-Choice or Panel state, this is YOUR CHOICE. Make an informed decision. Be comfortable with your choice. If you’re in an Employee-Choice state, it’s still a good idea to have an Occupational Health center you are comfortable with and use.   Often, you’ll end up sending your injured worker there, at least for an initial evaluation and quick treatment.

 

 

Starting with the best possible healthcare provider gets your claim off on the right foot (or shoulder, back, knee . . .). Do your homework and you’ll be ready!

 

 

Author: Kelly Haile, RN, CCM, WCCM is an experienced Nurse Case Manager who advocates working closely with each employer to refine their Workers Comp program to provide better post-injury care, excellent medical case management and timely communication. We provide services primarily in the PA, NJ, DE and MD areas.  You can reach Kelly in her role as Director of Case Management at NursePartners, LLC, by phone at 610-323-9800, fax 610-323-8018, Email: khaile@nptrs.com.


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MODIFIED DUTY CALCULATOR:   http://www.LowerWC.com/transitional-duty-cost-calculator.php

 

WC GROUP:  http://www.linkedin.com/groups?homeNewMember=&gid=1922050/
SUBSCRIBE: Workers Comp Resource Center Newsletter

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.


©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.

 

Filed Under: Medical Cost Containment, Medical Issues, Risk Management Tagged With: , , , ,

8 Ways One Doctor Can Reduce Workers Comp Costs Forever

February 9, 2010 by Leave a Comment
Dr. Nathaniel Evans has been very successful in helping his employer-clients reduce their workers’ comp costs by 50%, and because I have been a huge proponent of using MD's to better manage workers' compensation programs, I thought I'd write about it to let others in on the secrets. These are the eight techniques he uses.
8 Ways to Reduce WC Costs

#1 Time
Doctors are noted for impatience. One study reported that, when listening to patients’ problems, doctors allow patients (on average) 17 seconds to speak without interruption. In occupational medicine, it is critical that the physician acquire an accurate understanding of what the patient is claiming to be the setting, the time, and the mechanism of injury. The patient must be allowed uninterrupted time to describe the injury and the circumstances (time, place, witnesses, etc.) of the injury.

#2 Really Listen
It is so easy  for a busy doctor to be distracted by the pressures of the practice. It is very important the occupational medicine physician pay close attention to what is being said and what is being implied by the patient. The tone, content and “meta-messages” in the patient’s words can speak volumes about the patient’s motivation to get better, attitude towards work and impression of the co-workers and supervisors. Information picked up between the lines can help explain why a patient is presenting with symptoms in excess of what the stated mechanism of injury would cause the doctor to expect. Such an explanation can help the physician nudge the patient back to full productivity and help prevent unnecessary lost time.

#3 Examine For Objective Information
Sir William Osler,  a professor of medicine who helped establish Johns Hopkins as a world-class medical school, taught that the patient’s history is the doctor’s key to the diagnosis. Dr. Osler practiced medicine before workers’  compensation became law. Occupational medicine physicians must know the patient’s history is subjective and may be the key to the diagnosis. Objective signs should be valued more highly than subjective data. Objective data includes swelling, redness, spasm, vital signs, X-rays, EKGs, lab reports, digital imaging, EEGs, etc. Presence or absence of objective signs can help establish a diagnosis and can help authenticate or invalidate a claim of work-related injury. Some objective signs can suggest that the injury is real but was not caused by work.

#4 Defer to Personal Physician When Appropriate
Sometimes,  patients present to occupational medicine physicians (intentionally or unintentionally) with problems not caused by work. Sometimes the described mechanism of injury just does not fit with the complaint, the symptoms and the signs. In those situations it is usually appropriate to consider the problem “not work-related” and refer the patient to their personal physician for examination and treatment. Having the patient sign a statement agreeing to see the personal physician ASAP is a useful way to document the referral.

#5 Look For Signs of Symptom Magnification
Just as a well-prepared  lawyer does not ask a question without knowing the answer, the examining physician should have some idea (based upon the patient’s history of the injury) of what responses to expect from the patient at each phase of the physical examination. Specific validity tests can be used to assess the authenticity of a patient’s responses to physical examination. When discrepancies are noted, the physician should look for underlying non-physical causes of the complaint and should not just send the patient off to physical therapy hoping for improvement. Discrepancies are also a reason to reach out to the patient’s supervisor for information from another point of view.

#6 Reassure the Injured
The word “doctor”  originates from the Latin word for teacher. Very often, patients need to be taught about their injury. Patients often have unjustified fears and perceptions following minor injury. Patients’ questions need to be anticipated and answered. For example, typical (stated or unstated) questions about back pain include:
1.     Could this back injury make me paralyzed?
2.     Shouldn’t I stay home until ALL my pain goes away?
3.     Don’t I need an MRI?
When appropriate,  physicians should provide reassurance to patients and give clear, brief and succinct answers to patient’s questions. We should endeavor to acquaint patients with the basics of what to expect during the recovery process.  Even more importantly, we should give patients specific ways (e.g. exercise, stretching, ice, heat or injury care instructions) to expedite recovery. Instructions for wound care or medication usage should be stated clearly and should also be given in written form. Patients who understand their injury and who understand what they can do to expedite recovery generally feel empowered.

#7 Be Familiar With the Workplace
Workplace visits  give occupational medicine physicians understanding of the settings from which injured workers come for medical care. Such understanding can increase a doctor’s ability to appreciate the stresses and demands of the workplace. It can also help a physician evaluate the authenticity of patient complaints. I’ve noted that workplace visits also have the effect of causing injured employees to view the doctor as more informed and more credible because the doctor has some understanding of the workplace.

#8 Utilize Modified Duty When Needed
Of the injured workers  who cannot safely return to their regular duties, most can be accommodated in a modified duty position. Employers who do not offer modified duty miss a valuable opportunity to keep workers productive, keep them away from daytime TV, and keep them in the habit of reporting to work daily.   When employees spend extended time at home and away from work, some develop a reluctance to return to the workplace. (workersxzcompxzkit)

Summary
An experienced  occupational medicine physician can have a massive effect on the quality and the cost effectiveness of occupational medicine care. Unlike patients’ private or personal physicians, the occupational medicine physician cannot be a pure advocate for the interests of patients. Although committed to optimal medical treatment of the patient, the occupational medicine doctor also endeavors to maximize patients’ productivity, minimize lost time from work and limit testing and therapy to what is actually medically necessary. An experienced, attentive and skilled occupational medicine physician can produce great benefits for both patients and employers. The cost savings can be astounding.
 

Author Nathaniel R. Evans, II, M.D., FACEP,  is Medical Director of the Burlington Medical Center in Willingboro, New Jersey. A graduate of the Johns Hopkins School of Medicine, he is board certified in Internal Medicine, Emergency Medicine, Addiction Medicine, and Occupational Medicine. Dr. Evans has been successful in helping employers greatly reduce costs associated with workers’ compensation. Dr. Evans has served as an expert witness in cases involving occupational medicine, emergency medicine and internal medicine. Attorneys praise him for his clear and effective expert reports and expert testimony. He can be reached at nrevans@comcast.net.

Podcast/Webcast: Claim Handling Strategies
Click Here  :
 http://www.workerscompkit.com/gallagher/podcast/  Claim_Handling_Strategies/index.php  

 

We accept articles about WC cost containment.
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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.
 
©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com
Filed Under: Coordinating Medical Care, Medical Cost Containment, Medical Issues, Risk Management Tagged With: , , ,
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