Do Not Be So Quick To Diagnose Carpal Tunnel

 

Disclaimer—This is not a medical article.  This is not meant to diagnose or treat a condition. This is merely a guide to use as potential reference to occupational cases.  Always consult your physician for advice on what your diagnosis may or may not be.
 
If I went to a doctor’s office and said my hands are numb, and he automatically diagnosed me with carpal tunnel and sent me for an EMG, I would be looking for another opinion right away.
 
Why? I know that just because I have numbness in my hands, the automatic diagnosis of carpal tunnel is premature.  Numbness can be caused by a multitude of issues, both possibly occupational in nature, and, more importantly, not occupational in nature.  The background of getting to the root cause of a condition can take a long time, and just cannot be made in one or two visits to the doctor, whether this is a hand specialist or just a general occupational physician.
 
Below we discuss a little about the warning signs of carpal tunnel, and some other conditions that could be the cause:
 
1.    Where is the Numbness?
Generally speaking, if a person says their entire hands are numb, chances are that just carpal tunnel is not the entire cause.  Median nerve compression, an indicator of carpal tunnel, will isolate itself to a combination of the thumb, pointer finger, middle finger, and maybe part of the ring finger.  If your whole hand is numb, you can have a combination of carpal tunnel and cubital tunnel, or many other issues genetic in nature all combined.  To make a diagnosis of just carpal tunnel is incorrect, and not a detailed enough analysis to fly for any adjuster out there.
 
Cubital tunnel, or ulnar nerve entrapment, will tend to be the ringer finger and little finger, and the entrapment will occur at the elbow area.  Cervical radiculopathy will remain in the neck/shoulder region, with numbness maybe going down the back of the arm and wrapping around the arm to the forearm and possible referring symptoms into the hand. 
 
2.    Is Carpal Tunnel Work Related?
This is a debate that has gone back and forth for years.  Many physicians state that the primary cause of carpal tunnel is genetic predisposition.  Other contributing factors are diabetes, pregnancy, smoking, obesity, and others.  Waking up at night is a huge indicator, since we all at some point tuck our wrists into the fetal position.  Once this occurs, the symptoms of numbness and pain reproduce, waking up from sleep. 
 
If a person says they have carpal tunnel but they are also sleeping though the night with no waking, chances are the nerve impingement is not at the wrist. Even if you sleep on your back and you know for a fact that you will never once sleep in this fetal position, I would beg to differ.  But again most doctors either agree or disagree with this theory. 
 
 
3.    You Have to Look at the Medical/Occupational History of the Claimant
This includes both work related and non-work related jobs and movements.  All kinds of things can contribute to carpal tunnel, including medications, past/current illnesses, family history of illness, pregnancy, timing and location of the numbness, and any contributing hobbies.  I heard of a case where a guy claimed to have carpal tunnel from his desk job, but then the adjuster discovered the claimant had a second job as a violinist in a community orchestra.  Certainly the postures and movements of a violin player can contribute to the progression of carpal tunnel symptoms, or even cubital tunnel.
 
Another large contributory player in the realm of hobbies is carpentry work.  Use of vibratory or torqued tools that vibrate can start symptoms that are then aggravated by work duties that could be repetitive in nature.  Even minor movements that are repetitive in nature can be a culprit.  So take the time to do a careful medical and non-medical investigation since all movements or hobbies with gripping or movements could be included as a risk factor.
 
4.    So is it Cubital Tunnel and Not Carpal Tunnel?
That will depend on the location of the numbness.  The elbow is the most common site for compression of the ulnar nerve.  This syndrome is stereotypically known to affect men more than women, but again this depends on the study you review. 
 
Symptoms will include pain and tenderness around the inside of the elbow radiating into the forearm and the ring/little finger with associated tingling, numbness, and burning.  These symptoms again may occur more frequently at night than during the day.
 
Cubital tunnel causes can be frequent bending of the elbow from pulling items or levers on machinery, constant direct pressure on the elbow over time from leaning on the elbow, sleeping with bent elbows, or from direct trauma to the elbow area such as a fracture.
 
5.    So Can Cubital Tunnel be Work Related or is it Genetic in Nature?
Depending on your study and your physician, it is hard to say whether this is more of a work related diagnosis or one that is more genetic in nature.  You must take the time to delve into the case, and take a careful history of all employments, job tasks, and also all tasks or hobbies that your claimant does outside of the workplace.
 
Summary
Any type of injury that has associated numbness cannot lead itself to a blanket diagnosis of just carpal tunnel alone, but more times than not in the work comp world we see it more and more.  All physicians and adjusters have to take the time to do a full workup of the case, involving every job task both inside and out of the workplace. 
 
Many hobbies or activities outside of work can be the culprit of the cause of these issues, including the way you sleep, the way you drive your car, any hobbies the person partakes in, and so on.  Don’t be quick to accept the diagnosis and rush a person in for surgery.  Explain to your claimant the risk factors both in and out of the workplace, and that you just want to make sure you target the actual problem so it can be corrected and the person can move on with their lives, hopefully in a pain-free fashion.
 
 
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
 
©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.  

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

Best Practices in TPA Medical Management

TPA Medical Management Critical for Cost Containment

 

The third party administrator (TPA) who handles your workers’ compensation claims needs to be especially strong in their medical management skills.   The top tier TPAs will have their own medical management division overseeing and controlling the medical cost of your claims and working in conjunction with the workers’ compensation adjusters.

 

The most effective ways to control your medical cost include:

 

  • Telephonic nurse case managers
  • Field nurse case managers
  • Senior nurse reviews
  • Utilization reviews
  • Medical bill reviews
  • Prescription management
  • Physician review
  • On-site clinics
  • Injury triage
  • Wellness programs
  • Preferred provider networks

 

 

Nurse Case Managers

 

Nurse case managers are experienced nurses who are utilized to coordinate and manage the medical care for an injured employee.  There are two primary types of nurse case managers, telephonic case managers (TCM) and field case managers (FCM).  Both TCM and FCM will:

 

  • Coordinate the medical care
  • Consult with the physician on treatment options
  • Prevent over utilization of medical treatment
  • Monitor the employee’s medical recovery
  • Provide frequent updates to the adjuster and employer on the employee’s medical progress
  • Coordinate the employee’s return to work, either light duty or full duty
  • Facilitate communication between the employee, employer and physician
  • Manage the medical rehabilitation of the employee

 

The primary difference between the TCM and the FCM is the location of their work.  The TCM will work from his/her office and perform all activities on the workers’ compensation claim by telephone and e-mail.  The FCM will often meet in person with the injured employee and will accompany the employee to medical appointments when appropriate.  While not a strict division of injury assignments, the FCM is more often utilized on severer injuries.

 

 

Senior Nurse Review

 

With the senior nurse review, a highly experienced nurse provides continuous oversight of medical care. This provides for identification of recovery obstacles early in the life of the claim. Through continuous monitoring of the medical care, the senior nurse reviewer can also verify the quality of medical care if the recovery time exceeds the normal disability duration guidelines.  When a senior nurse reviewer is involved in the workers’ compensation claim, the medical management provider will also have physicians with whom the senior nurse reviewer can consult.

 

 

Utilization Review

 

The medical management company should provide utilization review services.  A utilization review is an independent confirmation of the necessity for medical services.  There are 3 types of utilization review.  They are:

 

  1. Pre-certification Review – an experience nurse will collect all the medical information including the symptoms, diagnosis, test results and the reason a physician is requesting a specific medical service.  The nurse will compare the medical information against the normal criteria for a specific treatment.  If the nurse concurs, the medical service is approved.  If the nurse determines the medical care is not necessary, the matter is referred to a physician for a peer review, and acceptance or denial of the requested medical service.
  2. Concurrent Review – is a review of the medical necessity while it is in progress.  This type of utilization review is often used during hospital stays, or on-going multiple outpatient visits, for example: physical therapy.
  3. Retrospective Review – After a medical service has been completed, but before a payment is made for the service, the nurse reviews the reasons for the service and the necessity for it.  If the medical service was not needed, the retrospective review gives the adjuster justification and documentation as to the reason the medical provider is not compensated for the medical service.

 

 

Medical Bill Review

 

The medical management company reviews and verifies the accuracy of the medical bill diagnostic codes and the medical bill charges. The medical bill charges are compared to the medical fee schedule established by the state.  When there is no fee schedule, the medical charges are compared with what is customary, reasonable and necessary

 

 

Pharmacy Benefit Manager

 

A pharmacy benefit manager provides a network of pharmacies to provide medications at the best possible price.  The pharmacy benefit manager will also monitor the utilization of prescription drugs to prevent the overutilization of drugs through premature fill request, excessive dosages, multiple providers, multiple pharmacies and multiple drugs used for the same purpose.

 

 

Physician Review

 

When an injured worker is not responding to the medical care within the range of normal recovery time, a physician review is often appropriate.  The physician review is a peer review by a specialist who will evaluate and document the medical necessity of the past, current and future medical treatment.  The physician review provides an in-depth evaluation of the medical necessity of the treatment being provided to the injured worker.  The review process can strengthen the return to work program by verifying the appropriateness of an injured worker being on modified duty work. The review process can also be used to evaluate the accuracy of an impairment rating provided by the employee’s medical provider.

 

 

On-site Clinics

 

On-site (employer’s work site) medical clinics staffed by RNs, nurse practitioners and physician assistants have proven they can curb the fast-rising cost of medical care for both personal and work-related injuries and illnesses. The on-site clinic provides the medical care making it convenient for employees who do not have to leave work for care.  Employees are referred to off-site medical facilities only if the injury or illness is beyond the scope of the medical professionals in the on-site clinic.

 

 

Injury Triage

 

Injury triage is the process of having an experienced nurse evaluate the injured employee’s medical needs through the use of algorithms, software and an in-depth interview of the injured employee.  Based on the information obtained, the triage nurse makes decisions on the appropriate level of medical care needed.  While triage nurse can be utilized any time in the course of the workers’ compensation claim, it is most effective when it is conducted immediately after an injury.  The triage nurse directs the employee to the most appropriate medical provide within the in-network of service providers. This prevents the employee from over utilizing medical care while ensuring the employee obtains the medical care needed.

 

 

Wellness Programs

 

A wellness program is a company sponsored effort to improve the health of employees.  A complete wellness program will include nutrition and health education, physical fitness, health screenings and behavior modification.  An employer benefits from a wellness program through both lower cost of health insurance and lower cost in the workers’ compensation benefits.  Additionally, a wellness program will result in lower absenteeism and a corresponding increase in productivity.

 

 

Preferred Provider Networks

 

A preferred provider network is an organization of doctors, hospitals, diagnostic facilities and other medical providers who have agreed with the insurance company or self-insured employer to provide medical services to injured employees covered by workers’ compensation insurance. In exchange for the insurer or employers sending a volume of business to them, the medical providers agree to a pre-determined reduction in their normal charges for services. The reduction in cost can be substantial for the insurer or employer.

 

Employers should select one medical management partner that can provide expertise in all of these areas rather than multiple medical management partners.  A medical management partner that covers all of these areas can integrate the medical cost control services eliminating duplication of services and eliminating gaps in medical cost control.

 

 

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.

 

©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. 

 


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

Industry Leaders Discuss Challenges at Broadspires First Pharmacy Summit

 

pictu1Medications and drugs continue to play an increasingly important role in the overall of medical costs in workers compensation claims. In addition to the increases in costs, the potential claim risks have also increased surrounding the growing use of narcotics in the treatment of pain. These issues impact all involved parties in the claim administration process – from injured worker, to employer, to carrier or payer. How to manage these issues has now become a critical issue.
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On March 22, 2012, Broadspire, a Crawford Company and leading third party administrator (TPA) and medical management services provider, brought together representatives from a number of key industry organizations to discuss the challenges in prescription drug management for workers compensation claims during its first pharmacy summit.

 

 

 

pictu2

The intention of the summit was to focus on global industry issues, trends and developments in the future. In bringing together resources from all aspects of the pharmacy management process, the group was able to have an all encompassing discussion of the issue, and examine the challenges from all perspectives and vantage points. Throughout the day, the group discussed the common threads that tie together claimant, payer, employer and carrier interests. The group also shared ideas that could be put into practice to improve outcomes for everyone concerned.

 

 

 

 

More than 50 brokers, practice leaders, clinicians and others from major insurers, insurance brokerage firms and pharmacy benefit management (PBM) organizations attended the summit, which was held at Broadspire’s Sunrise, Fla., medical management headquarters. The panels were divided into four key areas of focus

 

  1. Pharmacy program design
  2. Opioids and controlled substances
  3. Physician dispensing
  4. Key legislative updates.

 

 

 

pictu3The first session focused on the overall design of an effective pharmacy program. Panelists in the discussion included Eileen Ramallo, Executive Vice President of Healthcare Solutions; Lori Daugherty, President of PMSI/Tmesys; Atermis Emslie, President of MyMatrixx; and Kathy Tiemeier, Clinical Program Manager of Express Scripts.

 

 

 

 

 

 

pictu4Candy Raphan, RN, BSN, ARNP, MAOM Candy joined Broadspire in 1989.  For over 20 years, she has held various management roles within the Broadspire organization in a variety of functional areas, including Occupational and Non-occupational Disability Management, Utilization Management, Medical Bill Review, Quality, and Medical Management Strategic Outcomes.  In her current role as Director of Medical Services, Candy is a Practice Leader for Broadspire’s Comprehensive Pain Management Solution and responsible for the clinical components of the pharmacy program, medical analytics, reporting and other clinical program development.

 

 


In addition to her experience at Broadspire,
 Candy brings a varied background of clinical, managed care and health industry related experience.  She is a certified advanced registered nurse practitioner with a specialty in family practice, Candy holds a bachelor’s degree and advanced practice certificates in nursing from the University of Miami and a master’s degree in organizational management from the University of Phoenix.  Candy is also a member of the National Association of Professional Women and the American College of Healthcare Executives.

End Article
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WORKERS COMP MANAGEMENT MANUAL:  
www.WCManual.com 
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.
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