Are Diagnostic Testing And Physical Therapy Overused In Workers Comp?

If you are handling a pesky claim that just will not go away, or the objective signs are just not lining up, chances are a key diagnostic test is what you need to tie it all together. A well done MRI or EMG could be just what the doctor ordered (literally). However you must keep in mind that not all diagnostic testing is warranted. Below we point out some surprising statistics, and ways to prevent you from authorizing testing that may not be of any help:
 
  1. The right EMG test needs to be done at the right time
 
This is especially true for insurance claims, whether it is work comp or an auto accident injury. And it is especially true when dealing with Medicare, although it’s not necessarily applicable to our thoughts here. Doctors and their businesses sometimes are under the impression that once an insurance claim arrives at the waiting room looking for treatment they have free reign to treat at will. This is a big no-no, since if you get the wrong test done in the wrong location, what good does it do? Sure, numbness in the hands can mean impingement at the wrists or elbows, but what about the neck? Cervical radiculopathy can be the culprit underneath what seems like simple and basic carpal tunnel syndrome. 
 
So if a doctor performs an EMG at the wrist, which is negative, then they will be doing another test at the elbow, and possibly one at the shoulder, and one at the neck. When it is all said and done, they have performed 4 EMGs, when 1 would have sufficed if done properly at the neck level. 
 
Adjusters need to think outside the box a little, and look at the other symptoms as well as the medical history. Adjusters can also utilize their Utilization Review department, a nurse case manager, or a Record review from another physician to see what type of test should be done. All of these steps need to be taken in order to avoid medical cost leakage due to a hunch from the treating physician.
 
 
  1. Does an MRI really need to be performed?
 
The best way to see why a back injury will not subside is to obtain an MRI test. MRIs are probably the most common test performed, since a back injury is one of the most common injuries in the occupational world. However, if a back injury is not getting better after 3 weeks, obtaining an MRI may be jumping the gun.  Other symptoms need to be present, such as leg weakness, numbness, radicular pain, etc. If the claimant complains of just pain, should that warrant obtaining an MRI? Pain is a subjective complaint, not necessarily something that warrants expensive testing, other than possibly a series of routine X-rays.
 
It is my opinion that doctors sometimes want to pacify the patient by doing some sort of test. Plus, there are patients out there that want something objective and/or invasive to be done in order to feel “better.” So, to make lives easier on themselves, doctors will just order the MRI. When it fails to show anything remarkable, they move on to the next step in the course of treatment that they would have moved to anyway.
 
This is not to say that every spine MRI is unnecessary. If months have passed and the claimant is still in considerable pain with functionality issues, then yes it is time for additional testing to see what is going on. But not within the first few weeks after an injury occurs. Bearing in mind again that the other obvious symptoms are not there, those being the leg pain, foot drop, muscle atrophy, etc.
 
 
  1. Does the injured worker need months of physical therapy?
 
By default, there are many clinics that will see an injured worker, then dump them into their physical therapy program to help rehab their injury. The adjuster must stay on their toes when this situation happens. Oftentimes the patient will get prescribed a course of physical therapy after an injury, and this is the correct course of treatment for soft tissue injuries. But, to take a back strain injury and dump a person into a 6 week therapy program, then have the doctor reevaluate them 6 weeks later is not acceptable. The physician should be involved in the program, seeing the patient at least on a weekly basis so they can modify the frequency and duration of the program if needed. 
 
Dumping a patient in a long term therapy program happens more often than you would think, especially when the program is run inside of the treating doctor’s office. This means the doctor is getting two sources of income coming in: one from treating the patient, and one from the therapy program. 
 
Even if an injured party needs surgery, post-op patients need to be carefully monitored during recovery. Again, the doctor needs to be involved in the program, and watching the hopeful steady progress back to full duty. It is easy for these docs to forget about the patient, and just let the 6-8 week therapy run its course. What if the patient is not attending all of their therapy sessions? What if the patient tells their adjuster that therapy is causing an increase in pain? What if the patient is not being compliant with their home exercise and stretching program? All of these questions need to be addressed, and they need to be addressed right away, not 8 weeks later after the program has completed.  
 
 
  1. Some statistics to keep in mind (stats pulled from GAO Analysis of Medicare Part B Claims data; Boden et al. JBJS, 1990; Friedly J, Chan L, Deyo R; Spine, 2007)
 
  • Billing from 2000-2006 increased from $6.89 billion to $14.11 billion for lumbar imaging.
  • MRI research with patients that had “no back pain” showed that of those under age 60: 36% showed herniated discs, 21% had spinal stenosis, 79% had a bulging disc, and 93% had a degenerated disc.
  • The Medicare population increased 12% from 1994-2001, but billing for services increased 637%. 
 
 
Summary
 
Diagnostic testing and physical therapy can be two keys to helping discover what injury a patient has, and how they can get better. For the most part, these tests and therapy programs are done properly and when needed, but not all of the time. Adjusters have to use their network of professionals to help gauge what is needed and when. Nurses, Utilization Review departments, IME physicians, and Peer Record Reviews all can be implemented should testing or therapy not seem like the right course of action. The adjuster has to take the time to get involved in the claim, question why these things are being recommended, and keep the patient on the track to recovery. Just because a doctor recommends a certain action doesn’t make it in the best interest of the patient, or the carrier/TPA as a whole.  
 
 
Author 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.
 
©2013 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.

Differences between Physical Therapy and Occupational Therapy

 

Most Workers Comp Injuries Require Physical Therapy
 
To people who are not in the medical field, there is often confusion between physical therapy and occupational therapy.  People often think injured employees will have “occupational” therapy as the injury arose out of their occupation.  While there are some instances where an injured employee will need occupational therapy, in most workers’ compensation claims, the injured employee needs physical therapy, not occupational therapy.  While physical therapists and occupational therapists deal with many medical issues outside of workers’ compensation, this discussion will be limited to therapy treatment related to workers’ compensation.
 
 
Physical Therapy Restores Musculoskeletal System
 
Physical therapy is a medical service designed to develop, maintain or restore the injured employee’s musculoskeletal system.  When a treating physician refers an injured employee to a physical therapist, the physician will specify the anticipated number of physical therapy sessions needed to restore the employee to the maximum level of recovery. 
 
Upon the receipt of a new physical therapy prescription for the employee, the therapist will schedule the first visit.  At the first visit and in subsequent physical therapy sessions the therapist will:
 
·             Examine the employee’s body part needing therapy
·             Measure and test the employee’s
o   Strength
o   Range of motion
o   Balance, if applicable
o   Coordination
o   Muscle performance
o   Posture, if applicable
·             Develop a treatment plan to accomplish the physician’s goal in the allotted number of sessions
·             Provide exercises to improve muscle strength, range of motion and muscle performance
·             Provide traction and/or deep tissue massage, if needed
·             Provide cold compresses or hot packs, if needed
·             Provide ultrasound treatment or electrical stimulation, if needed
 
 
Goal to Improve Movement Dysfunctions
 
The overall goal of physical therapy is the improvement of an injured employee’s movement dysfunctions and returning the injured employee to the maximum level of musculoskeletal function.
 
 
Occupational Therapy Trains To Improve Functional Abilities
 
Occupational therapy is medical services designed to train and educate an injured person in how to modify their physical environment to improve their functional abilities. Often the occupational therapist will provide instruction on how to use durable medical equipment (prosthetics, crutches and wheelchairs) to increase the employee’s functioning.  The occupational therapist will evaluate the injured employee’s needs and will design a program to overcome the employee’s medical related deficiencies and improve the injured employee’s ability to perform the daily activities of their life.  The occupational therapist will teach the injured employee how to adapt to their physical limitations caused by the work injury.
 
 
Teaches to Adapt to Physical Limitations
 
In addition to teaching an injured employee how to adapt to their new physical limitations, an occupational therapist will often teach the employee on how to prevent and avoid injuries. The occupational therapist will recommend to the injured employee equipment, gadgets and devices that are designed to increase the employee’s safety and increase the employee’s functional ability.
 
 
Best Outcome When Physical and Occupational Therapist Work Together
 
While there can be overlap between the activities of a physical therapist and an occupational therapist, the best outcome for the injured employee is when the occupational therapist and the physical therapist work together.  For example:  An employee is involved in a horrific accident that leaves the employee a paraplegic. The physical therapist will work extensively with the employee to maximize the employee’s remaining functioning of their musculoskeletal system.  The occupational therapist will be brought in to train the employee in how to perform life functions from the confines of a wheelchair.
 
 
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.

The Benefits of Physical Therapy in Workers Comp

 

What is Physical Therapy?
 
When injuries result in damage to musculoskeletal parts of the body, treating physician often need to send an injured employee to a physical therapist. Physical therapy, also known as physiotherapy, is a medical service designed to develop, maintain or restore the employee's normal body movements.
 
With workers compensation claims, an injured employee normally deals with a physical therapist that specializes in working with muscles, tendons, ligaments, bones and joints. Other physical therapists specialize in skin problems resulting from burns or wounds, nerve injuries and related muscle or breathing and lung problems. The physical therapist’s goal is to help the employee regain prior functioning levels. A side benefit is often pain reduction from the injured body part.
 
 
The Primary Treating Physician’s Role in Physical Therapy
 
When an employee injures or has surgery on a limb or joint, the treating physician often recognizes that the employee's range of motion is limited, or the limb or joint’s functioning is below what it was before the accident or surgery. The injury created an abnormal body condition making it difficult for the employee to do normal tasks.
 
Primary treating physicians usually have a working relationship with various physical therapists in the local area. The physician recommends the physical therapist best suited for the employee’s type of injury. The physical therapy will be conducted in an out-patient clinic setting.
 
Depending on the injury’s severity and the physical therapy needs, the physician will prescribe the expected amount of physical therapy treatments the employee may need.
 
 
What Happens at Physical Therapy? 
 
At the first visit, the physical therapist will review the injury information provided by the physician, the amount of care prescribed and then determine a treatment plan to address the employee's needs. The treatment plan may include improving flexibility, endurance, strength, coordination and balance.
 
Usually the first step is to introduce therapy designed to reduce swelling, stiffness or pain. The initial modules may include water hydrotherapy, ultrasound, electrical stimulation, heat packs and cold packs. These are normally followed by stretching, walking, weight lifting and various types of exercise. The physical therapist will often teach exercises to be done at home that are specifically designed for the employee’s type of injury.
 
In addition, the therapist will create a total treatment plan. This will include educating the employee on how to avoid re-injury and injury caused by repetitive motion. The best physical therapists also incorporate the psychological and emotional support needed by the injured employee into their treatment plan.
 
Kim Lough, Vice President of Care Management Operations at Network Synergy Group, commented, “One of the key ways of delivering a positive outcome for patients during physical therapy treatment is ensuring therapy goals are tailored to the needs of each individual patient. This approach to individualized treatment plans helps ensure quality patient care while effectively managing claim costs.”
 
At the end of the treatment period, the employee returns to the physician to be evaluated on the progress made in recovering from the injury. The physician can request further therapy, end the therapy or try a different treatment approach. (WCx)
 
 
The Outcome of Physical Therapy 
 
The outcome of physical therapy depends on several factors including the level of disability, the type of physical impairment, any complicating medical issues (like degenerative disc disease or diabetes) and the skill and expertise of the physical therapist. Physical therapy is normally less expensive than surgery and is less invasive. Overall, physical therapy benefits the employee in most cases where it is used.
 

 

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.

The Best Tidbits of News From the Work Comp Community

 

 
We want to tell our readers a little about you, maybe something that wouldn’t make it you’re your corporate bio.  Where are you from?  Where did you go to school?  What was your first job in the industry?  How did you get into the workers comp TPA business?  I got in the TPA business when I interviewed for a supervisory position for a medical auditing firm…  Read more
 
 
 
In 2012, Network Synergy Group launched an aggressive campaign to build out its provider network to all 50 states. In addition to expanding the network, NSG has also broadened its product suite to include both a Condition Rate Program and a Visit Rate Program. These enhanced products support customers’ needs by enhancing workplace productivity while adhering to medical guidelines. Read more…
 
 
 
Build your personal daily agenda , Receive real-time reminders and updates, Find sessions, events, speakers and exhibitors, and more.  Check out the full list of features to help you navigate the country’s premier Workers Comp event here
 
 
 
 
The Work Comp Analysis group is the largest online discussion group dedicated exclusively to WORKER'S COMPENSATION issues.  It is a "spam free" discussion page used for asking questions and discussing industry issues. It was created on November 28, 2008 by Mark Walls from Safety National.  Congratulation Mark on hitting this milestone!  Join Group
 
 
 
The most difficult cost savings measurement is calculating the savings gained from what did not happen. Call it cost-avoidance measurement. Some say it cannot be done because if it has not happened, it certainly cannot be measured. Read more…
 
 

Author 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

 

 


WORKERS COMP MANAGEMENT MANUAL:  www.WCManual.com

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.

The 411 on Functional Capacity Evaluations

 

Tests Performed by Occupational or Physical Therapist
 
A functional capacity evaluation (FCE) is a comprehensive series of test administered by an occupational therapist or a physical therapist who has had specialized training in performing a FCE.  The tests are specifically designed to measure:
 
·         stamina
 
·         dynamic strength
 
·         mobility
 
·         flexibility
 
·         body mechanics
 
·         cardiovascular condition
 
·         balance
 
·         coordination
 
·         dexterity
 
·         ability to tolerate functional activities
 
 
Used to Determine Employee’s Readiness to Return to Work
 
In workers’ compensation claims, a FCE is often utilized to determine the injured employee’s physical readiness to return to work and to measure any physical limitations the employee will have as a result of the work comp injury.  A FCE can also be utilized to determine the injured employee’s physical capabilities for vocational retraining when the injured employee will be permanently unable to return to his/her prior vocation.
 
A FCE can be one of two types, either a job specific FCE or a general purpose FCE. In a job specific FCE, the therapist is provided a detailed job description prior to the testing in order to tailor the FCE to the specific job of the employee.  To have a very accurate FCE, the therapist should visit the jobsite to have a detailed understanding of the functions of the job.  In a general purpose FCE, the testing measures the employee’s strength and tolerance in completing standardized or common work task.
 
 
 
Test Can Last Several Hours to Two Days
 
After a determination of the type of FCE, the appointment date is scheduled for the injured employee.  A FCE can last from several hours to two days, depending on the nature and extent of testing.
 
At the start of the FCE, the therapist will perform a comprehensive interview of the injured employee.  The interview is designed to identify any factors that could impact the employee’s ability to participate in the FCE.  The therapist will want to know if the employee has any issues with asthma, COPD or other lung/breathing problems, high blood pressure, physical limitations besides the work comp injury, and obtain the employee’s own assessment of their physical condition including the employee’s perception of his/her pain level.
 
 
Measure Various Physical Tests
 
In conjunction with the interview, the therapist will complete a clinical assessment of the employee to establish a base line for the FCE.  The therapist will measure the employee’s range of motion, balance, grip strength and coordination to establish the testing plan.
 
In a job specific FCE the therapist will measure the employee’s ability to lift, carry and perform other tasks in comparison to the performance levels identified in the employee’s job description guidelines. In the general purpose FCE the therapist will measure the employee’s maximum ability to lift, carry and perform routine work related task.
 
 
5 Categories of Physical Demands
 
The U.S. Department of Labor characterizes jobs in 5 categories depending on the physical demands of the job.  For instance, an over-the-road, or long-haul truck driver is classified as a “heavy” physical demanding job.  The 5 categories are defined as:
 
·         Sedentary:  exerting up to 10 pounds of force occasionally
 
·         Light:  exerting up to 20 pounds of force occasionally or up to 10 pounds of force frequently
 
·         Medium:  exerting 20 to 50 pounds of force occasionally or 10 to 25 pounds of force frequently
 
·         Heavy:  exerting 50 to 100 pounds of force occasionally or 25 to 50 pounds of force frequently
 
·         Very Heavy:  exerting in excess of 100 pounds of force occasionally or in excess of 50 pounds of force frequently or in excess of 20 pounds of force constantly
 
If the therapist is performing a general purpose FCE on a truck driver, the therapist would determine the truck driver’s job is a “heavy” physically demanding job. The general purpose FCE testing would measure the employee’s ability to meet the requirements of the “heavy” job classification.  However, some truck drivers are “drive and drop” drivers where they never touch the cargo.  The hardest part of their job is cranking the landing gear of the trailer up and down and disconnecting the fifth-wheel.  Their job requirements would fall in the “medium” job classification for physically demanding.  Therefore, when there can be different levels of physical effort needed for a job title, it is to both the employer’s and the employee’s benefit to provide a detailed job description to the therapist and to request a job specific FCE.
 
 
Biggest Issue is Validity of Effort by Injured Employee
 
The biggest issue with FCE is the validity of the effort put forth by the injured employee.  If the injured employee has been advised by his/her attorney that the better they do on the FCE, the lower their permanent partial disability settlement will be, the employee is given a financial incentive to put forth less than their best effort.  If there is any concern the employee may not make a sincere effort in the FCE, the therapist should be advised prior to the FCE.  The therapist can give the employee several different tasks or activities that measure the same physical ability.  If the test results reflect a variation in the employee’s ability within a specific category when measured by two or more different methods, the therapist will be able to identify the employee who is trying to game the testing and include in their post testing report the fact that the effort put forth by the employee was inconsistent.
 
 
Results Compared Against Specific Job Description
 
When the FCE testing is completed, the therapist will compile the employee’s test results.  The test results will be compared against the specific job description requirements or the general physical level classification of a job to see if the employee can return to performing the job. The results of the FCE are then reported to the treating doctor and workers’ compensation adjuster and/or nurse case manager. 
 
 

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

 


WORKERS COMP MANAGEMENT MANUAL:  www.WCManual.com

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.

Physical and Occupational Therapy Management Basics Explained

 
 

What is therapy management?

Therapy management is a system aimed at controlling costs of physical medicine such as but not limited to physical and occupational therapy. An entity utilizing clinical and non clinical personnel; contracts with a network of skilled therapy clinicians and actively arranges for and coordinates the most appropriate physical medicine services for patients and employers alike. To learn more about the topic, Roundtable sat down with Greg D'Ambrosio, vice president of client services for the Network Synergy Group to give us an insight to the world of therapy management.
 
 

Why do therapy services need to be managed?

Physical and occupational therapy is no different then other medical costs that have skyrocketed over recent years. Proper management of therapy services can ensure appropriate and medical necessary treatment by expediting scheduling, monitoring patient care and compliance, reimbursing network providers fairly and timely. The result should be a positive outcome and experience for the payor and patient. Better outcomes result in lower costs.

 

Is this a new concept?

Conceptually, managed care arrangements date back to the early 1920s when insurance companies began using prepaid insurance arrangements for specific employee populations. However, the term managed care became popular in the 1980s. The need and development for physical therapy management had its origins in the following decade around mid- to late 1990s.
 

 

How does this help reduce my workers compensation costs?

Physical and occupational therapy is often the last form of treatment prior to a claimant receiving a disability status, reaching maximum medical improvement and returning to work. Therefore, since workers’ compensation is predicated on either restoring the claimants functional capacity prior to the injury and/or returning the claimant back to work, a therapy management program that ensures medically necessary and appropriate care is critical in reducing the overall medical and indemnity costs of a claim.
 


Who should be using therapy management?

Any entity that has a stake and interest in reducing their overall cost of their workers’ compensation claims should be using a therapy management program. This would include self insured employers, insurance carriers, captives and pool arrangements, municipalities, public entities and third party administrators.

 

Why is it advantageous?

Other than the obvious reduction in overall claims costs, the management company should alleviate many of the administrative burdens of an adjuster and or nurse case manager that would have to manage therapy on a case- by-case basis. This allows them to focus on other aspects of a claim.
 

 

Can all companies use this type of service?

There are no restrictions as to what type of companies can use this service. Many companies use this service simply by contracting with their insurance carrier or third party administrator.
 
 

Are there times it might not be beneficial to use such a service?

In workers’ compensation there are always unusual circumstances whereby an adjuster may have a need to manage therapy themselves. However, an overwhelming majority of claims are handled by a therapy management company.
 
 

How does an employer find a good therapy management company?

However, management companies vary significantly in their approach to how therapy is managed. Insurance carriers and TPA’s (third-party administrators) often are affiliated with a therapy management company, but that does not necessarily mean it is the best fit for the client. With the proliferation of the internet and maturation of the industry it would be easy to locate a therapy management company. I would search specific workers compensation sites and blogs such as reduceyourworkerscomp.com to obtain information. Organizations should also identify the best fit for them by speaking with others references in similar industries and positions. Conferences and associations offer great opportunities to speak with peers to obtain information.
 
 

What should a company do if their TPA or insurance company objects to using a therapy management service?

This is simple — ask “Why?” Large employers with high deductibles that assume all or most of their workers’ compensation risk should be able to dictate which service providers are the most appropriate for them. Transparency is critical. A company should ask, “Does the carrier and or TPA somehow benefit in the arrangement by using a therapy management company they have contracted with?” A company should also ensure contractually that they are not limited in selecting service providers when negotiating their workers compensation program or TPA services.
 
 

As a service provider what are the biggest obstacles you encounter with implementation of a new client?

Adjusters are busy and even more so in today’s environment. Scheduling time to fit into adjusters’ schedules to properly implement a program is our biggest challenge. Although not as effective as in person meeting, video conferencing, webinars, and conference calls can help alleviate this.
 
 

As a client, how will I determine the return on my investment?

A client should always focus on outcomes. It is up to each individual client to define what a good outcome is. Patient satisfaction, number of visits per treatment, the duration of care, and the functional capacity status of the patient upon discharge are just a few outcome driven metrics. In addition, there are many overlooked costs associated with therapy management such as bill review and percent of savings charges that need to be contemplated when evaluating the cost benefit of a therapy management program. The customer has to place a value on outcomes that meet or exceed their expectation. Then the analysis becomes simple. If outcomes are meeting or exceeding expectations at what the client can define as a fair price, then the return on investment is a positive one.
 
 

 

 

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.

 

Greg D’Ambrosio joined Network Synergy Group in 2010 as Vice President of Client Services.  His responsibilities include directing client training and ensuring NSG's therapy management programs are delivered with ease, efficiency and support. Greg has over 20 years of experience in the insurance and PEO industries.  Greg has also been a featured speaker for the NAPEO and Florida Workers' Compensation conferences. He can be reached at: gdambrosio@network-synergy.com or (888) 533-0727 x. 160.

Pat Merrill joined NSG as Vice President of Network Development and Provider Relations in 2011. Pat is currently responsible for the strategic and operational leadership of NSG's Network Development and Provider Relations Departments. She has over 25 years of experience working with large employers; providing solutions for their occupational medicine and workers’ compensation injury care needs.  Pat is a member of the Southern Association of Workers’ Compensation (SAWCA) and the Georgia Self Insured Association. She can be reached at: pmerrill@network-synergy.com or  (813) 207-0727 x. 120 or (404) 314-3225 (c).
 

WORKERS COMP MANAGEMENT MANUAL:  www.WCManual.com

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.

Physical Therapy Management Company Celebrates 15 Years, Expands

2012 is Network Synergy Group (NSG)’s 15th anniversary. Its physical therapy management programs started in 1997 and this year expands to Illinois, Indiana, Louisiana, and Mississippi. NSG now offers a Therapy Management Solution to self-insured employers, insurance companies, and Third Party Administrators throughout those states and others – 25 in all.
 
 
According to NSG employees, the company broke the fee-for-service model in which medical providers were rewarded for more, not better, services. “NSG’s idea was simple – realign the financial incentives of the therapy providers to do the right thing, and reward them for providing better care, not more care. This idea would grow into a unique concept known as NSG’s Condition Rate Program,” the company writes.
 
NSG provides management services for physical therapy, occupational therapy, functional capacity evaluations, work hardening and other medical management services. Having a firm manage providers of these services ensures that networks will be more tightly controlled and follow rigorous guidelines for management, cost and monitoring. It also ensures they will provide a solid return on investment for the money employer's invest in their services.
 
 
NSG partners with therapy providers across the country and won the Tampa Bay Chamber of Commerce: Small Business of the Year Finalist in 2010. It also was acquired by GENEX Services, Inc., one of the nation’s leading providers for managed care solutions in 2010.
 
 
NSG now offers a Visit Rate model that gives payers and providers a reimbursement method that improves clinical outcomes and results in claims cost reductions. Greg D’Ambrosio, vice president of client services, said, “We are pleased to provide our services in these states with a keen focus on expanding our network nationally in 2012. This product offering allows us to maintain our core philosophy and values while meeting our clients needs to manage therapy on a national level.”(WCxKit)
 
 
To learn more about their products or to join the provider network, visit NSG’s website www.network-synergy.com or email us at info@network-synergy.com.
 
 
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. He is an editor and contributor to Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: Info@ReduceYourWorkersComp.com.
 
 
 
New 2012 WORKERS COMP MANAGEMENT GUIDEBOOK:  www.WCManual.com
 
WORK COMP CALCULATOR:  www.LowerWC.com/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.

Physical Therapy Management Basics

When an employee has a musculoskeletal injury keeping the employee from returning to work, it is routine practice for orthopedic doctors to recommend a physical therapy program. The purpose of the physical therapy program is to assist the injured employee to restore function, to restore the pre-injury level of mobility, to control pain, and to limit or prevent permanent physical disability. This can be accomplished with physical therapy providing both range of motion exercises and strengthening exercises.

 
 
The orthopedic doctor treating the injured employee will prescribe the amount of physical therapy the employee should have. Some orthopedic doctors are very good at estimating the number of physical therapy sessions an injured employee will need and will prescribe accordingly. For instance, the doctor will prescribe physical therapy for the lumbar spine “3 x 4," which tells the physical therapy facility to treat the injured employee three times per week for four weeks. The return appointment with the doctor’s office is normally scheduled after the anticipated date of the last physical therapy treatment. This allows the doctor to assess the benefits of the physical therapy treatment program, but it is after the fact. (WCxKit)
 
 
Unfortunately, some orthopedics will prescribe the same amount of physical therapy for just about every patient they see. If every patient is "3 x 4” or “3 x 6,” some injured workers end up having too much physical therapy and some end up not having enough. When the injured employee does not get enough physical therapy, they return to the doctor before they have not recovered from their injury. The doctor then prescribes more physical therapy and sets up another return visit to the doctor’s office.
 
 
When the orthopedic describes physical therapy, the physical therapy facility wanting to insure payment, will normally call the workers compensation adjuster for approval to provide the treatment. The adjuster does not know whether the physical therapy is needed or not. Most adjusters will not question the need for physical therapy, figuring if the doctor requested it, it must be needed. This often results in the injured employee receiving more physical therapy then is needed.
 
 
One approach to the adjuster’s dilemma of whether to approve physical therapy or not, is to refer the request for physical therapy to utilization review. Utilization review can eliminate some excess physical therapy treatment, but utilization review makes their judgment calls based on the information in the doctor’s medical notes. Utilization review will not know if the injured employee recovers faster than normal resulting in the injured employee continuing to go to physical therapy when the physical therapy is not providing any further benefit.
 
 
A recent innovation in managing the physical therapy treatment is the development of results based treatment approach. Instead of the injured employee going to the physical therapy office 15 times because the doctor wrote a “3 x 5” script, the injured employee goes to the physical therapy office for as many or as few times needed for the employee to make a proper recovery from their musculoskeletal injury.
 
 
In the traditional fee for services model of physical therapy treatment, it is in the financial best interest of the physical therapy facility to continue physical therapy treatment until the doctor sees the injured employee again. This often results in excess treatment. The results based approach to physical therapy aligns the interest of the employer and the insurer with the physical therapy facility, where the timely recovery and return to work benefits all parties including the employee.
 
 
A results based approach to physical therapy allows a single flat fee for service. This reduces a lot of paper work for the adjuster, by having one bill to pay, rather than many physical therapy bills. (WCxKit)
 
 
Results based physical therapy treatment appears to be an innovative way for employers and insurers to manage the physical therapy treatment process and to provide the injured employee with the treatment needed in a timely manner. The management of physical therapy through results based treatment benefits everyone.

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.
 

REDUCE WORK COMP 20-50% BOOK:  www.WCManual.com
 
WORK COMP CALCULATOR:  www.LowerWC.com/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.
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact

6 Times To Question Whether Medical Care is Reasonable and Necessary

pic7Workers compensation statutes vary significantly from state to state, but one thing all states have in common in workers compensation laws is the requirement that employee be provided all reasonable and necessary medical care. The goal of all work comp jurisdictions is to return the injured worker to full productivity, if possible and to the level of maximum medical improvement if the employee can not be returned to work with full productivity. While all states require reasonable and necessary medical care, the divergence in the laws starts again when it comes to determining what is reasonable and necessary.

 

 

The employer/workers compensation insurer has the obligation to pay for all medical care for a work-related accident. Medical care includes not only doctor visits; it includes surgical care, hospital care, nursing services, medicines, and durable medical equipment. However, this obligation is not unlimited. It is limited to what is reasonable and necessary. Also, in states where the employer can control medical provider selection, it can also limit what is authorized.  (WCxKit)

 

 

6 Areas Where the Question of Reasonable and Necessary is Debated:

  1. Special devices.
  2. Home improvements.
  3. Massage, yoga and aqua therapy.
  4. Attendant care by non-medical assistants.
  5. Continuing medical maintenance.
  6. Diagnostic testing.

 

 

  1. Special devices

A question that often comes up when an employee has suffered a severe injury is the need for specialized equipment. While the adjuster is not going to question the need for a cane by someone who recently had back surgery, the criteria gets murky when the doctor states the employee needs a motorized wheelchair with four speeds, capable of doing wheelies. There is a tremendous cost difference between the non-motorized wheelchair for $99 and the motorized deluxe wheelchair for $1,999. Is it reasonable and necessary for the work comp insurer to pay for a deluxe piece of specialized equipment if the employee will only be using it for a month or so? The answer is, “No!” On the other hand, if the employee is going to permanently be in a wheelchair, the power version may definitely be reasonable and necessary.

 

 

  1. Home improvements

A medical provider who specializes in providing favorable impairment rating reports for plaintiff attorneys also wants to keep the injured employee happy. If the employee complains to the doctor she is not sleeping well, and the doctor writes a prescription for a new, extra firm pillow-top mattress, should the insurer have to pay for it? The answer is, “No!” Usually the doctor will not insist on such if the adjuster denies it. (In one situation, a doctor tried to justify a new mattress but the adjuster arranged for a furniture rental company to provide a mattress until the employee was at maximum medical improvement.) Other favorites include plaintiff-friendly doctors prescribing a new hot tub for an employee with a back injury, or a new Bowflex Ultimate Home Gym for an employee to do physical therapy at home. When physical conditioning home improvements are recommended, an adjuster should offer physical therapy, whether hot water soaks or stretching equipment, at a reputable physical therapy facility.

 

 

  1. Massage, yoga and aqua therapy

One well known “plaintiff friendly” Atlanta doctor sends all his back and neck injury clients to water aerobics, yoga, and massage therapy. Of course the doctor owns the water aerobics, yoga, and massage therapy facility. This is another situation where an adjuster must be vigilant to deny such medical services as not reasonable and necessary. If the doctor insists they are, then the adjuster should insist they be provided at a facility where the doctor does not have a financial interest.

 

 

  1. Attendant care by non-medical assistants

The seriously injured or debilitated employee may need some at-home assistance. Reasonable and necessary medical care in some states is not limited to medical professionals. If the employee needs at-home nursing services, the insurance company’s nurse case manager needs to consult with the primary medical provider to establish exactly what the employee needs in the way of home assistance. The work comp adjuster may have to approve the compensation for non-medical personnel to assist the injured employee with bandage changes or toilet needs. However, the adjuster should resist any efforts to expand the at-home assistance to cooking or doing laundry as not medically necessary.

 

 

  1. Continuing medical maintenance

Most states allow for continuing medical maintenance (a few states end medical maintenance when the employee is paid a permanent partial disability award and most states will allow future medical exposure to be transferred to the employee in exchange for compensation to the employee). When the medical is left open for continuing medical maintenance after the indemnity claim has been settled, the only reasonable and necessary medical care is medical services directly related to the initial injury. State laws vary but a significant number of states have statutes that close the exposure for future medical care if the employee has not sought any medical care for the injury in a specific time period — a year in many states. After that point, the adjuster should maintain that long-delayed medical care is not reasonable or necessary.

 

 

  1. Diagnostic testing

Diagnostic testing is an area in which some adjusters have difficulty determining whether the medical care is reasonable and necessary. Often it is necessary for the doctor to run various tests to determine the precise nature of the injury. If testing is a duplication of testing that has already been completed — for example, a repeat MRI — the diagnostic testing can be denied as not medically necessary. If testing is for a different body part — for example the cervical MRI on an employee who injured his lower back — the diagnostic testing should be denied as not being reasonable and necessary.(WCxKit)

 

 

Most industrial commissions and state work comp boards will approve anything the medical provider determines is medically necessary. However, in the areas discussed here, commissions and boards will often side with the employer when the medical necessity of an item or service is questionable and available alternatives are proposed.


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

WORK COMP CALCULATOR: http://www.LowerWC.com/calculator.php

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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.

 

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