7 Signs Your Injured Worker is Treating with a Physician Who is Not Employer Friendly

Most states allow an injured worker to seek care with whatever physician the employee prefers.  There are some rules to follow, but as long as the doctor cooperates there usually is not a problem.



But when there is a problem, it is a big problem. When the adjuster is working with a doctor that does not want to cooperate and respond to certain questions, that is a major issue.  This issue will affect the injured worker by affecting care and time off of work. It can cause the claim to go to litigation, etc.   So something as simple as going to the doctor for an injury can morph into a really big deal.  Here are some warning signs that a claim could be heading down the bumpy road. (WCxKit)



  1. The physician places the worker off of work with no restrictions and no explanation

This one item frustrates adjusters more than any other.  If a person comes in with a hand laceration, and the doctor places them off of work for 4 weeks, how is that legitimate?  The worker has another hand that is perfectly fine.  Even if the workplace is a dirty environment it does not mean it is risky to be at work with a hand laceration to one hand.



Physicians familiar with workers comp know better.  They know if they place a worker totally off of work and do not address restrictions, the adjuster will call.  In the world of workers comp, if a worker is on total off work status that means the employee either just had surgery or sustained a major injury.



There are 2 roadblocks to return to work: (1) the employer does not cooperate with creating light duty work for the injured workers, and (2) the doctor totally disables the employee for no good reason. But it depends, if this injury is acute and very severe, then certainly some time off of work is warranted for rest.  But the doctor has to explain why.  There is nothing the adjuster hates more than to see a back injury, and the worker is totally disabled, but in physical therapy.  So the worker is good enough to go to therapy, but not good enough to go do some light desk work for the employer?



Physicians have to explain the diagnosis and work restrictions, and they have to have good objective evidence to support the decisions.  The adjuster has the right to demand that the doctor answer specific questions, and if the doctor disregards that, then it can affect the benefits being paid out on the file.  So warning sign #1 if there is an off work slip with no real explanation as to why.



  1. Makes a return appointment in 3-4 week intervals

A doctor that is monitoring a condition on a comp claim knows the worker’s main goal is to get back to work.  So they closely monitor the situation.  They schedule to see the injured party at least once every week, if not sooner depending on the injury.  A warning sign for a complacent doc is a return visit in 4-6 weeks.  That is a long period of time to go without being evaluated.  If it is a surgical claim, and this worker is post-surgery, and starting rehab, then this may be ok.  But for early on in a comp claim, anything over 7-10 days I would raise an eyebrow.  He will drag out the claim costing the employer more money.



  1. Everyone at work knows the physician or has treated there

If the injured worker goes to Dr. Smith, and everyone knows Dr. Smith at the shop, and everyone treats with Dr. Smith both for personal medical issues and for workers comp injuries, I would be concerned.  Maybe Dr. Smith prescribes a lot of Vicodin for simple injuries.  Maybe Dr. Smith disables them from working for a longer time than anyplace else. It could be anything, but if this particular clinic is a place where 85% of your workplaces treat, something is awry.  It may not be “illegal” activity, but there is some trend that this doctor does that nobody else in town will do. And that is always cause for concern in an insurance claim.



  1. The doctor prescribes narcotics for minor strain injuries

This is perhaps the most popular trend these days.  I have observed countless claimants going to the doc for a simple strain and walk out of the clinic with a 30-day RX for Vicodin.  That is never a good sign.  I am not a physician.  I did not go to med school.  If Vicodin is needed for 3-5 days, that is warranted.  But for an initial visit, for a simple strain, that is not really all that severe, a 30 day supply is unnecessary. RX stands for “prescription.”


The cost of the RX is determined by quantity and type of drug. If you look at the work slip and the doctor prescribed Vicodin and Percocet, Valium, and Motrin, that is not acceptable.  Not only did this doc over-prescribe by giving the worker 2 similar narcotic drugs (Vicodin, Percocet) but also prescribed Valium, which may or may not even be needed for this particular case.  Probably the only RX a simple strain needs is the Motrin.  All the other RX’s are warning signs that this doctor is happy to prescribe anything at will, and these medicines are not cheap, and some are not even necessary.



  1. Recommend physical therapy (at his clinic) for everything

I recall a while back there was a large occupational clinic that would give anyone that walked in a script for physical therapy (PT).  You can have sprained your hand, and you were going to go for 4 weeks of PT. Back injuries, finger lacerations, elbow pain, the answer was PT. They were using PT as a stall tactic, not the way it should be used by reputable doctors.  Finally enough people must have stepped up and said “This is ridiculous!  You mean to tell me every person that walks in needs PT?”



But this shows a crucial point. Some physicians are also financially tied in to therapy facilities as well as to other testing facilities.  So not only do they make money off office visits for evaluating the patient, but they make even more money billing for 12-16 PT visits.  Then they will probably see the patient again at the clinic for another evaluation.  And maybe more PT is needed.  And, before you know it, the cycle begins. In most states this is illegal and unethical. Excessive PT is an indicator that something fishy is going on, and you can use your tools, such as an IME, to deem if more PT is really reasonable and necessary treatment in your given claim. Employers can eliminate the risk of using the wrong PT facilities by using the services of a Physical Therapy Management Company instead of simply working with the least expensive PT network.  Physical therapy can be extremely effective in facilitating recovery and return to work when used appropriately. I know, I’ve been there, done that.



  1. Hesitant to refer out to a specialist

This is a warning sign because the physician wants to keep seeing the patient and wants to keep billing the carrier/TPA.  As soon as the patient goes to an ortho or other specialist, that patient no longer treats at this clinic.  So, the doc has incentive to keep that patient around for a longer period of time. Repeat business is what makes money, and if the patients are continually coming back, that is more money in someone’s pocket.  So if it has been a few months and the injured party is no better, it is way beyond time to be evaluated by a specialist.  And if the treating doctor is not bringing this up, you may need to force the issue.



  1. No dictation and very few hand-written notes

The adjuster will always want to see the doctor’s actual notes or transcribed dictation.  This is where the adjuster can see exactly what the patient said, what the doctor saw on examination, and what the doctor’s plans are for resolving this medical condition.



If the adjuster requests the notes, and they consist of 1-2 sentences of barely visible hand written scribbles, this is not good.  Not only is it worthless to the adjuster, it is worthless in general.  There is no info about the patient, about the exam, or about the treatment plan.  These doctors are out there. An example of their medical note could consist of the items below.



“Jack feels the same.  Continue therapy for 4 weeks and return afterwards.”


As crazy as that seems, that sometimes is it.  And the bill was probably $100-$150 for that “exam.”  So beware of the doctor that does not dictate or does not have properly typed notes.  It does not mean the doctor is necessarily bad, it just means that if the worker continues to treat with this physician, it is going to be a struggle to get information and clarification the longer the claim goes on. Those issues are very important, and if you struggle getting that much needed information, the rest of the claim will be a struggle as well.




There are good doctors, and bad doctors.  There are doctors that care about their patients, and doctors that could care less.  There are doctors that write up fantastic notes, and some that jot down a sentence or 2.  Physicians are just like everyone else.  They all have a unique style.  They have good days and bad days.  Some have successful practices, and some do not. (WCxKit)



But the bottom line is if a doctor is going to treat the injured worker, in a workers comp situation, then they have to abide by the rules.  And if they choose not to do so, it is going to complicate the claim one way or another.  Use the above warning signs to evaluate current claims for rough roads ahead.



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.comContact: RShafer@ReduceYourWorkersComp.com.





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

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

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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.


©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


An Adjuster Pinpoints Eight Medical Provider Red Flags of Over Treatment

Back again with the final part of the series on medical provider red flags.  This could be 50 red flags, but these are some of the most common. This is to provide continued awareness that not all medical clinics are on your side.  The caveat again is that this is not the norm. This article is just meant to raise awareness.  Because these issues, while uncommon, really do happen. That is about as politically correct as I can make it.  Here are the physician red flags you should be watching for. This article is summarized from an interview with an adjuster I met recently.



  1. The medical records are “template” style, or barely exist at all. Out of all of the red flag issues we discuss, this one does not indicate a shady doctor.  It could just be that the doctor is very poor at note taking.  But the two go hand in hand.  Great doctors do great analysis, and back up opinions with objective medical facts.  They arrive at this point by walking through the medical records, and creating a great conclusive medical report.  Doctors that get by by pairing up subjective history from a patient’s mouth are another story. (WCxKit)


  1. Missing dates of service, or no date labels on the medical notes.  
    I suppose if the “template”style medical record, is paired with one that is similar to a fill-in the-blank system (Patient came in with complaints of _______ which they attribute to work causing them _____ pain out of 10, with 10 being the worst pain imaginable) and pair it up without a date of service, I guess you could use that medical record for every date of service you ever have.  If anyone is watching, a physician will not get far by doing this.  But, if nobody is paying attention, thousands of dollars could be paid and for who knows what.  Make sure the notes are clearly labeled, dated, and legible.  If not, you need to contact the physician’s office right away.
    3. Different handwriting or inks on same dates of service.  Granted again, that may be the nurse or the medical assistant jotting some notes down before the doctor jots the notes down, but if you get the feeling that something is not adding up, then call them.  Their patient may be contacting them and coaching them what to put in the record, which we all know is not OK.
    4. The medical provider office will not send medical records or state that they do not keep a medical “record”.  I cannot think of one legit company that does not keep a note or record of some sort, for whatever reason.  Even the most trivial of companies store records of some sort.  So using that as a comparison, the medical record is very important.  And for a clinic to say they do not keep a record is unbelievable.  As a matter of fact, you should not pay any bill ever without a medical record attached to it.  How do you know what is being paid and for what?  If a doctor’s office ever tells you that they do not keep a record on a patient, my advice is to alert your counsel and have them step in right away.
    5. The medical notes showed continued high levels of pain. I have never broken my arm, but I anticipate that it hurts quite a bit.  Enough to be uncomfortable anyway.  So if it is 2 months later and you still have “10 out of 10” pain, that is just not correct.  If the pain is so unbearable, and you have treated with this doctor for 2 months, why go back there?  And how is the worker driving to these appointments?  And how can the worker go to the bank and cash your check, all with “10 out of 10” pain that has not lessened?  The doctor should be stating in the medical notes that the objective indicators for pain do not match the subjective complaints of “10 out of 10” pain.  If the physician is not doing anything about it, or the person is no better, then you have to find out what is going on medically and get that person to a specialist or set up an IME to address these ongoing complaints.


  1. Consistent improper billing practices.  Your Carrier/TPA usually cannot process a payment off of an invoice.  Usually the bill has to be printed on an HCFA-1500 form so the Carrier/TPA can process it.  This is standard.  A lot of offices that handle any type of insurance work know this.  So if they keep trying to submit their bills improperly, something is going on.  Why are they doing this?  Have any others had this sort of problem with this provider? Coding errors, print errors, ICD-9 code errors, etc. should be correct and correlate to the claim.  A few errors are to be expected.  But if it is constantly going on and on and on, you have to dig a little deeper.
    7. Conflicting medical reports or conflicting subjective complaints that are not addressed.  Let us say you are the adjuster and you are reviewing a stack of medical records on your claimant.  One day your claimant states they are in very bad pain, 8 out of 10.  It is hard to bend, and walk.  The next day they show up for therapy and they tell the therapist they are doing great, and they think treatment is really helping them.  2 days later they go back to the doctor and say they feel the same, about 7-8/10 pain. Then the same day they have therapy and tell the therapist they feel great, and are looking back to getting back to work.   I believe in the fact that people have good days and bad days.  But if you are hurt, and in legit pain, your symptoms should not yo-yo up and down like that.  Therapy can flare pain up a bit, but over the course of a few weeks the pain should be gradually lessened.  If you start to notice yo-yo pain complaints and pain out of proportion to the injury, think about getting your IME in order because the claimant is trying to extend their time out of work.


  1. Consistent excessive referrals or quick referrals to physical therapy where it may not be needed.  I know of a very popular occupational clinic.  A very large one. And I have handled a ton of claims where the clinic is the treating provider.  And over the course of a year or 2, I wager to say that everyone that walks through their doors with a comp case had a referral to go to the same physical therapy facility after the first or second visit. These were strains, sprains, lacerations, contusions, etc.  Every injury you could think of and they were all sent for therapy.  We had to call and talk to the doctor to find out the rationale.  This took a lot of time, but after a while they go the point and started to go by the medical norm for a referral for physical therapy.   This is meant to be a very loose example, but a lot of times personal doctors or practices also own therapy companies or diagnostic laboratories, or they have partial ownership in them, so they get to make money twice; once when you go to see them, and again when you go to their therapy facility.  So trust your instinct.  If you think a referral is questionable, call and talk to the doctor.  Make that doctor defend their decision and ask them questions.  After all they have a service to provide to you, and you have rights too in these work comp scenarios. Depending on your jurisdiction anyway. NOTE:  Make sure your company is aligned with a high-quality independent physical therapy network, perhaps even a national network, and put that in the account handling instructions, then monitor compliance and make sure the adjuster is helping monitor compliance.




Again this is not every doctor, at every clinic, attempting to get extra.  These questionable doctors are few and far between. But they are out there, and your adjuster and counsel know of some of them.  Physicians will say that they can only treat what the patient is telling them, and if the patient states they are in pain, then no matter what doctors are going to do what they can to help them.  So part of this problem is on the doctor, and part is on the claimant or patient. However, all of it can be questioned by you in a workers comp scenario.  Keep names of doctors and group practices that you had trouble with in the past.  If something does not seem right call and talk to the doctor about it and share your concerns. Remember the doctors or practices that caused you problems–chances are you will cross paths with them again.  Continue to stay proactive, and trust those instincts.


Your responsibility as an employer is to establish procedures, select vendors, and make sure you are actively involved in who treats your employees and the results they get from treatment, assuming this is allowed in your state. Working with a good TPA is important; ask them how they control these issues and learn what they are doing to prevent over treatment.



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.comContact: RShafer@ReduceYourWorkersComp.com.



Our WORKERS COMP BOOK:  www.WCManual.com


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

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

WC GROUP:   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.


©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


Ways to Ensure Prescription Medication is Appropriate

The challenge:   A grey zone medication is any type of drug for which special attention is required to determine if it is appropriate for the injured worker based on compensability, relation to injury and medical history. Ensuring medications are appropriate has become increasingly complex due to an aging and unhealthy workforce. Workers who have more simultaneous ailments are leading to the use of medications that are unrelated to the actual injury.
The most common grey zone medication categories mirror the prescription trends within workers compensation as a whole; antibiotics, pain medications, hypnotics, anticonvulsants, antidepressants, ulcer medications, cardiovascular medications.
The solution: Implementing effective strategies to monitor grey zone medications helps ensure injured worker safety and reduces opportunities for instances of fraud, misuse and abuse.
  1. Develop customized medication plans
By working with a pharmacy benefit manager (PBM), payors can create medication plans that are based on specific criteria to ensure that medications are appropriate for the injured worker. Medication plans should be specific to body part and nature of injury, as well as the acute or chronic nature of the injury. PBMs should also offer electronic notification of approved and misaligned medications. This will reduce administrative burdens on claims professionals, allowing them to focus on jurisdictional issues related to the claim while the PBM can focus on medication concerns.
  1. Establish comprehensive utilization management programs
Utilization management programs are essential to limit cases of fraud, misuse and abuse and ultimately ensure injured worker safety. A quality program should include working with a clinical staff capable of performing in-depth, injured worker-specific drug utilization reviews. While PBMs offer utilization review programs, payors should also ensure their partner has a process in place that is managed by clinical pharmacists. The clinical utilization review program should use a combination of evidence-based medical guidelines, peer review journals and recommendations provided by government organizations.
·    Prospective utilization reviews– A prospective program allows all involved parties to plan for future outcomes with up-front information. Guiding future decisions through historical data and practices allows for the achievement of cost control and utilization control.


·   Concurrent utilization reviews– A concurrent program can prevent abuse involving the use of multiple pharmacies and physicians for different medications, or excessive early refill attempts. The PBM can trigger concurrent alerts to inform the dispensing pharmacist about possible reasons a medication should be questioned before filling. This process can ensure that prescriptions are not filled at the point-of-sale unless the medication is allowed or the PBM receives authorization from the payor.
Retrospective drug utilization reviews and clinical intervention programs– Conducting retrospective drug utilization reviews, physician monitoring and clinical intervention programs should be used to continually evaluate claims for grey zone medications and monitor inappropriate and/or excessive use. Staying on top of potential patterns can cut back on unnecessary spending and ensure injured worker safety.


·     Retrospective reviews– After a prescription is filled, the PBM’s clinical pharmacist team should audit the claim for indicators of misuse; multiple physicians, duplication of therapy, excessive duration and use.
 .  Clinical intervention programs– Seek a PBM that offers a wide range of clinical intervention programs to assist with evaluation needs. The range of programs should consist of registered pharmacists, nurses and other health professionals available for consultation on medication questions and peer reviews. The PBM’s clinical intervention team should provide recommendations for specific claims that require further evaluation.
  1. Physician monitoring
It is essential to have a process that monitors an injured worker with multiple physicians. A successful program should be based on established best practices and contain multiple components including:
    • Monitoring for appropriate medication utilization using evidence-based published therapeutic guidelines
    • Overseeing prescribing patterns at the physician level to establish appropriate/inappropriate use of brand name medications when an FDA approved generic equivalent exists
    • Participating in mandatory and voluntary state reporting programs that monitor for excessive prescribing patterns
    1. Pharmacist support
    The PBM must have a staff of clinical pharmacists available to provide customized support for medication-related decisions. The exchange of medication education between pharmacists and claims professionals is important for both general and injured worker-specific information.
    1. Nursing support
    A more holistic clinical picture of the claim should be obtained by the claims professional. Nurses on an experienced clinical services team are uniquely positioned to assist in explaining the details on medical service claims. Having access to experts in non-drug therapy can allow the claims professional to make more informed decisions.
    1. Claims professional education
    Effective seminars that train and provide guidance to claims professionals on the payor’s policies for managing grey zone medications should be provided. These sessions should be included within claims professional’s regular education and training,
    Summary: Managing medication utilization for injured parties has become increasingly complex for workers compensation payors. As new medications become available, the workforce continues to age and medical histories increase in complexity, navigating the grey zone medication maze will remain a challenge. By putting best practices into place to manage the appropriateness of medications, payors will ultimately ensure injured worker safety while reducing opportunities for fraud, misuse and abuse.
    For more detailed information on the definition and classification of grey zone medications and common grey zone drugs please visit Progressive Medical’s Grey Zone Resource Center.
    Author Tron Emptage, who holds a BS in Pharmacy, is Chief Clinical & Compliance Officer with Progressive Medical. Mr. Emptage has overseen Pharmacy Services, Clinical Services, National Account Management served as Vice President of Strategic Initiatives and Executive Vice President of Business. His 20-year plus experience in pharmaceutical and managed care defines him as a key player in moving the company forward in the arena of national pharmaceutical managed care. Contact him: tron.emptage@progressive-medical.com or 800.777.3574 or visit Progressive Medical.
    About Progressive Medical
    Progressive Medical offers cost management services and programs to the workers compensation industry. By combining its clinical expertise with access to an expansive network of pharmacies, home health care services and medical equipment and supplies, the company enables its clients to manage costs while providing quality care to injured workers. Learn more at Progressive Medical or call 866.939.5365.  http://www.workcomptransformation.com/narcotics-quandary/
    Manage Your Workers Compensation Program:
    Reduce Your Costs 20-50%
    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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