Stay Out of Fraud’s Way with RateFast

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Last year the California Department of Industrial Relations, Division of Workers’ Compensation (DWC) sent out a letter to the workers’ compensation community regarding fraud. You can read the full letter from 2014 here. But in order to keep things simple, RateFast has created an easy to follow guide for understanding regulations and making sure your practice isn’t making common mistakes.

Workers’ Compensation fraud can be committed by all parties in the workers’ comp process. This includes medical providers, attorneys, claims adjusters, and employers. Below are details and real-world examples of what fraudulent activity might look like for Medical Providers. For a full discussion and review of the 2014 Fraud warning notice, please listen to our podcast “Staying Out Of Fraud’s Way”, available on the iTunes store.

Fraudulent activity for medical providers includes:

  • Billing for services that weren’t performed/ billing for procedures that weren’t indicated.

  • This can occur if an office is not in the practice of correctly documenting the amount of time a provider has spent with the patient.

  • Employing Individuals to Solicit New Patients

  • Using another individual in the community to funnel cases to you.

  • Unnecessary treatment.

  • A patient is authorized for a cortisone injection, and it doesn’t work. If the doctor continues to provide cortisone injections, that may be viewed as unnecessary treatment.

  • Self-interested referrals.

  • If a provider has stock or ownership in a physical therapy group across the street and the provider sends their patients over there, then they make an additional profit on that patient.

  • Failure to report a work injury.

  • Employers are required to report work injuries. If a doctor is not reporting an injury then be in favor in employer, then insurance premium doesn’t go up.

  • If a doctor is aware that a work injury has occurred they have to report it whether or not the patient wants to continue treatment.

Let’s take a look at a fictional, but quite possible real-world scenario:

An employer brings in an injured worker and they have a laceration on their arm. The medical provider examines the wound and makes a determination that the wound needs to be closed with sutures. If sutures are used it becomes a reportable case. If it’s closed with surface tape, the injury falls under first aid. The employer states that they would like it to be closed with butterfly tape. They will pay the provider cash for this and also promise to send other injuries to the provider’s clinic.

If the doctor complies and places the butterfly tape, then fraud has occurred because the medical recommendation was for stitches. The doctor knowingly changed their medical treatment plan to provide a first-aid remedy as opposed to a reportable one. This can be very difficult to prove after the fact.

Bottom line for medical providers concerned about fraud? Simply remember to be careful about processes in the office:

  • How you assign medical codes

  • How you interact with employers

  • What something might look like to a third party

Understand the law, familiarize yourself with the annual fraud notice, and you’ll stay out of fraud’s way!

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What is MMI?

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Your patient or injured worker has reached MMI. But what does MMI mean when we’re talking about California workers’ compensation?

MMI is shorthand for Maximum Medical Improvement, defined on pg. 2 of the AMA Guides to the Evaluation of Permanent Impairment 5th Edition as the following:

An impairment is considered permanent when it’s reached Maximal Medical Improvement, meaning it’s well stabilized and unlikely to change substantially in the next year, with or without medical treatment.

The date of MMI is important: it’s the date when a patient is ready for an impairment rating, and for decisions about future care and permanent work restrictions.

How Do You Know if a Patient is MMI?

How can you tell when a work injury has “stabilized” and is “unlikely to change substantially in the next year, with or without medical treatment”?

To find out what goes into determining MMI, keep a few key questions in mind:

1. Is there any on-going medical treatment that will change the injured worker’s functionality?

For instance, imagine a case where a patient has a back injury, and can only lift 25 pounds.

Physical therapy helped improve the patient’s condition in the past, and they still have six more physical therapy visits authorized by the insurance carrier.

In this scenario, the patient may be able to lift more weight after completing all their physical therapy visits.

Why declare a patient MMI if they are in the midst of ongoing treatment that may improve their condition?

2. Is the impairment rating going to change?

Another example: a worker with a shoulder injury is improving their range of motion with physical therapy, but they cannot improve their ability to lift more weight.

Until their range of motion remains the same, they will not be eligible for MMI.

As soon as the claim is filed, MMI becomes the ultimate goal for treatment. Patients obviously want to get bet better after a work injury, but sometimes they continue to have pain. MMI does not mean that the patient is no longer experiencing pain. It’s the doctor’s responsibility to communicate this to the patient, and to everyone involved in the case.

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Assembling the Perfect PR-4 Report

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Your patient or injured worker has reached MMI and is ready for their final impairment rating: it’s time to complete the California PR-4 Report.

What goes into these reports, which are required for each reported work comp injury in California?   A summary of how the injury occurred, attempted treatments to date, how the patient is doing currently, future care and medications… to name a few items.

But perhaps most important to the PR-4 report is a detailed set of measurements which create a value for the injury (Whole Person Impairment or WPI%). These measurements are required by the AMA guides to be reproducible, and determine if the employee is eligible for a payment benefit based on permanent impairment findings.

We recommend using RateFast for fully reproducible findings on PR-4 reports. RateFast provides a digitized patient exam for correct prioritization of all data. But, whenever you’re performing a PR-4 report, keep these tips in mind:

  • For multiple body part claims remember to keep all injuries in mind when providing treatment.
  • Create a consistent system for collecting information for all patients.
  • Remember incorrect measurements lead to incorrect impairment ratings. Always measure twice for accuracy.

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Untangling the PR-2 Report: 6 Tips For Faster, Better Treatment

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You’re in the middle of a complex work injury claim. You, whether you’re a doctor, patient, or adjuster, are under a lot of time pressure. You want to get back to work, or to close the claim, or see your patient healed. This is where the  PR-2 Report comes into play.

What is it? Before the patient has reached permanent and stationary status, it’s a report which summarizes the active management of the claim. It helps the provider communicate to the insurance company how the patient is responding to their treatment. After the claim has closed, PR-2 reports are used to describe future care necessary for the continual functional rehabilitation of the injured worker.

We’ve got six simple tips to help you understand the PR-2 Report better, and avoid common mistakes which can cause major delays.

  1. Don’t try to do too much in one single PR-2 Report. Time is short in any doctor’s visit.
  2. Select a focus for the visit and stick with it. Listen to how the patient is doing and select a plan of care which addresses the most debilitating parts of their injury first.
  3. Remember to keep all injured body parts on the radar. Injured body parts can get left off of the claim because the pain has seemingly fizzled out, only to flare back up again. If dealing with a multiple body part case it’s vital (literally!) to continue providing care for each aspect of the injury.
  4. Clear next steps. Future care should be a major priority of the PR-2 Report. For example, if you exam only the neck of an injured worker in one visit, be sure to plan to assess the functionality of the fingers in the next.
  5. Review the charts of fellow providers on the case.
  6. Remember to see the patient every 45 days (6 weeks) until the patient reaches MMI. Longer time between visits creates a lapse in care which can lead to delayed recovery and return to work.

If you’re confused about new RBRVS questions and how they change billing for the PR-2 report, check out question two in this helpful post from our friends at DaisyBill.

Listen in on the conversation at our new Podcast, CA WorkComp Report, here.

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AMA Guides 5ed Glossary Definitions (Pages 599-603)

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AMA Guides 5ed Glossary Definitions (Pages 599-603)

Below is a common list of terms that help RateFast users better understand the basics definitions used for impairment ratings. You will find many of these terms used in RateFast to provide more consistent and reproducible reports.

Aggravation

A factor(s) (eg, physical, chemical, biological or medical condition) that adversely alters the course or progression of the medical impairment. Worsening of a preexisting medical condition or impairment.

Ankylosis

Fixation of a joint in a specific position by disease, injury or surgery. When surgically created, the aim is to fuse the joint in that position, which is best for improved function.

Apportionment

A distribution or allocation of causation among multiple factors that caused or significantly contributed to the injury or disease and existing impairment.

Assistive devices

Devices that help individuals with a functional loss increase function. Examples include reachers, extended grabbers, hearing aids, and telephone amplifiers.

Causation

An identifiable factor (eg. accident or exposure to hazards or disease) that results in a medically identifiable condition.

Chronic pain

Pain that extends beyond the expected period of healing or is related to a progressive disease. It is usually elicited by an injury or disease but may be perpetuated by factors that are both pathogenically and physically remote from the original cause. Because the pain persists, it is likely that environmental and psychological factors interact with the tissue damage, contributing to the persistence of pain and illness behavior.

Combined Values Chart

A method used to combine multiple impairments, derived from the formula A+ B(1-A) w combined values of A and B, which ensures that the summary value will not exceed 100% of the whole person.

Contracture

A permanent shortening (as of muscle, tendon, or scar tissue) producing loss of motion, deformity, or distortion.

Desirable weight

A range of optimal weight given an individual’s sex, age, height and body habitus.

Disability

Alteration of an individual’s capacity to meet personal, social, or occupational demands or statutory or regulatory requirements because of an impairment. Disability is a relational outcome, contingent on the environmental conditions in which activities are performed.

Effects of medication

Medication may impact the individual’s sign, symptoms, and ability to function. They physician may choose to increase the impairment estimate by a small percentage (1% to 3%) to account for effects of treatment.

Functional limitations

The inability to completely perform a task due to an impairment. In some instances, functional limitations may be overcome through modifications in the individual’s personal or environmental accommodations.

Handicap

A historical term used to describe disability or a person living with a disability or disabilities. A handicapped individual has been considered to be someone with a physical or mental disability that substantially limits activity, especially in relation to employment or education.

Impairment

A loss, loss of use, or derangement of any body part, organ system, or organ function.

Impairment evaluation

A medical evaluation performed by a physician, using a standard method as outlined in the Guides, to determine permanent impairment associated with a medical condition.

Impairment percentages or ratings

Consensus derived estimates that reflect the severity of the impairment and the degree to which the impairment decreases an individual’s ability to perform common activities of daily living as listed in Table 1-2.

Malingering

A conscious and willful feigning or exaggeration of a disease or effect of an injury in order to obtain specific external gain. It is usually motivated by external incentives, such as receiving financial compensation, obtaining drugs, or avoiding work or other responsibilities.

Maximum medical improvement (MMI)

A condition or state that is well stabilized and unlikely to change substantially in the next year, with or without medical treatment. Over time, there may be some change, however, further recovery or deterioration is not anticipated.

Normal

A range or zone that represents healthy functioning and varies with age, gender, and other factors, such as environmental conditions.

Pain

An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

Paresthesias

A sensation of prickling, tingling, or creeping on the skin, usually associated with injury or irritation of a sensory nerve or nerve root.

Permanent impairment

An impairment that has reached maximal medical improvement.

Prosthesis

An artificial device to replace a missing part of the body.

Radiculopathy

Any pathological condition of the nerve roots.

Recurrence

A return of the disorder or disease after a remission.

Reproducibility

Synonymous with reliability. Consistency in results when examinations (tests) are repeated.

Sciatica

Pain along the course of a sciatic verve, especially in the back of the thigh, caused by compression, inflammation, or reflex mechanisms.

Teleroentgenography

A radiographic method used to determine actual limb length.

Treatment

The action or manner of treating an individual, medically or surgically. Medical treatment is the action or manner of treating an individual, medically or surgically by a physician. Treatment may include modalities recommended by a health care provider.

Validity

An accurate measurement apart from random errors. Validity refers to the extent to which a test measures what it is intended to measure.

Whole person impairment

Percentages that estimate the impact of the impairment on the individual’s overall ability to perform activities of daily living, excluding work.

Workers’ compensation

A compensation program designed to provide medical and economic support to workers who have been injured or become ill from an incident arising out of and in the course of their employment.

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How to write a good Doctor’s First Report (DFR)

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Somewhere in California, a workers’ compensation injury is about to occur. The initial steps in a work comp claim are some of the most important, as they can determine the complexity and timeliness of an injured workers’ case. The Doctor’s First Report (or DFR) is the first step in determining care. What are these first steps?

          1. After a worker is injured on the job, the worker reports the incident to the employer.
          2. A medical provider examines the injured worker.
          3. The medical provider completes a Doctor’s First Report (DFR) that includes information about the patient and the history of the injury.

A DFR must be filled out for all on-the-job injuries according to the California Department of Industrial Relations.

Errors in the DFR can delay the patient’s ability to return to work or to receive treatment. Unfortunately, these errors are far too common.

How to make your Doctor’s First Report count

Here are some tips to keep in mind to ensure that your Doctor’s First Reports are as effective as possible.

  • The DFR should include a detailed description of the injury according to the injured worker. Get all the facts in the patient’s own words.
  • The physical exam taken for the DFR should be supported by the patient’s own story about the injury. The more consistent the patient’s account is with measurable findings, then there will be fewer complications further down the line.
  • List all injured body parts. Each individual body part will receive different types of treatment, and, ultimately, a different impairment rating.

So, if a patient comes in after injuring her cervical spine after falling off a ladder, but she also complains about a sore wrist, then you should make a note of both body parts in the Doctor’s First Report. This way, medical treatment for all aspects of the injured worker’s claim will be addressed. Further steps for reproducing the Doctor’s First Report are listed on the Division of Workers’ Compensation website, here.

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Effects of Medication and Impairment Rating

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How the AMA Guides 5th Edition approaches impairment is complex, and accurate impairment ratings are tricky as a result.

For example, many medical providers don’t realize that the effects that medication has on an injured worker can actually change the worker’s impairment rating. This is defined on page 600 of the AMA Guides.

With page after page of definitions and tables, little details like these can easily be glossed over. We designed RateFast so that you don’t need to spend your time reading and re-reading the Guides. If you use RateFast to write your California PR-4 reports, then our software will prompt you with easy-to-answer questions about the effects that medication has on your patient.

But it’s still important to understand how the effects of mediation impact a worker’s whole person impairment. Here are a few key facts:

  1. “Effects of medication” are defined on page 600 of the AMA Guides, 5th Edition: “Medications may impact the individual signs, symptoms, and ability to function.”
  2. If an injured worker is affected by the medication he or she takes for the work-related injury, then the physician may choose to increase the impairment by small amount—between 1% and 3%. (Frustratingly, the AMA Guides do not give specific instructions on how to do this.)

So imagine that your patient has reached MMI for an injury to the low back. Let’s say that she is assigned a DRE category II and given a 5% WPI.

Now, imagine that the muscle relaxant she has been prescribed causes excessive drowsiness and limits her ability to drive. Is she eligible for an increased whole person impairment rating? Yes. The muscle relaxant has affected her life by limiting her ability to drive.

The moral of the story: if you’re a medical provider, make sure to ask your patients if their medications cause any side effect. It could make a real change in their impairment rating.

If you need help remembering to ask if medications are affecting your patients symptoms, try RateFast today for free. This question is built into our patient history questionnaire and our impairment calculations.

Increase Your Impairment Rating Accuracy

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Understanding impairment is essential to workers’ compensation cases. Without a working definition of how the AMA Guides approaches impairment, accurate impairment ratings are impossible to assign or review. If you are working in the world of California workers’ compensation then you understand how complex impairment rating can be.

If you don’t have a thorough knowledge of how ratings are assigned in accordance with the AMA Guides then the accuracy of your permanent and stationary reports may be suffering. This leads to delays in patient care as well as extra work for you and your staff. 

Impairment severity, functional limitations and regional impairments… there’s a lot to wade through. Fortunately there’s a simple explanation for all of these moving parts. To learn more about the whole body approach to impairment simply follow RateFast’s easy walkthrough. How does the AMA guides fifth edition approach impairment? There are only 6 facts to keep in mind:

  1. The impairment severity reflects resulting in functional limitations.
  2. Most chapters report impairment as a whole person impairment units.
  3. Upper and lower extremity chapters have a regional impairments to assign additional weighted value to the specific areas of the arms and legs.
  4. Chapter 16, the upper extremities report sub impairment at the levels of digits, hand, and upper extremity.
  5. Chapter 17 the lower extremities report sub impairment at the levels of foot and lower extremity.
  6. Regional impairments of the spine are weighted accordingly to contribution of function.

So let’s say there’s a 52-year-old right-hand dominant labor worker sustained an amputation to his right thumb at the MP joint (40% HI), and the right small finger at the MP joint (10% HI).

Why is there such a big difference in impairment values? Using the organ system and whole body approach to impairment, the thumb is given four times the value as the little finger for functionality importance. Remember, The Guides 5th edition gives relative weights to organs and body systems. A keen understanding is critical to creating and reviewing accurate and reproducible impairment reports

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How to Request Authorization for Treatment

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If you are a medical professional working in California workers’ compensation, then you will probably need to prescribe treatment or diagnostic testing for your patients.

When you’re working in California work comp, all treatment, testing, and other medical services must be authorized by the employer’s insurance administrator. To request authorization, you need to submit a Request for Authorization (or RFA). The RFA is a written request for treatment, diagnostic testing or other medical services for the injured worker.

Anybody can fill out a form. But it takes a true professional to complete an RFA form with all the information that insurance administrators need.

If you don’t complete an RFA form correctly, then your treatment authorization may be delayed, or not approved at all.

But you can easily submit a RFA that will give insurance administrators all of the information they need. You just need to cover all the bases by following a few simple steps.

How to Correctly Submit a Complete RFA in 8 Easy Steps

  1. Get the correct RFA form from the DWC website, here: https://www.dir.ca.gov/dwc/DWCPropRegs/IMR/IMRFormRFAClean.pdf

  2. In the top box of the form, check the reason for the RFA.

    • Check “New Request” for all treatment that you have not previously requested.
    • Check “Resubmission – Change in Material Facts” if new information is available about the employee’s medical condition.
    • Check “Expedited Review: Check box if employee faces an imminent and serious threat to his or her health” if the request is urgent–but not life threatening. (If the request is life threatening, and the employee requires hospitalization or emergency surgery, then submit a concurrent RFA.)
    • Check the “Check box if request is a written confirmation of a prior oral request.” if you have spoken with the claims adjuster, and you have agreed that the employee needs care and that the treatment will be approved. For example, if the employee requires immediate surgery or medication, and the adjuster verbally approves the treatment, you will still need to submit an RFA.

     

  3. Complete the rest of the form by providing basic information about the injured worker.

  4. In the “Requested Treatment” section, ensure that you give all details about the treatment you’re requesting in the “Other” column. For example, if you’re requesting physical therapy, then make sure that you indicate the amount of treatments; if you’re prescribing medication, then specify the dosage and refills.

  1. If you’re the treating physician, then sign the RFA. If you’re not the treating physician, make sure you get his or her signature.

  2. Submit the Request For Authorization form with the visit report (the Doctor’s First Report, PR-2 report, etc.) via fax or email. If you don’t submit the RFA with the visit report, then the RFA will likely be returned to you.

  3. You should receive your approved or denied RFA within 14 calendar days after you submit it. If you don’t, then contact the insurance administrator.

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What is the technical definition of disability?

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Whether you’re a doctor, an attorney, or an insurance adjuster, a precise definition of disability is essential in impairment rating. However, for such an important term its technical definition often goes unexamined.

What You Need to Know About Disability

  1. Disability is an inability to meet social, occupational, personal, or statutory requirements because of impairment.
  2. Disability is different than impairment.
  3. Someone may have disability at home but not at work. Likewise, an individual may have disability at work, but not at home.
  4. A physician may provide an opinion on disability if he/she has expertise and is acquainted with the individual’s work activities and activities of daily living.
  5. An impairment evaluation is only one aspect of determining disability. A disability evaluation includes information about skill, education, job history, adaptability, age, environment requirements and modifications.

Time for an Example

Consider this: a 43 year old man performs sedentary clerical work. He has a permanent impairment from an amputation of the right leg below the knee. He cannot climb stairs in his home. Is he disabled from occupational demands? No. He performs clerical work that doesn’t require him to walk around. Is he disabled from personal demands? Yes! His activities of daily living are affected. Feel free to email us if you have any questions about disability and impairment rating.

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