RateFast Podcast: Institutional Bias and What You Can Do to Prevent It

People have the tendency to cut corners sometimes. This might come as a surprise to some, but in some cases doctors are no exception.

That said, cutting corners doesn’t necessarily mean that the job is done lazily. For a doctor this can happen because they are pressed for time, they are making an inference based off of prior experience, even outside forces could be pressuring them to fill in a number here and there.

When cutting corners like this becomes routine, we get institutional bias.

Our interview with Dr. John Alchemy covers institutional bias, why it happens, and what doctors could do to avoid dragging out their claims by letting their bias get the better of them. Listen to the podcast on iTunes here.

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RateFast Podcast: Came for surgery, left with some antidepressants?

After they ask themselves the 3 questions before referring a patient to a spine specialist, your provider may follow through, and when a primary treating physician refers an injured worker to the specialist for diagnostic tests, the worker might suspect that there is surgery ahead. This is not always the case.

In fact, there’s a chance that they might even leave the specialist’s office with a prescription for antidepressants, among other possibly unexpected treatments.

RateFast’s own Dr. John Alchemy and Claire Williams interview orthopedic surgeon Dr. Athanassious about the circumstances surrounding complications with spinal injuries in injured workers, and where the primary treating physician may direct them when more specific care is needed. Click here to listen to the podcast on iTunes.

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RateFast Podcast: Understanding the RFA

In workers’ comp, providers must fill out a Request for Authorization form (RFA) when requesting a service, treatment, or tests for a patient. The RFA must be filled out correctly in order to receive approval from the employer’s insurance.

This excerpt from our podcast on How To Submit an RFA features RateFast’s founder Dr. John Alchemy in conversation with Arun Croll and Claire Williams about the intricacies and limitations of the Request for Authorization process.

There are certain steps that providers can take to make an RFA likely to be accepted, such as making sure that appropriate ICD-10 codes are included on the form. Insurance carriers may deny an RFA for all kinds of reasons, so it’s imperative to be as thorough as possible.

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RateFast Podcast: What are The Chances? Probability and RateFast

An educated prediction is a critical element in decision-making when face to face with the future. This is because the future is always uncertain.

Whether you’re making bets, conducting a weather forecast, or working in medicine, knowing the probability that something will or will not happen can have a huge impact on which action to take next.

Making observations to measure the probability of an event happening involves collecting data from past events in order to compare them to the expected outcome. This is why we can have a sense of confidence as to when we should bring an umbrella, buy buy buy, or sell sell sell.

Check out our podcast titled Probability in Workers’ Compensation with RateFast intern Marten Thompson, where we discuss probabilities, Sherlock Holmes, and more.

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Greater Than or Equal To: Percentiles and RateFast

A percentile is a value below which a percentage of data falls.

This means that if you are in a group of 10 people, and you are the 9th tallest at 6 foot 5 inches, then 6′ 5″ is the 80th percentile height in your group. Note that the value falls below your point in the data set.

It is difficult to dispute the numbers when they are on paper, but what happens when there is a dispute about how that data is organized?
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Common Objections to Workers’ Comp Reports: Examination

This article is part of a series on the top reasons why insurance carriers object to a workers’ compensation report and return it to the medical practice unpaid. This article is intended for medical providers, administrative staff, office managers, as well as insurance claims adjusters.

This is now the fourth in our series of Common Objections to Workers’ Comp Reports. If you haven’t already, read the previous articles on History of Symptoms, Activities of Daily Living (ADLs), and Prior Injuries.

Not everybody can do the splits, but your injured worker used to be able to get pretty close. Maybe they can’t go as far now because their range of motion in their left hip has been limited due to an injury at work. In fact, the key to measuring how much they can do the splits now lies in how far the injured leg moves from the hip as compared to the uninjured leg. This gives a crude idea of the examination in workers’ comp.

Failing to perform the examination according to the rules laid down in the AMA Guides 5th Edition gives the insurance carrier a great reason to object to your report, and the impairment rating that’s based on. Even if the insurance carrier accepts a report with an incomplete exam, the impairment rating is likely to be either too high or too low, which is bad news for at least one of the stakeholders.

Failure to document an exam correct on the report is setting yourself up to have a QME called. Take it from us: it’s better for everybody if the primary treating physician gets the exam right the first time.

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Common Objections to Workers’ Comp Reports: Diagnostic Tests

This article is part of a series about why insurance carriers object to workers’ compensation reports and return them to the medical practice unpaid. This article is intended for medical providers, administrative staff, office managers, as well as insurance claims adjusters.

If you’ve been following our series on objections to workers’ comp reports, you know about the importance of including a complete history of symptoms, activities of daily living (ADLs), prior injuries, and examination in your visit note. If you’re covering these bases, then you should be getting payment for your workers’ comp visits!

Welcome to red flag #5 in our series, where we will discuss the importance of diagnostic tests.

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Common Objections to Workers’ Comp Reports: Prior Injuries

This article is part of a series on the top reasons why insurance carriers object to a workers’ compensation report and return it to the medical practice unpaid. This article is intended for medical providers, administrative staff, office managers, as well as insurance claims adjusters.

We have now covered two reasons that an insurance claims adjuster may object to your impairment PR-4 report: First, due to an incomplete history of symptoms, and second, because of an incomplete activities of daily living (ADLs).

It is the intention of the claims adjuster to be skeptical about any and all things that can set off red flags in the review process of your reports. Should they find any documentation regarding a previous claim, the insurance company will go through the worker’s history of injuries in the workplace with a fine tooth comb to ensure that the current injury is not a result of symptoms of a prior injury.

Reason #3: Prior Injuries

If an employee gets hurt at work, the patient’s previous medical history may be relevant to the claim.

For example, imagine that someone has had back pain for a long time due to a childhood injury. Then she gets a job. One day while at work, she falls off a ladder and hurts her back even more.

The physician’s work comp report should include information not just about the current injury—the falling off the ladder incident—but also about the previous injury.

Why?

Well, the patient has symptoms—back pain, inability to sit for long periods of time, difficulty dressing—but it’s possible that some or all of these symptoms existed before the work-related injury. The question becomes—which symptoms were caused by the work-related injury? Which symptoms existed previously, but are now worse due to the work-injury? Make sure to listen very carefully when taking your patient’s history.

These questions are all oriented around the one central question: what was the patient’s life like prior to the injury?

When it comes time to write the impairment report and calculate the impairment rating for the injury, information about all previous conditions will be critical for calculating apportionment—but that’s a different story.

For now, the important thing to remember is that the history of any injuries affecting a body part that has been injured at work should be included in workers’ comp reports. If the claim’s adjuster is reviewing a report on an employee’s spine injury, and the adjuster knows that the patient’s spine had been previously injured but doesn’t see any information about that prior injury in the report, it will raise a question: how much of the symptoms are caused by the work injury?

The goal is to answer that question before the adjuster can ask it. This way, there will be no reason for the insurance carrier to deem your report incomplete.

Note that the prior injury is only applicable to the specific body part injured in the current impairment report, e.g., a prior injury to the left arm is not applicable to an injury in the right leg.

In your workers’ comp report, include a section for each prior injury that is relevant to the claim. In RateFast, information about prior injuries is automatically presented under a “Medical History” heading, and organized by each body part. Information should include how any prior injuries affected the patient’s ADLs, whether there was surgery, medications currently being taken for the prior injury, and so forth.

Here’s an example of a decent description of a prior injury:

Employee reports that her cervical spine was injured in a car accident when she was 12 years old. Symptoms included limited mobility (range of motion unknown) and pain. Prior to work-injury, took 300 mg ibuprofen daily. ADLs impacted: sleeping (caused patient to wake up) and driving (difficulty turning neck).

Here’s a poor description of a prior injury that is likely to raise questions in the insurance adjuster’s mind:

Employee reports that her cervical spine was injured.

But the worst description of all is no description. Always ask about prior injuries, and take detailed notes.

In Conclusion

In an impairment report, the description of prior injuries should be like a miniature report in-and-of itself. The physician must work with what he/she has in order to ensure that the prior injuries are thoroughly and accurately described. It may be difficult to obtain a detailed record of an injury from many years ago, but if the information about prior injuries doesn’t satisfy the claim’s adjuster, then the report may be returned—unpaid and with questions.

Common Objections to Workers’ Comp Reports: Incomplete Activities of Daily Living (ADLs)

This article is part of a series on the top reasons why insurance carriers object to a workers’ compensation report and return it to the medical practice unpaid. This article is intended for medical providers, administrative staff, office managers, as well as insurance claims adjusters.

In our previous post of this series, we discussed the history of symptoms in the doctor’s impairment PR-4 report. The following section covers the next step in the subjective complaints category.

You are facing the possibility that your report could be returned, possibly for the second time, and it is very important to you and your patient that you cross your t’s and dot your i’s so that you make this as timely of a process as possible. Like anything else, taking a few moments to take extra care can save your hours or even days of trouble in the future.

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