Imagine that you were able to know whether or not your claim was going to drag out due to errors in writing workers’ comp reports. How much time would it save you to go back and correct a few simple mistakes?

Data Integrity, a unique feature of RateFast, does exactly that.

Adjusters Send Back Bad Reports

A doctor writes reports for each visit that an injured worker has in their office. This report includes things like how the injury is coming along, as well as requests for treatment for the injury. If the report is badly written, the insurance adjuster can (and often will) send it back, and wait for the doctor to write a better report. This is a very, very common problem in workers’ comp.

As we mentioned before, reports that are sent back can result in prolonged claims, piling bills for the injured worker, and possible legal action[link when should i get an attorney].

The solution to the issue is feedback and accountability. When a doctor has an idea of how well their report was written before they send it to the insurance adjuster, they have the opportunity to correct their mistakes, saving them additional hours, weeks, months, even years of unnecessary work.

Data Integrity: The 10,000 Foot View

Just like assignments in school, RateFast gives you a grade based on how well your report is written. This is what we call Data Integrity. Data Integrity is the final grade determined by two factors in the report: Data Completeness, and Data Quality.

When RateFast evaluates your report, we will return the results as a letter grade from A to F, as well as a percentage of integrity based off of our calculations.

The Pillars of Integrity: Data Completeness and Data Quality

When your report is submitted to RateFast, it is first screened for Data Completeness, or how much of the data required for the injury is included in the report. If a physician treats an injured worker for a herniated disk, RateFast scans the report for how much data the doctor provided based off of the state’s specific workers’ comp rule set (in California, this is the AMA Guides 5th Edition). The completeness of the report is determined in percentage, and then rated for quality.

Data Quality looks at how well the data given was written. Does the report simply say that “The disk still hurts,” or are all measurements taken with the appropriate tools. Was the range of motion for the herniated disk measured with a dual inclinometer?

Once the completeness and quality are determined, RateFast calculates the Data Integrity. The integrity is a letter grade based off of the percentage of completeness and accuracy.

A Low Grade isn’t Necessarily a Bad Thing

We mentioned that poorly written reports are a very common problem in workers’ comp. This is fortunate for almost any doctor looking to improve the integrity of their reports because frankly, the bar is set pretty low.

If your report was returned with a C+ integrity score, it doesn’t mean that the report is likely to be rejected, though an A+ score is much more likely to be accepted, by comparison

What if the Report is Sent Back Anyway?

RateFast is a tool that is built by people with over a century of combined experience in workers’ comp. If your report is sent back citing reasons of not being complete or accurate, RateFast will re-evaluate the report for you. Rest assured, this isn’t a problem that the A+ doctor will face often. We have a track record of excellence in workers’ comp.

In the end, the final say of the accept-ivity of a report comes down to the stakeholders willingness to accept the level of (completeness and data quality) integrity and the delivered results. The data integrity feature of RateFast helps focus energy and resources on understanding what is and isn’t there, of course, RateFast takes care of the data set rating accuracy as always. If you are a stakeholder with interest in better understanding what your are looking at in impairment reports, contact us for more information on impairment rating integrity analysis.

Conclusion

We understand that being part of a work comp clinic means taking on hard work. The Data Integrity tool is meant to enrich the workload that is already there, in fact saving you time by evaluating the work that was already done before it’s too late.

To learn more about Data Integrity and Data Set Completeness, listen to what RateFast creator Dr. John Alchemy has to say on our podcast, the California Work Comp Report.

We’ve now mentioned the many different stakeholders that can enter a workers’ comp claim. The stakeholders in any and every work comp claim are the injured worker, the PTP (Primary Treating Physician), and the insurance adjuster. In California, if a claim gets tricky, an attorney and a QME can join the claim.

Still more stakeholders can join the claim in order to help things along. The nurse case manager is one such stakeholder.

What is a Nurse Case Manager?

A nurse case manager, simply put, is the individual (usually a registered nurse) who is responsible for managing a workers’ compensation claim. For our purposes, the words case and claim are the same thing.

There are so many factors in a single workers’ compensation claim that details both big and small can be overlooked. It is the case worker’s job to make sure that the claim is going smoothly.

For the injured worker, the nurse case manager will make sure that their appointments are scheduled and their injuries are prioritized and documented. In some cases, nurse case managers arrange rides for injured workers who have trouble getting to their appointments. They are also responsible for making sure that the injured worker is getting the correct care and treatment for the injury.

The nurse case manager will then communicate the results of visits and examinations from the PTP to the insurance adjuster. They will also relay any information that the insurance carrier has to send back to the PTP or the injured worker. They may be in attendance for the injured worker’s appointments, attend court hearings when attorneys are involved, and more.

Since both PTPs and insurance carriers are working on multiple claims at once, communication between the two can go very slow sometimes, at the expense of the injured worker. Having a person that works on one claim specifically (the nurse case manager’s job) can be a tremendous help.

Who Does the Nurse Case Manager Work for, and Why are They On My Claim?

The nurse case manager is an impartial third party who is hired by the employer’s insurance company. A nurse case manager will be called in for a claim if the insurer feels that it’s necessary to hire one. This can be because a claim is dragging on and the insurer wants more scrutiny on the doctor or injured workers’ visits.

In a perfect world, workers’ comp would mean an insurance company handing over the exact dollar amount owed for a specific injury. Because of the countless different factors that can complicate a work comp claim, nothing is so cut and dry. This makes hiring a nurse case manager necessary in some cases.

Wait a Second…

You might be wondering how a nurse case manager can be impartial when they are working directly for a stakeholder in the claim. This is a very valid question.

Essentially, the information that the nurse case manager conveys between parties is accurate and impartial, but it is what the stakeholders do with the information given to them that can affect how the claim plays out. Attorneys may advise an injured worker to keep their communication about their claim to a bare minimum, in case something that they told the nurse case manager could be used against them in court.

Conclusion

Different medical professionals can enter a claim for all different reasons. Though they might seem similar, they each serve a different purpose. A QME differs from a nurse case manager in that the QME acts as a secondary physician for the injured worker, while the nurse case manager takes care of all of the arrangements and paperwork of the claim without ever doing any examinations themselves.

Opinions may differ on which side a nurse case manager is really on, but an understanding of what they do can prove that a nurse case manager can be very effective at moving a claim along. If there is a nurse case manager who is brought onboard for your claim, refer back to this article to remember some best practices when working with them.

Every week, several news stories surface about another person, or group of people, being caught for workers’ comp fraud. Those are just the stories that are being published. While it may be true that there are still people getting away with it here and there, this people are just one investigation away from dire penalties.
Continue reading Workers’ Comp Fraud: It Isn’t Worth the Consequences

If You Need Emergency Medical Assistance, Dial 9-1-1

This guide is intended for employees who wants to know what to do if they sustain a workplace injury or illness. This article series goes beyond the moment of injury, and gives a picture of what to expect when choosing a doctor, getting treatment, and beyond. This guide is specific to California, but many of the steps described cross state lines.

This is the second part of the series covering what a worker should do in the event that they have suffered an injury or illness in the workplace. If you have recently been injured or have fallen ill due to an event or conditions at work, and have not yet filed a workers’ compensation claim with your employer, please see part 1 of this series. If you have filed a workers’ comp claim with your employer, read on.

Now that your claim has been filed with your employer, there are still steps that you must take to ensure that you receive your benefits (and partial pay for time off work, if applicable). This the beginning of your journey through the workers’ compensation system.
Continue reading A Worker’s Guide to Workers’ Comp Part II: Making the Most of Your Injury

Some workers’ compensation claims need future care after reaching MMI (Maximum Medical Improvement). The need for future care means that the claim stays open while the injured worker gets treatment. Sometimes treatment is needed indefinitely.

The patient who we interviewed, we’ll call him David, was injured at work in 2012 and has been receiving future care since his case reached MMI in 2014. His claim involved a personal injury to his spine, which continues to affect his ADLs (Activities of Daily Living) to this day.

His claim represents a fairly common snapshot of what an injured worker experiences when their injury results in lasting impairment. It shows a larger picture of the workers’ comp machine in motion, and the ingredients that make the system so resource intensive for all stakeholders.

Continue reading Beyond MMI: The Workers’ Comp System from a Workers’ Perspective