A California Nurse Case Manager’s Guide to Discussing MMI with Patients

Dr. John Alchemy answers questions submitted by Nurse Case Managers regarding ways of discussing common work comp questions with their patients.

If you’re a workers’ compensation provider, adjuster, or case manager check out RateFast Express: the service that writes your impairment reports for you!

A California Nurse Case Manager’s Guide to Discussing MMI With Patients

Cory Oleson (Host): Welcome back to the California Work Comp report. Today is Tuesday, August 3, 2021. This is your host Cory Oleson here with Dr. John Alchemy. For today’s episode, we have a California nurse case manager’s guide to discussing MMI with their patients.

And we are live with the California workers comp report. It is me Cory, like you heard in the introduction. And I’m here with Dr. John Alchemy. How are you today, John?

Dr. John Alchemy: Good afternoon, Cory. How are you doing?

Cory: I’m doing all right, just a kind of a humid day over where I’m at. But that’s just fine.

So the topic of the podcast today is a nurse case managers guide to discussing MMI, which is maximal medical improvement with patients in California workers compensation. And we had previously done an episode on nurse case managers, that will be linked in the description. But you know, we owe it to ourselves to do a little brush up of it. And remember what what a nurse case manager is, and a couple other points about them. So John, what is a nurse case manager as in respects to California workers compensation?

Dr. John Alchemy: A nurse case manager is a nurse with obviously nursing background, it could be a licensed vocational nurse, it could be a registered nurse, it could be a telephonic nurse. But this is an individual with a medical background that is assigned to assist with an injured worker for some reason, like for instance, if it’s a catastrophic car accident, multiple injuries, they’re in a wheelchair, they need home health, they’re going to be in a rehab facility, a nurse case manager will be assigned to that to help the injured worker and the insurance company navigate the work comp system, getting them to their appointments, logistics, making sure medications get to them on time and, and all of that sort of thing.

They can be assigned to someone who has a significant social challenge. Maybe they’re homeless, I’ve had that happen before and they’re living out of their car. They don’t speak English very well, or English isn’t their first language or they can’t read. I’ve had a couple of patients that are illiterate and just, you know, can’t read anything that gets sent to them. Maybe they don’t have internet, maybe they you know, can’t even get an email. So there’s a lot of reasons why nurse case managers can get assigned, but the main take home as they’re assigned, because the injured worker needs help.

Cory: Yes, absolutely. So it doesn’t, it doesn’t necessarily mean that there’s any sort of like, legal ramifications to the claim the way that you know, if an attorney was involved or something like that, it’s simply that the patient needs help. And, you know, that would help everybody else close the claim.

Okay, so a nurse case manager assigned to a claim to help a patient get to their appointments or do other things that, you know, they’re just kind of thrust into the system all of a sudden, and, you know, oftentimes they need assistance. And so this nurse case manager, where do they come from? I mean, who assigns them? And, you know, it sounds like there’s multiple reasons that one could, you know, come on a claim, but are there, you know, specific or common reasons why a nurse case manager would would jump on the claim?

Dr. John Alchemy: Well, usually they’re assigned by the insurance adjuster, the adjuster is either become aware that there’s going to be some significant challenges in delivering or coordinating care, or, often myself, I will identify that from the primary treater. The patient comes into clinic, you know, I just can tell that they’re going to have a hard time they, you know, really need a lot of help a lot of instruction, a lot of redirection. And I’ll actually just put in a request for authorization for nurse case manager, I’ll maybe put it in there for six months or three months, or just enough to help them get through a surgery and recover and then you know, we can kind of take it from there.

So it can be a doctor. It can be the insurance company, usually. But I would say, you know, either one can assign it. And the biggest question I always get from the injured worker, because nurse case managers come to the appointments so they know what’s going on. They ask questions, they find out what the next steps are. They write reports, submit those to the insurance adjusters, the adjuster knows what’s going on. But the most common question I get from the injured worker, is this nurse case manager hear from the insurance company to spy on me?

And most common concern is that, you know, this nurse case managers hear, you know, because they’re, you know, want the insurance, they want to help the insurance company out and they don’t want to help me. And I think that’s the biggest misconception that I need to realign people’s thoughts around and let them know no, this nurse case manager is really here as an advocate for the claim. The insurance company pays everybody they pay the doctor, they pay me you know, I’m paid to take care of you. It’s we’re all paid by the insurance company. But we’re all supposed to have the goal of you know, getting you better doing what’s right and not ordering things that are going to hurt you. So we often will have to get some of the patients back on track and let them understand that, you know, having a nurse case manager is really a benefit and not a handicap in the case.

Cory: Absolutely. Absolutely. To all of the people who developed a very, very specific and lofty ideas over the last year, I can say that nurse case managers are not a sysop.

Dr. John Alchemy: Thank you for clarifying that.

Cory: They work neither for the FBI or the CIA. As far as I know.

Okay, so you’ve clarified that they don’t work for the insurance company. You also, you know, it’s natural to assume that okay, who’s this person all of a sudden, who’s going to be giving me rides or something like that? But yeah, they’re nurses just kind of got, you know, they got assigned to the claim to help.

Dr. John Alchemy: Yeah, they’re a paid advocate. And obviously, the insurance company pays pays their bills.

Cory: And that’s a good point that, you know, for work comp claims and everything the insurance companies pay you as well. And that’s, you know, any, if there’s any nurse case managers listening, who has to tackle that sort of suspicion, or like, or establish some sort of trust with their patient or anything, I think that’s a wonderful point to make, or that would just drive them insane thinking about now the doctors working for the insurance company!

Dr. John Alchemy: It really becomes clear.

Cory: Yeah, at that point, if your patient is kind of on that on that vibrational level, then there’s nothing much you could have done anyway. And, and that’s what would happen if you got me as a patient if I didn’t talk to John. So, um, so how long is the nurse case manager on the case?

Dr. John Alchemy: Yeah, so they, they run on the case, typically, until the case reaches MMI. And on our podcast, we always like to talk about maximum medical improvement or time to write the case or 12 months, no change with or without treatment, which is MMI. So they’re there to get the patient as well as they can. And then they sign off the case.

Cory: Yeah. And MMI in the words that I could only understand when I started doing this podcast was as good as you’re going to get after. Which is a very subjective thing. And the funny thing is that, you know, the, I mean, it’s not the patient that walks up and says, I’ve reached MMI. If only it were that easy. Because it’s all the other people who think that it’s the doctor that’s supposed to say that and everything but or to determine that, but, um, so now, okay, so we have our framework for what a nurse case manager is, it’s a professional nurse who has been assigned to a patient, when a claim needs help, the person who assigns them can either be from the insurance company, or the doctor themselves, or possibly even another stakeholder in the claim, if there was like an attorney involved, I guess they could recommend it.

Dr. John Alchemy: Sure, yeah. Possibly.

Cory: And they do basically, any kind of task that is required to make sure that the patient makes it to their appointments, and that their work comp claim goes smoothly, including attending the appointments, which is just part of the part and parcel with being a nurse case manager, for a work comp claim. So the next portion of our podcast here today is that we actually asked a nurse case manager, what are the most common questions that you get from your patients?

And what we’re going to do is we’re going to provide those for you today. So that you have those answers kind of in your back pocket, when, as we understand, inevitably, these questions are asked to you. So I’m going to start off with the first question here. And the first commonly asked question from patients to nurse case managers, John, is, how does the MD come up with impairment ratings? And does pain come into play?

Dr. John Alchemy: Yes, common question, how does this number get made? So we need to tell these injured workers that when you’re done, we need to figure out what your loss is, and how much you’ve lost as a result of the injury. So we have a book, we have a book in California. It’s basically a doctor’s recipe book, if you will, and it tells the doctor how to do a special exam based on the part of your body that got hurt, and come up with a percentage loss of that body part. So for instance, your whole body is worth 100%. Meaning if you’re in a coma, you’ve lost 100% of your of your person, if your arm or to be removed, unfortunately from an accident, you know, you would lose 60% of your person for that, or 40% if you lose a leg, so it’s based on a percentage of an entire person.

And, and there’s special rules, it’s a special exam. It’s not the typical exam that you might get when you’re going in for a route, recheck or even your first visit. But it’s it’s a physical exam that allows the doctor and the insurance company to take your findings, your findings alone, and put them into a context of how much you’ve been injured, and how much function you’ve lost as a result of your particular impairment. And yes, pain definitely does come into play. Pain is considered in all of the ratings and all of the body parts, pain and or symptoms. So that’s definitely part of it, what you can do, what you can do at home, what you can no longer do at home, how fast you can do it, or if you can even do it at all. All of that is placed into the context of your impairment rating.

Cory: Yes, the way that I was thinking about the AMA Guides, when you were describing it just now as I’ve never thought of it in the context of if I was talking to somebody who had never heard of them before, anything like that, and I just had the idea. The AMA Guides is is a lot like almost like a math book, where instead of the one train leaves from Chicago when train leaves from LA, you know, it’s your body.

Okay, so question number two, does the PTP or primary treating physician have to agree with the final final report recommendations? What if a qualified medical examiner or QME says says that the injury is permanent and stationary, but they want to continue treating the patient? Or vice versa? What happens if, if the insurance company says you are not permanent and stationary? But the doctor says they most definitely are, what happens? I guess in either scenario?

Dr. John Alchemy: Well, let me just clarify for everyone. So the QME is a state assigned doctor and the insurance company can call that at any time. So if your treating doctor for some reason, you know, isn’t writing clear reports, or that doesn’t clear to be a clear arc on that treatment plan and stuff. Sometimes, the insurance company will order a state qualified medical evaluator this can be ordered by patients as well. And they’re supposed to step in, you pick a specialty, and they’re supposed to step in, and basically just give an opinion. Remember, these doctors are not allowed to provide any treatment, and they’re not allowed to direct treatment, they can make treatment recommendations, but they can’t say, you know, I’m going to give you Advil, or I’m going to do shoulder surgery on you next week to fix your problem. So they’re only there as consultants.

And the insurance company can choose to, you know, follow the QME report, or they can choose to follow the PTP or a combination of both. Often what happens is a QME report comes back, the insurance adjuster will say, hey, the QME he thought that this patient needs maybe some further testing, what do you think primary treater? And the treater can say yes or no. Sometimes the QME says, oh, no, I think this person is reached maximum medical improvement, there’s nothing more to do for them. And, you know, here’s the rating value, and that can go the wrong way, too. I had a case where a QME basically gave my patient who couldn’t raise their shoulders, at or above shoulder level, they gave him a 0% impairment and said, there’s nothing else to do. This case was MMI.

And I wrote back and I said, well, I respectfully disagree. The patient hasn’t had any therapy. They’ve had no X rays. Their arm doesn’t work. So it’s like, you know, I don’t I not really quite sure what planet that QME may have done this exam on, but I’m pretty sure that it’s not maximally medically improved. And you can always tell the insurance company and the patient yeah, take this into the state have, you know, have a judge look at this. You know, if this just doesn’t make any sense at all.

Usually, it’s not that extreme, usually other reasonable recommendations, but the bottom line is, at the end of the day, the PTP has to write their own impairment report, that’s part of California Labor Code. There’s no way around it. The PTP can adopt the QME report if they think is reasonable and accurate. But they are required to come up with their own version of the patient’s whole person impairment and MMI report one way or the other and that often gets missed because a lot of treaters think, oh, this person saw QME, I’m totally excused from having to do an impairment report. Not true. Not true.

For those of us who do impairment reports for living, after you’ve seen a few QME reports, you realize that some of them are less than complete, and less than accurate sometimes. And so it’s important that if you see a mistake in the system, you have to stand up and say something and say, look, this needs to be fixed. Or there’s an error here, because if we don’t address it, now, it’s only going to come back later with an attorney. And it’s only going to take you know, longer and be more expensive and more frustrating for everyone. So I tried to get these QME reports called out early if there’s a problem, because it only benefits everyone. You know, going forward.

Cory: Yeah, if everybody if everybody’s doing their job, then it’s gonna be a smooth work comp claim. Yeah. If people aren’t doing their jobs, you’re gonna have these stakeholders just walking in the door. You’re gonna have the patient in the doctor’s office, you’re gonna have a the rep from the insurance company… No, not really, but I’m just imagining you just the whole, kind of like the Richard Scaries book of Workers Compensation, then you’ve got this sub Rosa guy outside with the binoculars looking through the window, waiting to come in.

Okay, um, all right. So question number three, do the temporary disability benefits stop when injured workers are permanent and stationary? Or they’ve reached MMI? And and if they don’t, then when do they?

Dr. John Alchemy: Yeah, that great question. And an important question, because a lot of these injured workers are dependent on the income if they can’t work. So, in general, the payments for temporary disability will go on for about two years, and at two years, they’re going to stop regardless. But as soon as the patient becomes maximally medically improved, the payments also stopped. Because the patients no longer temporarily disabled, they are permanently disabled at that point, if they can’t perform their usual and customary work.

And then the decision of accommodations need to be made. So when when the case becomes MMI, or permanent, and stationary, or PNS, whatever term you want to use for it, the employer has to decide if they can make a permanent accommodation and keep that injured worker on or if they can bring them back to work with the permanent restrictions like no lifting over 25 pounds. If they can’t, the employer can release them permanently and go out and find someone else. And then the injured worker is left with either going out and finding a job that’s within their capacity, or getting retrained in another vocation, another job.

Cory: Yes. And on to the next question, does the patient have to accept the settlement offer?

Dr. John Alchemy: Well, it’s an interesting question, because the offer is really based on the impairment rating. And the real question is, is the impairment rating accurate enough for the justification of the settlement offer? So if you think of a whole work comp claim, as like the building of a house, the impairment rating is the foundation it’s the bricks and mortar that support the entire building, if you will. And it basically says, you know, how much loss is there? Why is there loss? What are the basis for this? Where are the measurements? You know, what did you do? What are the tests, and all these things are the foundation of the claim.

So once you have the claim number, and it’s the doctor that delivers the whole person impairment, okay. And once that doctor delivers that whole person impairment, that is the piece that the injured worker needs to be confident in, that they’ve been adequately reviewed. And this is also a concern of the insurance adjuster too. Is this an adequate representation of the individual because if it’s not, you can bet someone’s going to come back and it’s going to go to court, and it’s going to get dragged out for months and years, if it’s not accurate.

So it’s in everyone’s best interest to know if the settlement offer is solid, you know, and that’s why I just plead with insurance people sometimes like, hey, do not go out hunting for a 0% whole person impairment. That is not what this is about. This is about going out and getting the accurate number to settle this claim. So it doesn’t bounce and keep coming back and keep coming back. Because, you know, the goal is to find the right value settle the claim, and have a basis to the claim settlement, as opposed to just saying, oh, I found a case with a zero. I’m going to use this one or likewise, the injured worker finds a case with 100% whole person impairment. I’m going to use this one.

And neither one of those are reasonable options, though, the real question is, what is the real accurate whole person impairment because once we have that number, it gets put into effect, a simple formula that calculates permanent disability. And those two things are probably the most easily confused by everyone in the system. It’s the whole person impairment, and then the permanent disability. And the permanent disability is nothing more than a number that is generated based on a fixed formula on age and occupation, as a main driver inside of it is the whole person impairment. And that’s what sets the price.

Cory: Yes. Okay, so we have two more questions here. But I’m going to kind of condense them together, because it’s just about the same thing, essentially. Yeah, the last question being, what if the insurance company offers a low settlement amount, but it has future medical care, versus a high settlement amount, but no future medical care? What should the person do? And why in that circumstance? And then regarding the future medical care and everything, is there a time limit on it?

Dr. John Alchemy: Good questions, excellent questions. And I think sometimes doctors, when they get this question, or insurance adjusters, or, well, probably more than nurse case manager and doctor who are in the field with the patient, when they get asked this, there’s always a tendency to, you know, want to try to give the patient your best advice. But, you know, doctors are really only supposed to give medical advice, they’re not supposed to give legal advice or settlement device or say, well, that claims too high or too low.

Now, the way I approach it, is I always take them back to the whole person impairment value. And I say, Look, this is a good value, or this value is correct, or this value is incorrect, in my opinion, and I’ve already told the insurance company about it. So I substitute money for whole person impairment, because that’s where I’m allowed to talk to the patient. And that’s where I’m allowed to do an analysis on the medical report that will ultimately determine their settlement amount.

Now, this whole thing about future medical care, and then this other concept, also known as compromise and release. So the way that this works is that you get a fixed payment for your loss based on your measurable permanent disability, which is, as I said, based on your whole person impairment, so you get an amount of money for that, that’s not going to change. But this future care means that you can continue with treatment, and the insurance company will continue to pay for it. So if I need medications for the rest of my life, or I was told I need a surgery in 10 years, if I keep my future medical care, the insurance company, theoretically will pay for that, which what what the patients don’t always understand, is that everything in the future has to go through utilization review appeals, just like everything before the whole before the MMI exam.

So that doesn’t change. So just because future care says this person is going to need a surgery in the future doesn’t mean that it’s going to be approved, because all the information has to be you know, brought up to utilization review, etc, etc. So future care simply means access to ongoing care, but it’s still under the same rules as your pre-impairment rating.

Cory: So everything’s not full smooth sailing right after you go. You can’t just get that face work you’ve been meaning to get? No, I’m kidding. Yeah, well, that’s is insanely practical advice. And I imagine that there’s so much going on in workers compensation that I imagine that the nurse case managers just might need to brush up on some of this stuff.

Dr. John Alchemy: And here’s the other road that I’ll just say, before we wrap this up, is that, you know, I think sometimes patients get this misunderstanding that, oh, I’m going to do a compromise and release, I’ll get this money in my pocket. And then I’ll just go out and get the treatment I want, you know, I’ll get that surgery done. You know, and what I caution them on is, first of all, you really need to understand what the horizon is on your treatment needs. So are you going to need treatment only for the next five years, the next two years or the next 20 years for the rest of your life, really. And then you have to remember that as a patient, you are paying retail, and as an insurance company, they are paying wholesale. So you know if they’re going to give you $8,000 In the future for you to go out and pay for your own shoulder surgery. And then they’re going to release you with no you know, with no responsibility for your future care in the future. You better go out and ask what a shoulder surgery is going to cost you have to pay out of pocket, you know, last time I checked is about 27 to $30,000 and there’s double double digit inflation in health care every year. So that it sounds like a good thing but you better check with your financial planner. Just to make sure that your numbers are correct.

Cory: Yeah, have a have some sort of exponential, use exponential when you’re planning years ahead. Well, great. So we have learned today that you know, nurse case managers are good and sometimes even necessary in moving claims forward and getting them closed, for sure. And, yeah, are there any kind of final words that you have today, John?

Dr. John Alchemy: Well, these are all great, really great practical questions, anyone who works with patients or nurse case managers, or even, you know, insurance adjusters, etc. These are just bread and butter questions this nurse case manager brought to us so I want to say thank you very much. And you know, always send in questions. And if you think that there’s a topic and a podcast you’d like to hear more about, let us know.

But just wrapping this up, nurse case managers absolutely are extremely valuable. They are advocates for the claim, they’re going to be with you until the claim is MMI. And you’ve got everything you need. They’re a great source of information for the adjusters for the doctors and the patients. And they’re really there to be used as a resource and support for the best outcome possible for the patients and that’s the way we need to think about it.

Cory: Well, thanks again for coming on John. And we will talk to you next time and nurse case managers, if you’re out there. Listen to this podcast and share it with your your nurse case manager friends, it might help them and it might help their patients.

Dr. John Alchemy: Thanks!

Cory: Thanks again for listening. For more information about our episode, visit our blog at blog.rate-fast.com and if you want your workers comp impairment reports done and your claims finally closed, visit us at rate-fast.com

Summer 2021 COVID-19 Report

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Factors to Consider Regarding the Future of California Workers’ Compensation

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RateFast Express is Free… Here’s the Catch

Gotcha. There is none.

When people have become accustomed to working in a poorly functioning system, they are naturally suspicious when something comes along which seems to have solved the problems which everyone has come to accept. In fact the skepticism often comes along with an unwillingness to change out of habit, a dangerous cycle.
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RateFast Podcast: Calculating the Integral of ADL Functions in Work Comp Reports

If you’re a workers’ compensation provider, adjuster, or case manager check out RateFast Express: the service that writes your impairment reports for you!


Calculating the Integral of ADL Functions in Work Comp Reports

Cory Oleson (Host): Hello, and welcome back to the California Work Comp report. Today is Monday, June 14 2021. And today Dr. John Alchemy will be educating me about calculating the integrals of ADL functions in workers compensation reports.

And we are back. How are you doing tonight, John?

Dr. John Alchemy: You know, we’re back at it, Cory.

Cory: We definitely are. So today’s topic, we are talking about calculating the integral of ADL functions in impairment rating. And this is going to be one of those ones where, John, you’re going to be educating me quite a bit. I have a list of questions here. And, I am all ears for these things. So I guess we could start out with with calculating the integral of ADL functions and impairment ratings. What is it?

Dr. John Alchemy: Well, impairment ratings are driven as, as we’ve talked about before on the podcast, with regards to pain in ADL function and the pain chapter kind of drives the definition of ADL function. And that analog pain scale of 0 to 10. One of the common problems with impairment ratings is that a number often gets thrown down in the report for body part, for instance, low back pain, 7 out of 10. And they might say that it’s frequent. And then you go on to do the ADLs. You know, and the AMA Guides, table one, dash two and page four, you know, it’s got 34 ADLs. And so you go through that, you know, in good report, and you, you answer those, and you get a number some number out of 34, like, let’s say 7.

Cory: Which by the way, I jumped in without doing my job. ADLs, by the way, are activities of daily living, as defined by the AMA Guides, fifth edition, and those are the things that you do every day, which kind of if you were injured at work, you know, if those if your injury affects any of those things, and it affects your claim, and it affects ultimately your impairment rating. So that’s what ADLs are when we refer to them here. For the new for the brand new listeners, you just happened upon this word called podcast.

Dr. John Alchemy: Starting in the middle of your RateFast podcast binge, right here. Right, so ADLs. And remember, those are things at home not work. Everyone has the same activities at home, everyone has a different activity at work. So we go by the activities of daily living in the daily life. And in so you know, when you look at a number like that, in, we refer to that as a pain signature. And the pain signature is simply the 0 to 10, the frequency, the number of ADLs affected that are only painful, but don’t stop or alter the activity, and then the number of ADLs that are limited or do alter the activity of daily living, that’s what we refer to as pain signature. And so what happens is that you have to look at people’s activity and their pain in function throughout the day, of all the activities of daily living that they’re doing.

So the question comes up, that if my pain is 7 out of 10, and 7 ADLs limited, that means what is my pain across the other ADLs that are not included in the 7. And I know that those 7 are limited, because that’s consistent with a number of 7 out of 10, we define limiting pain as a 5 over 10 or higher. So we know that in that example, that I just gave, that the individual has limited ADLs. And therefore, you know, they have some ADLs that are limited, and sure enough, they have 7.

So the problem comes up often that the number tends to not be properly scaled across the individual’s full day. And that’s what the integral is about integrals. For those of you who have ever taken calculus, it’s all about calculating an area under a curve. And if you think about your day as activities, you know, that you can can’t do certain activities as a subset, you can really think of that day as a curve of when you can and can’t do things in a split line. And that’s what we’re talking about. We’re talking about further adjusting the accuracy of reports to better reflect an individual’s limitation on their activities of daily living. That’s what this whole feature and concept is about.

Cory: Okay, yeah. So you know, the injury that you’ve incurred, mixed with The myriad factors of how the body works, and also the things that you do in day to day life, you know, it can affect the amount of pain or the amount of, you know, kind of impairment or what have you, like physical not in the work comp, sense, but the, the amount of actual, like physical impairment that you have on your activity of daily living, which can vary throughout the day. And it’s it. And it sounds very important to know all these things. But why is it important to know these things, John?

Dr. John Alchemy: Well, you know, in the old system, when this is not done, ratings may be at risk for being overrated, meaning that the amplification of what’s written in there is being carried across all 34 ADLs for your pain, as opposed to just the ones that have been identified. So, you know, the calculations of the pain signature are used in various areas throughout the AMA Guides. And they’re used often, when there’s a range of ratings to be done, you have to bring in the ADLs. And you have to be able to calculate them as a scalar. Or something measurable, that has a measurable range in order to pick is this rating going to be 10? Or is it going to be 13% whole person impairment. And that’s done over and over and over and all the chapters of the AMA Guides. And if you don’t hit that number, right, your rating is going to be too high, or it’s going to be too low.

Cory: And then you’re going to you’re going to experience of what happens. And the reason that RateFast is a company to begin with is a you know, a disputed work comp claim, which slows down your whole process, and it makes it not really start over but it feels like you start over things. So I’m sure I’m sure it feels like it.

Dr. John Alchemy: Well, that’s really the whole mission of everything we’ve done and why RateFast was created was simply to get an accurate report and, you know, get these claims to a value that’s accurate and consistent, and that can be reproduced i I don’t want to go into all the details and the frustrations that that the people in this space deal with on trying to get an accurate report. But it I think just suffice to say that we’re working extremely hard to make it better and better. Every day, every report we do.

Cory: Yeah, absolutely. The binge listener will have plenty to hear about that. If they’re going through our archived episodes.

Dr. John Alchemy: Yes, they will. Yes, they will.

Cory: Great. Well, so, um, we know that, you know, calculating the integral of ADL functions is sort of calculating how any one activity of daily living is affected by the injury throughout the day. And we also know that it’s important because you know, not accurately calculating that and also not calculating the correct body part will result in sort of variations and fluctuations in the claim, which is going to set off, you know, alarms for the insurance adjuster who, you know, will may dispute your report, and then it will slow things down, and which is the tragedy of workers comp as we know it. So, the next question is, how does calculating the integral of ADL functions and impairment rating work?

Dr. John Alchemy: Yeah, that’s definitely a mouthful.

Cory: I think I just like saying it.

Dr. John Alchemy: It is it is fun to say I obviously. The way I best explain it, to people who are unfamiliar either with what an integral is, or what, what the calculation is set out to doing is that if you have, like, let’s say you have a cantaloupe, and you know, you got to cut the cantaloupe skin off the cantaloupe meat, right? So you can cut off the exterior of the cantaloupe. And let’s say eight cuts around, you know, the curve of the cantaloupe. Now, if you do that in eight cuts, and you look at your cantaloupe, your piece of cantaloupe is going to be kind of small. And if you look at a profile of the skin on the cantaloupe, you’re gonna see the edge of the skin, and then you’re gonna see a lot of cantaloupe attached to it. And that’s really the crude way that a lot of ratings are done right now, they kind of hack if you will, the exterior off or do a very blunt type of assessment. And the calculation is something what you’re left with something less than what it really should be, and I’m not saying the number should be higher or lower. I’m just saying the number should be different and more accurate.

Cory: I see what you’re saying. So yeah, cutting you’re cutting the skin. So what you’re gonna have at the end is – wait which one is cantaloupe? The green one is? Yeah, because honeydew is the orange one.

Dr. John Alchemy: No, no, I think you got that backwards. We got some we have an orange cantaloupe and a green honeydew.

Cory: Oh.

Dr. John Alchemy: That’s a different podcast.

Cory: Yeah! So when you say you’re skinning the entire cantaloupe, so you kind of have an octagon, an octagonal kind of shape. And then you have all of this, you know, cantaloupe that’s leftover and these big slices of skin that you took off. So you, you’re missing a lot of the meat of the fruit.

Dr. John Alchemy: Yeah, you’re throwing it out. Yeah. And it’s in, it’s just not being considered, right. So. So it’s kind of just like, it’s just like serving up an impairment report to one of the stakeholders, because at the end of the day, they’re going to get their little ramekin of fruit in front of them. Right. But that’s all they see. And they don’t know how much meat was left on that skin. Yes. Because that’s back in the kitchen. They’re not checking that out. Yeah. Yeah. So all they see is what’s in front of them. And I guess we could maybe make an analogy that they’re like, hey, this portion is too small, or this portion is too big, you know that, but they’re not quite sure. And that’s really what happens, you know, in reality, you know, one of the stakeholders is going to say, I don’t know how this calculation was done, but I think it’s wrong. You know, and, and that’s the problem we’re dealt with, because these things are, you know, not down to the highest science that they could be, shall we say, and RateFast is there to raise the bar, and make sure that everyone gets the report that they deserve.

Cory: Absolutely, and as much cantaloupe is they can get.

Dr. John Alchemy: That’s right. There’s a spectrum here, you know, and the integral, basically what we’re doing, if you think in your brain, okay, instead of taking eight cuts on this cantaloupe, I’m going to take 80 cuts. And instead of taking 80 cuts, I’m going to take 800 cuts, and instead of 800 cuts, I’m going to take 8000 cuts, and ultimately you push that towards infinity. And so your slices get smaller and smaller, which means the precision, and the fruit that’s left and the skin that’s removed, just becomes basically pushed to near zero, as far as the error rate and the and the reflection of the ADL loss, which is our cantaloupe in this in this discussion.

Cory: Yeah. And then, you know, as, as we’ve discussed before, the process of workers comp is laborious, and there are quite a few things for the work comp professional to do, which they simply don’t have time to do. So if you’re a work comp professional, and you’re trying to figure out the, you know, you’re trying to make as many cuts as you can with the time that you have allotted. But unfortunately, it doesn’t always work out that way. Because there’s the real life, things that that happen. Um, and, you know, as much as one would like to be able to make these infinite cuts, you know, you don’t have time to do it.

So sometimes you have to outsource or you, you know, you may consider outsourcing to somebody who is capable of doing that, who spends, who not only knows how the heck to cut a cantaloupe, but has also created a system, you know, which allows them to kind of share that ability with others, and that’s, in this metaphor, I’m talking about RateFast the service that we offer. So, you know, I think that the calculating the integral of ADL functions and impairment rating, which I could pare that down to say account calculating the integral functions. That is what we do and what we do well, so, you know, for the, for the binge listener, who has also worked called professional who is frustrated or temporarily embarrassed or however you want to say that. Yeah, consider RateFast.

So, we have somewhat discussed what the rating implications are for getting it wrong. But I guess we can elaborate on that a little bit. What are the rating implications of, you know, doing these calculations and everything and how will that, how will that benefit report?

Dr. John Alchemy: So the at the ADL, you know, functions and the ADL checklist and the pain is used in multiple parts, as I mentioned at the opening of the podcast, it’s used anywhere that there’s a possible range in impairment rating, which are many tables. In the AMA Guides, it’s used, for instance, in calculating the nerve deficit, if you’re calculating a peripheral nerve loss, you know, for carpal tunnel, for instance, or if you’re doing the range of motion, you know, lumbar spine calculations, and you have some radiculopathy, you have to use it to calculate the step three, nerve impairment, you know, so it goes into the recipe frequently, and often throughout the AMA Guides.

And so, you know, it’s all over the AMA Guides, and I can’t stress enough, you know, that if you are putting in the wrong value, you’re going to be getting out the wrong rating. And what I commonly see in reports for this type of thing is, you know, there’s, there’s a range to pick from, and the user usually picks the high range, the highest or the lowest, because it’s easy. Sometimes they’ll pick some number in between, but it’s really interesting, because in my experience, there’s never really any explanation why they pick the number in between, you know, it’s that they just pick it, but in a RateFast report, you know, you’re not going to have to guess, you know, did this person pick, you know, 50? Or did they pick 10, you’re gonna see numbers like 37, and 44, you’re gonna see real numbers based on the real experience of the individual being rated, you know, and that’s, that’s what really brings for me brings to life these impairment ratings, and makes them applicable.

And, you know, consistent across all the patients, because really, what we’re talking about is, this is the thumbprint of the individual, you know, no one else will have an impairment rating, just like this particular individual that’s being rated, because they’re experiencing their pain and their symptoms, and they’re affecting their ADLs in a very unique way. So all we’re doing is we’re translating that uniqueness and that individual experience into a numerical value, which is what the AMA Guides really strives to do.

Cory: Yes, and we’re calculating it against a real life data, you know, data that is taken to be calculated, where, you know, it’s so common that the data is kind of, you know, ball parked, you know, given a ballpark estimate, which is just not it’s just not right for the patient, who’s whose compensation is affected by the calculations that are made for the doctor, by the doctor. It’s not right for the doctor who may have to put up with a disputed report, which, you know, drags on longer than needed, and, you know, gets him, him or her caught up in it. Or, you know, the staff writing a, you know, redundant report all these things. So, and, yeah, and it’s not great for the adjuster, who has to just play phone tag all day.

Dr. John Alchemy: No, it’s no, it’s not. And remember, the stakeholders also have to sell this to the state, they have to get, you know, someone to sign off to say that this is an accurate rating. And, you know, if that goes into the disability valuation unit in California, you know, and your rating isn’t detailed enough, or isn’t well reasoned enough, you know, they’re going to say, this doesn’t work, you know, and if we have one priority and work comp, it’s settlement, and it’s getting people their benefits, it’s getting them the right benefits. Okay, and making sure that they get the right report.

Now, we’ve talked in some earlier podcasts about data integrity, that’s something else, how much data am I working with, with this report? You know, and how much how close is it to a perfect report or an imperfect report? That’s another issue. What we’re talking about here is getting that that secret sauce of the ADLs, and that pain signature, as tight and as accurate as possible to be reflected in the result in the rating.

Cory: Mm hmm. Absolutely. Yeah. Um, workers comp doesn’t have to be difficult. It’s not, you know, it’s not designed so that it’s a contentious series of, you know, problems that a committee of people who are, you know, kind of representing a different party entirely have to You know, be be embattled about with each other and with themselves. You know, it can work easier, it just needs to. There just needs to be the correct tools and the correct time and everything like that. And sometimes that is not available for everybody. So that’s what we tried to do.

Dr. John Alchemy: Well and the bigger problem is is that you know, from make another analogy here is that we’re having people try to build these reports by using a screwdriver to drive a nail, and a hammer to turn a screw. I mean, it’s very difficult, it just doesn’t work very well. And the product just is not very good when when it’s all done. So, you know, we put the right tools with the, with the right kind of work. And it’s easy for us, because it’s all we do. And we’re totally set up to do it. So, you know, putting reports in the hands of people that maybe have some challenges with comprehensive understanding of the way that the AMA Guides work, in addition to trying to understand how to prepare the data to go into the rating in the first place. That’s, as far as I’m concerned, one of our major limitations in the system, and why it’s so frustrating to get a decent report in front of people.

Cory: Yeah. So we mentioned how this is a different thing from the data integrity, which is, you know, the data integrity is basically it’s, it’s almost like, the way that I think about it, at least is a like a, like a grade, like you get a test or you take a test and you get your grade back. Except, you know, we’re not testing you. We’re called information that you get from your patient. There’s nothing additional than that. But you know, it’s just telling you how good the data was. And similarly, the thing that is similar with this that we’re talking about today, is that it also appears on your work comp report that you get back from RateFas. And so the question about that is, where will these calculations appear on the report that you get from RateFast?

Dr. John Alchemy: So each reporting rate fast has a section for each body part that’s being rated. And at the very top, we placed this information before the rating even begins to get discussed, because people need to know if the you know, rating has been adjusted in some way. But they have to be able to at least trace the steps of the rating and how the data is taken in how it’s adjusted before it’s processed.

And then of course, at the bottom of the report, you get your final whole person impairment. So it’s interesting because not all rating signatures have to undergo an adjustment, some of them are actually correct when they’re taken in the native form from the injured worker. But often more times than not, they are not, and they need to be recalculated, put in to the put into the function, and then adjusted so then the rating can begin properly and accurately.

So you’re going to see something at the top of your RateFast Report to the effect of the functional rating signature has been adjusted for full activity spectrum for lumbar spine, you know, the adjusted values are 3 out of 10 100% of the time, and for activities of daily living pain only. So it might be something like that. But it’s going to be posted up there, if it’s not posted, it wasn’t adjusted. It didn’t need to be adjusted. So we put it right up at the top because it’s such a key ingredient. And the numbers are everything in these impairment reports. So if there’s an adjustment that’s done, the reader will be notified right there in the report at the very top.

Cory: Yeah, a lot of these. So, RateFast is a product that has come, you know, it is a cumulative effort of you know, a lot of you John, the, you know, the workers comp professional as well as mathematicians, and, you know, programmers, developers, things like that, and we’ve come up with this system. So a lot of these things that we discuss in the episodes. You know, it’s kind of a, like a peek behind the curtains.

And you know, not everything is labeled in the report, the way that it’s labeled in say the title of the podcast or something, but it’s definitely there. And then these podcasts and the other material that we have on our blog is sort of telling you where it is, where to look for it, where to see it. And that is how we that is how we stay transparent as a company as well, which is, you know, one of our biggest interest because I mean, if we were, you know, this this sort of ominous specter of sorts then how trustworthy would it be as you know, as a company that take takes the patient data and just magically does some numbers with it. So, it’s important for, you know, the person that’s listening and the person that uses RateFast to know how these things work and where to find them in the report.

So, John, at a glance, how, you know, what, what can our listeners walk away with today regarding the calculating the integral of ADL functions in apparent rating, and also with cutting cantaloupes?

Dr. John Alchemy: Oh, well, a couple of things on the cantaloupe, one, you have to have the knife and you need to have the right tool and number two, you have to know how to use it. So RateFast gives you gives you both of those skills. But the bigger thing I think any listener to this should walk away with is that there are a lot of unobvious things in the AMA Guides and getting a correct reading, things that are not openly discussed or thought about or directed in the AMA Guides. It basically says don’t do this, you know how you do it is not stated anywhere. And the problem is, is that there are a lot of areas for incorrect interpretation, improper calculations if they’re done at all. And and the non standardization of the reports that we struggle with, which is again, why RateFast was created to standardize these reports, make sure all the stakeholders get the correct report and get that settlement done. So these are non obvious things that RateFast is addressing for the stakeholders. With every report we do with every update we do with every, you know, new improvement in the system that we run.

Now, the other thing that people forget about is once you have something unobvious that has been solved or put into the recipe, or that’s now being calculated, we believe we’re doing a huge benefit for the stakeholders in society. Yeah, because getting reports settled correctly and fast, are efficient ways to save money for all the stakeholders. The injured worker gets their proper settlement right away, the employer gets to figure out if their employees coming back and what the injury cost is going to be their costs and their premiums. And the insurance company, of course, they get to settle a claim much faster. And they doesn’t have to get dragged through all these legal processes in months and months of you know, QMEs and having the case redone, and recalculated and telling their story again, and all of the problems that go with that. So truly time is money. And time is probably the greatest resource and benefit that RateFast has to offer to all the stakeholders in the work comp space.

Cory: Absolutely, absolutely. And before we sign off today, John, I’ve got just one more thing for you. You know why? You know what melons don’t often get married?

Dr. John Alchemy: Am I gonna regret this Cory?

Cory: Because they can’t elope. I had that one in the chamber the whole day.

Dr. John Alchemy: You mercifully saved it for the end.

Cory: Exactly. Exactly. So thanks again, John. And we will see you next time.

Dr. John Alchemy: Awesome. Thanks, Cory. We’ll talk later. Thanks for listening.

Cory: For more about calculating the integral of ADL functions in workers compensation reports visit our blog at blog.rate-fast.com and give rate fast to try at rate-fast.com.

RateFast Podcast: Automation in Workers’ Compensation

This article is a transcription of an episode of the RateFast podcast, which you can listen to by searching “RateFast” in iTunes or the iOS podcast store.

If you’re a workers’ compensation provider, adjuster, or case manager check out RateFast Express: the service that writes your impairment reports for you!

Do you feel secure about your job? What if you heard that a robot was about to take over the occupation that you’ve had for the last 10 years? How would you react then?
Continue reading RateFast Podcast: Automation in Workers’ Compensation

RateFast Podcast: In the Engine Room: Special Guest, Marten Thompson

This article is a transcription of an episode of the RateFast podcast, which you can listen to by searching “RateFast” in iTunes or the iOS podcast store.

If you’re a workers’ compensation provider, adjuster, or case manager check out RateFast Express: the service that writes your impairment reports for you!

Who says you’ll never use the major you graduated with? Application developers like Marten Thompson bring their skills to the table to keep the RateFast service up and running. One of those skills involves a great deal of math.
Continue reading RateFast Podcast: In the Engine Room: Special Guest, Marten Thompson

RateFast Podcast: A Look Inside the RateFast Engine Room

This article is a transcription of an episode of the RateFast podcast, which you can listen to by searching “RateFast” in iTunes or the iOS podcast store.

If you’re a workers’ compensation provider, adjuster, or case manager check out RateFast Express: the service that writes your impairment reports for you!

RateFast is an original web application that streamlines and simplifies the workers’ compensation process for doctors. All the physician has to do is enter in information and the program will tell them which data, if any, is missing. This reduces any confusion on behalf of both the physicians and doctors; a doctor’s version of TurboTax, if you will.
Continue reading RateFast Podcast: A Look Inside the RateFast Engine Room

RateFast Podcast: Data Reliability: The Chicken Price Index

This article is a transcription of an episode of the RateFast podcast, which you can listen to by searching “RateFast” in iTunes or the iOS podcast store.

If you’re a workers’ compensation provider, adjuster, or case manager check out RateFast Express: the service that writes your impairment reports for you!

You might not think that they could be related, but there are actually a lot of similarities between the topics of the price of chicken and the price of insurance claims in workers’ comp. For starters, if there is no standard that sets the value of the price for either, then that means the powers that be can charge what they want, with no rhyme or reason.
Continue reading RateFast Podcast: Data Reliability: The Chicken Price Index