Dr. John Alchemy meets with California patent attorney Tom Haverstock to discuss patent law, the process of submitting and receiving a patent, and much more!
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Continue reading RateFast Podcast: Interview with Patent Attorney Tom Haverstock
In this episode, Dr. John Alchemy elucidates the process of informing workers’ comp patients about their impairment ratings, and focuses on how to keep communication clear and open with them through their work comp journey.
If you’re a workers’ compensation provider, adjuster, or case manager check out RateFast Express: the service that writes your impairment reports for you!
The Rene and Brian McCoy Cancer Recovery Research Monarch Fund is a philanthropic effort to provide a scholarship for students in STEM who are attending Hamline University.
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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
We’re in the age of data! Data helps us improve things in our day to day life, as well as track the progress of our ventures. Data analytics could be incredibly helpful to workers’ compensation as a whole, we know because we’ve seen it. Dr. John Alchemy expands on RateFast data analytics and how it helps close workers’ compensation claims.
For more information on this episode, and other helpful tips about workers’ compensation, visit the RateFast Blog.
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 Podcast: The Data Science and Impairment Rating Advantages of RateFast Digital Analytics
Cory Oleson (Host): Hello and welcome again to the California workers comp report. Today is Monday, July 12 2021. This is your host Cory Oleson here with Dr. John Alchemy to discuss the data science and impairment rating advantages of great fast digital analytics.
How are you today, John?
Dr. John Alchemy: Hey, Cory doing great. Good to be back and good to chat.
Cory: Yeah, we’re back in the saddle again. A little a little update about last week’s episode. And this is not at all relevant to anything. But I did tell that I saved this for the episode, by the way, because I wanted to tell tell you and our listeners that I told a joke about cantaloupes last episode. And, you know, for those listening, you will know and for those who don’t know, I recommend the episode. But since I’ve had multiple opportunities to tell that joke, that it was just sort of like well, here’s the cantaloupe joke, again, all to different people. And I don’t know why, but it’s just a cosmic thing that I felt I had to, to mention it being the podcast being the first place, I want to say, this year that I told the, the jokes.
Dr. John Alchemy: It’s a good play to the wider audience, Cory.
Cory: Um, a lot better than some of the jokes. Okay. So today, onto the topic, the data science and impairment rating advantages of re pass digital analytics. We’re talking about basically the things that make RateFast incredibly powerful. And the reason that is still something that we highly recommend is because we’ve been waiting for anybody else to catch up in terms of doing what we do and doing it well and correctly. But in order to have any sort of idea or point of reference for how it’s how it’s good, and how it works in anything, we do need to know how it works.
So first off, John, if we’re talking about, you know, RateFast digital analytics, then what is it that we’re talking about?
Dr. John Alchemy: Well, you know, when we do impairment rating, across impairment rating, in whatever state you are, or in California, the two main things that are really, the basis or the foundation, if you will, is being able to have someone take a look at a report and know the integrity of it. Now, we’ve done other podcasts on data integrity. So you know, I’ll refer the listeners there to what data integrity is, but in short, it’s a quick score of what is in your report, and what isn’t.
And I’ll tell you, you know, a lot of impairment rating, as you alluded to earlier, is basically Stone Age, you know, it’s 1000 different people doing impairment ratings, 1000 different ways with different levels of you know, quality and scoring, and then throwing in the variable that I love, my clinical experience, that just kind of smears the edges of a rating and really doesn’t hold anyone you know, responsible in in a meaningful way that can be checked, or that can be compared against the next report that person does, or the same patient that’s reported on by a different provider.
There’s, just no way for the stakeholders to take a look at a report and say, you know, this doctor A did a 60% data integrity and his report, and this Dr. B, did a 78% integrity on her report. And it’s just crazy for the size of the market, and the money that’s at stake. And all of the cases in California that get rated every year. It’s just mind boggling to me that you know that it works or doesn’t work in the present system.
And I’ve talked about this previously that unfortunately, because the impairment rating has been such a black box or such a curtain with the Wizard of Oz behind it, that the stakeholders, mainly insurance adjuster and patients are left only to value reports based on the result of the impairment and a subjective gut check on what they think is fair or not fair. And that’s the big problem with the system. This system was set up so it stopped being a subjective, you know, quote unquote, gut check, impairment rating where you know, one person would say, oh, yeah, this is a great rating and the other one says, no, this is totally off base because that’s the way it used to be. But unfortunately, when we brought in the AMA Guides, no one has ever thought to create a system that’s like, hey, now that we have, you know, certain clear elements and report that are to be used for rating, why aren’t we tracking them? And why do we have no tool that will give us insight into the report?
So, you know, the data integrity with RateFast analytics is a huge benefit for stakeholders. And, you know, I absolutely love it, we’ve had these inner reports now for maybe 8 to 12 months. And I can’t tell you how valuable it is when someone brings up a complaint, or when someone wants to bring up a challenge on RateFast report, and they have some other report they’re pointing to and you say, okay, well, the RateFast for this provider found a fun and integrity rating of 78%, what’s the integrity of the report in your hand? And then you just hear crickets and a bunch of silence, because they don’t know. And, you know, that’s really what I want to do with rate fast and advancing technology. Is let’s get this into some type of transparent system. So we’re not wasting everyone’s time. And right now, there is a lot of wasted time and money in this space.
Cory: Absolutely, absolutely. You know, anybody that works in any sort of industry will tell you, you know, they, they sort of understand that there’s a totally nitty gritty side of it, which anybody that works outside of that industry, especially if it interfaces with the public in any sort of way. You know, if you ask anybody that doesn’t know about this industry at all, they they’re not aware of how inefficient this just gigantic thing actually is, I mean, work on being only one example of that, I mean, the other thing that comes to mind, is sort of like the way that people talk about AI, like the any sort of user that’s interfacing with Internet of Things product, there’s something things that there’s some sort of, you know, genius world of digital infrastructure behind sort of a lot of the things that they use, which is, in a lot of ways true, but sort of some of the, the tables are being held up by napkins, sometimes there’s things like that, um, and if you work in an industry that doesn’t have, you know, things that are sort of obscured from the public eye that are just messy than we were, I’m dying to know what industry works well.
But yeah, that said, we’ve had a previous episode about data integrity, which I, which I also recommend, and it’s essentially kind of solving this issue of you have this huge, bloated system where everybody that works in it is aware that it doesn’t work great, or at least to the point where people are spending extravagant amounts of money just to solve problems that are inherent in the system. And yet, a lot of the time, people just live with these problems, because fixing a certain aspect is sort of like untangling a huge, you know, not in 10 different cords or wires or something, it’s just kind of at that at a certain point. It’s just like, it’s not my job. It’s, it’s this is, but we at RateFast made it our job. So in data integrity, things like that, ways to tell how good your information was, after you’ve handed it over, instead of just defaulting to well, this information is probably bad, this is probably going to be a mid legal case or something.
Dr. John Alchemy: Yeah, exactly. So the integrity, you know, is a huge piece of kind of understanding what’s there, what isn’t. The next piece that’s really big about this technology? Is the reporting internal reporting consistency, and scoring the ADLs. You know, again, we’ve talked about ADL values and how they play into impairment ratings, and how fundamental they are, and the AMA Guides, you know, multiple other podcasts. But um, when when you have a system that can now consistently process data and answers from patients and scoring from physicians, you have a tool that is going to consistently give you you know, a value based on what’s actually in the report. And I alluded to earlier in the podcast, you know, one of my most frustrating answers to hear or see written in like a QME report or an impairment report is well this is based on my medical experience. And I mean, that’s, I just don’t know what to say to that because it just it doesn’t mean anything.
Cory: Yeah, yeah. It’s it’s it’s pulling it’s it’s kind of like pulling the expert move or the professional move. I’m a professional but you’re speaking to other professionals who see right through it, or you know other professionals who are supposed to see right through it. Who didn’t, you know, whose job is to scrutinize your work and things like that. Yeah, it’s amazing how, how this could be sometimes if you think about you think about it, it’s kind of the way that I think about reports is that it’s almost like a, it’s almost like a pass fail grade for a test, where you have to solve like, one problem that’s made up of a bunch of, you know, small problems versus something like a, you know, this is what an impairment rating is, it’s like a holistic, sort of report on, you know, the human body and its injury and recovery. And it just seems like, just from what I hear, it seems like a lot of people treated almost as if it’s a kind of like a math test, where all the, all the questions are different questions, and you know, the answer to number one does not necessarily relate to the answer to number five, things like that. Not the case, we work on reports.
Dr. John Alchemy: Yeah, and I think the other difficulty with the marketplace is that I talked about, you know, price sensitivity, and people just having this subjective, you know, value in their head about what they want to pay for a knee or a shoulder, because that’s what they think they should have to pay for a knee and shoulder, not being able to see, you know, the data nuances between a shoulder one and a shoulder two case, you know, yes.
And, the big value of RateFast, is that, you know, when we tell you the value, it’s defensible. And it’s very clearly objectified in the report. So, you know, if we lay a number out, you know, one shoulder might be, you know, 4%, but the other one might be 15. And there’s a reason for that. And when you have that type of insight into the settlement of a report, it gives incredible power to the stakeholders that value consistency and objectivity. Because all of this, you know, my medical opinion, goes out the window, all the times that the Almaraz Guzman rating might be abused, for whatever reason, goes out the window. And, you know what the price is.
And so you can avoid the litigation or you can shorten the time of litigation, and you can promote a more equitable settlement than using this current system. Because I mean, think about it if you’re handed an invoice every month for the same service, and it’s wildly different between each month with no explanation.
Cory: Sounds like my electricity bill.
Dr. John Alchemy: Possibly, yes. I think that that’s excellent. You know, there’s no, I think, no rate hikes and times you use your electricity. It’s just all over the place. And it’s very difficult to understand impairment ratings the exact same way.
Cory: Yeah. Oh, absolutely. Absolutely. And so it’s, you know, it’s at least good to know what you’re paying for. And it’s good to have everybody to be in agreement that you’re paying for the right thing. So that’s kind of bringing it back around to what we’re doing. Um, so yeah, I mean, so the RateFast service, it’s important because it saves you time saves you money, it standardizes things, and it just takes care of a problem that was a problem that was too big for any, you know, one person that sort of in it and of it to tackle at the time because you know, it’s your job to see the patient or it’s your job to you know, read these reports or it’s your job to adjudicate these these issues and everything, so we did the job that everybody else is stupid to do.
Dr. John Alchemy: And most importantly, we’re still doing the job, you know, we’re still stopped but you know, at least we have a framework and a system and, you know, another example is, um, you know, the whole Almaraz Guzman thing, and the whole Almaraz Guzman thing currently, is prefaced on, you know, my medical opinion. And like I said, that’s a non starter for me, you know, to read that in a report yet, you know, the Almaraz Guzman was created because there was a sense that the impairment ratings were not always an accurate reflection of the individual’s functional loss, and I’m totally on board with that they weren’t. And part of the reason that they weren’t is because the integrity was not consistently in one report to the next or pieces one through five or in this report and pieces, you know, three through seven were in this report, and it was all over the place.
But the problem was, is that the Almarez Guzman was just thrown out there. But again, as we’ve discussed in prior podcasts, no instructions, you know, no basis for how it’s really used, you know, no guideline. But RateFast has proprietary algorithms. So we can take a look at it and anchor the value of that claim based on what I call the ADL functional loss, which is really what the ADLs are all about. They’re the things being rated in the AMA Guides and ranges of motion and strength and blah, blah, blah, are basically there to match up with what’s your functional loss is. And so we have that ability to say, here’s what came in, here’s your integrity, here’s your rating. And then here’s what the rating should be based on the functional loss. And then we can very simply tell, hey, this rating is within tolerance or not. And if it’s out of tolerance, here’s how many points it has to be adjusted to become intolerance.
So, you know, either way, you’re going to win with a system like that, because you have, you know, an expectation that’s pinned, and then you see where the exam comes in. So, you know, it’s so it’s a very interesting system, I call it the belt and suspenders of impairment rating, because either way, you’re going to get an accurate rating that you can use. It’s, it’s just a question of, you know, what the examiner is claiming, is the reasonable data in the exam?
Cory: Yeah. So when I, you know, if I say something like data scoring, intake and vector creation, for the AMA Guides, work comp isn’t the first thing that necessarily comes to mind. But it is something that is absolutely crucial in RateFast. Could you describe these things and how they work, John?
Dr. John Alchemy: Yeah, so, you know, data scoring is something that we’ve really been working on for the last couple of years. And you know, making sure that the way we process and intake data from an impairment report is consistent from report to report. And I’m going to take just a little sidebar here and step out and say, I think eventually what needs to happen in the space of impairment rating is that it needs to be brought into a digital environment, like we’re building as opposed to letting people just make up ratings off the cuff. And with varying levels of understanding, I’ve talked about this multiple times, the qualified medical evaluator in California has absolutely no testing to prove that they have any competency and impairment rating.
Yet, for some reason, the marketplace seems to think that you know, QMEs do better ratings in the PTPs. But, you know, not necessarily the case at all. And it’s just one of these big myths that have been propagated, you know, along with the system that, you know, has said, oh, well, we think, you know, for some reason, the QME has a magical better understanding of impairment rating than the primary treaters. But I mean, if you pull the curtain back, there isn’t one question. On the, you know, that the QME test about how to do an impairment rating, it doesn’t even ask you the color of the textbook.
Cory: Yeah. I’ve been reading edition six this whole time, I just figured I should buy the new one when it came out. That’s to those who don’t know, who are listening. That’s because California still uses the AMA Guides, fifth edition, where the sixth edition is currently out and used by other states. And as I’ve learned throughout the course of working with RateFast, people feel all kinds of ways about the new and the old editions and whether or not to use it at all. Different states don’t. Not all states, some states use old, you know, going back to the third edition states use versions of the AMA guide. So um, yeah, so there’s that. So what are the rating implications of brief, fast digital analytics? And, you know, the way that we use it advantageously?
Dr. John Alchemy: Well, I think one of the big benefits is, if you were, if I were to spread out, you know, three reports on the table from three different doctors. And I’m not gonna say that they were a QME or a PTP, let’s just say it was three impairment reports from three evaluators in the work comp system. You know, one report might say this patient has a 5 out of 10 pain 25% of the time, and can’t perform 7 of the ADLs on table one, dash two, okay. The next one might say, this patient has moderate pain and can’t perform most of their activities of daily living. That’s all you get in that one. And the third one might literally say this person and has back pain. Okay?
And that is the big issue here, when you’re looking at a series of reports, because if you have a system that can take these descriptions at varying levels, and put them all at the same vector, if you will, or measurable value for a pain, a frequency and an ADL, that’s really what this is all about. Because, you know, and I’ve seen reports from a QME that basically says the patient still has shoulder pain, that’s it, and the patient is working, modified duty. That’s the history, there’s nothing more than that. And this is a quote unquote, QME report.
And, you know, and so when you’re given that you have to make some type of understanding or sense of that, in the framework, have a digital analytic system, and you can, and this is the reason why trying to just get another provider and another rating, and another provider in another rating does not work, you know, because the next rating could be better, but it could be worse. And all it’s doing is delaying cases, minimizing the accuracy and the consistency. And again, why because people are looking for a number, instead of really looking at the data and saying, what should this really, you know, rate at, you know, what should this score be?
And what is the basis in this report, because it’s, it’s interesting, because the, the DWC, you know, has their impairment, raters to my knowledge, they have no standard, you know, infrastructure on how to interpret when someone says their pain is minor, or moderate, or 7 out of 10, or a 2 out of 10. You know, all they really do in my experience, is they look at the report and make sure that the doctor used the right table. And sometimes that’s even a little dicey with them. Because, you know, you could rate someone in a neurological chapter, you could rate them in the upper extremity chapter, you could rate them in the spine chapter and all be considering, you know, ratings of a nerve.
So, to me, the DWC results that I’ve seen are very superficial and very concrete. And they don’t really understand or they don’t appear to understand or discuss huge discrepancies in the data sets that are there in the reports. So they’re supposed to be there to help. And I think that maybe that’s their intention. But again, it appears to me as an outsider, having read, you know, many of these DWC, you know, quote, unquote, evaluation reports that, you know, they’re very limited in their scope and their understanding. And, you know, that they asked for, you know, maybe clarification sometimes, but, I mean, if you look at the stuff they’re actually asking, I think it often misses the big picture and is, you know, just focusing in on what we think you should use this table. You know, it’s just not a great oversight. Again, this is my opinion.
Cory: Yeah, totally. I mean, what you know, you get any thing that you buy a say it’s like a, you know, an electronic of sorts, or something like that, it’s going to be quality controlled. And then in an industry that has, you know, billions of dollars moving through it, you don’t get any sort of degree of quality control even though the people who are essentially it is their job to do so often. Don’t do it. So that’s a that’s always very reassuring. I’ll make sure I get injured at work as soon as possible so that I can go through this system.
So yeah. Okay, so let’s say I have made the decision to make my life the life of my patient, the life of the adjuster, the life of the employer and the life of everybody else a lot easier by doing such things as going with RateFast Express to write the impairment reports, and I receive the RateFast impairment report, or you know, if I wanted to see it back, because we also have an option of just letting us have it and putting it out of your life. So if you’re listening and you’re waiting for that in your life, then just run right down rate-fast.com right now, however, if you do still look at the report, or you know, you’re using RateFast for one of our other services, where will you see the calculations that we’ve described here today in the report?
Dr. John Alchemy: Well, each body part when it’s calculated with RateFast, you’re gonna see an analytics report at the very bottom, at the bottom line where it says, you know, the WPI of this shoulder is, you know, you’re going to see right below that you’re going to see what the data integrity is. And you’re also going to see what’s called the overage report. So those are, those are two very key metrics that, that if you understand the value, you can at least say, okay, I know this report has a minimal value of data in it that I’m willing to accept. Maybe that’s a 51% data mark, maybe it’s 75. You know, maybe it’s, you know, 90, whatever the stakeholders agree upon, either independently, but at least they can say, look, this rating has, you know, this amount of integrity in it.
And then the other big key is, they can look at the report, and very quickly see, how close is this report to spilling over into an Almaraz Guzman report, and I’m not aware of any reports that do this on a standardized objective level, like I said, it’s usually just goes to, you know, the provider saying, oh, in my medical opinion, the rating I provided in the four corners, does not rise to the Almarez Guzman requirement, and therefore we’re going to use this, you know, that’s basically the best you get. But when you’re doing a RateFast report, and if there is an overage or if the impairment load has exceeded the four corners rating, and remember that four corners rating is dependent on two things, the accuracy, and the amount of data that was actually collected for the report, we’re going to tell you exactly how much you’ve crossed the line, this rating has exceeded the four corners by 22%, 16%, 5%, 90%. You know, and so you at least know what you’re paying for.
And you know, that hey, look, this report, you know, shorted me 50% of the data set. And as a result, based on the patient’s functional loss, I know that you know, the individual has coming do a WPI of 17%. Okay, and that’s a very powerful thing to go into a settlement with, because no one else at the table is going to have that information as to 17%. The best you’re going to get is oh, it was the doctor’s, you know, medical opinion based on their experience, again, a total non starter from my standpoint. So you know, that is where you’re going to basically find the integrity. And you know, that borderline of crossing over into that, until now mysterious area of the Almarez Guzman ratings?
Cory:Absolutely. And as we’ve mentioned before, I mean, you know, it would be one thing, if somebody handed us a report, we wrote the most killer report that the insurance company had ever seen. But we turn that in from, you know, data that was, you know, the one set and say, you said this patient has back pain or something like that. That’s why we included the data integrity, kind of, you know, it’s not a good thing or a bad thing. It’s exactly it’s it’s a reflection of what was given to us. I mean, I guess being one of the very few, I guess, what have you implements of that disproved the garbage in garbage out thing, just because we’re very good at turning a trans mutating garbage into gold, if you will, you know, we couldn’t let it end there. We have to let people know, the human element. And if there is garbage going in, because it’s just important for the claim. In general, it’s important for all stakeholders.
Dr. John Alchemy: Yeah, and you know, and I mean, you have what you have, exactly, on the paper in front of you. And like I said, you can roll the dice, and you can spend 1000s of dollars on chasing that next impairment rating from the quote unquote, expert, and hoping that you’re going to get a number that you like, if that’s the way that you handle your impairment and claim settlement pricing, which is a big way that it’s handled right now. You think, oh, shoulder shouldn’t be more than 7. Because, you know, I’ve never settled a shoulder on more than 7% therefore, it cannot exist. You know?
Cory: Why have you never done a shoulder over 7%? Well, it’s because I’ve never done a shoulder. So, you know, there’s no logic to it.
Dr. John Alchemy: There’s a lot of circular reasoning that goes with it. But, you know, in closing the podcast, I would say how many of the listeners do their own tax returns and I would be willing to guess that probably less than 5% people sit down and you know, do their own taxes every year. No, you hand it over to someone who knows what they’re doing. And someone who understands and has the tools to write an accurate tax return for you. Because you don’t want to be getting audited and you want someone responsible if you do get a kickback, who understands what the question is, and more importantly, what the answer is, for whoever is asking the question, and that’s probably the greatest value of RateFast to our clients, is we give you that understanding and we’re able to answer those questions for you. So you don’t have to claim that oh, yeah, I know exactly what’s going on. Because you may not but it’s unreasonable to expect that the doctors and the providers can understand the AMA Guides to a granular level it’s just not a realistic expectation. So RateFast is out to change that.
Cory: Absolutely. For more information on why doctors don’t have the time to do this and why reports are written the way they are, to elaborate on the things we’ve said, check out any of our back episodes where we go into granular detail ourselves on these little things and why they happen. So that does it for our show today, John. Any closing words on RateFast analytics or the greater work comp field at large?
Dr. John Alchemy: Well I’m going to make it really short this time around and all I’m going to say is: stop guessing and use impairment ratings with RateFast.
Cory: Stop guessing!
For more information on RateFast analytics, visit our blog at blog.rate-fast.com and get your California permanent stationary reports for free at blog.rate-fast.com.
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
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
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
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
