3 Critical Questions to Ask About your Qualified Medical Exam

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This is article is meant for injured workers’, medical providers, qualified medical examiners (QMEs), insurance adjusters, and other stakeholders in a California workers’ compensation claim.

When a medical condition has reached Maximal Medical Improvement (MMI), the QME (Qualified Medical Examiner) is required to perform an impairment rating exam.

The impairment exam consists of a series of detailed questions and measurements defined by California law and the American Medical Association (AMA) Guides, 5th Edition.

An accurate and correct impairment exam leads to faster settlement and delivery of benefits, whereas an incorrect exam leads to delay, confusion, and or costly litigation.

As a stakeholder in the system, here are three simple questions you should ask in order to determine the accuracy of your orthopedic medical exam.

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David and Goliath: RateFast sets a new standard for accuracy in California Impairment Rating

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An underdog tale of a physician armed with a simple tool

David vs Goliath

Not so long ago, a certain patient with a work-related injury was sent to a state Qualified Medical Examiner (QME) by the insurance carrier. The QME gave the patient a 0% whole person impairment rating. The QME charged the medical-legal fee schedule, which is approximately twice the primary treating fee schedule.

Then, the patient’s primary treating physician (PTP) performed an impairment rating exam using RateFast.  Guided by the RateFast app, the physician obtained a complete history and measurement set. Four body parts were evaluated: neck, right shoulder, right elbow, and right wrist. After the exam and measurements were analyzed by RateFast, it was determined that the patient had a 17% whole person impairment—compared to the 0% WPI assigned by the QME.

The insurance company was understandably confused. The patient couldn’t have both a 0% and a 17% impairment rating. So which rating was correct? The rating that was calculated by the qualified medical examiner? Or the number produced by the treating physician?

In search of answers, the insurance company showed the RateFast report to the QME and asked for a review. The QME responded that he had not actually performed any of the required exams, or measured the range of motion for the injured body parts. After reviewing the RateFast report, the QME advised that the insurance carrier discard his own 0% rating, and instead adopt the 17% impairment rating from RateFast.

The RateFast report was then shot like a pebble from a sling into the heart of the the California state disability evaluation unit (DEU).

The RateFast report was accepted by the DEU, and the case prepared for settlement.

What can we learn from this story?

A qualified medical examiner’s process is not necessarily any more accurate than reports created by primary treating physicians. The main factor that separates good reports from bad reports—and excellent reports from good reports—is the tool used to document, collect, and analyze data from the patient’s examination.

When the QME and the stakeholders were confronted with overwhelming documentation and actual measurements supporting the findings, there was a little else to do but accept the RateFast report as correct—for the benefit of all. Correct reports that deliver the right value the first time serve all stakeholders—the injured worker, the insurance carrier, and the employer. Incorrect reporting invites frustration, litigation, delay, and skyrocketing costs.

RateFast invites you to get on the right side of impairment rating—while at the same time increasing efficiency and profitability in your medical clinic. You can contact us for a demonstration.

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How to re-send an invitation to join a RateFast practice account

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Update for 2021: RateFast Express is an even easier alternative to the wonderful RateFast software. Try RateFast Express today!

This post is intended for RateFast users who want to invite other users to join their RateFast practice account. Last updated on April 26th, 2016.

Inviting other members of your clinic or organization to join your RateFast practice account is easy, as described in this article about how to invite new users.

But what can you do if you’ve sent an invitation to somebody and they never got the email? Or they got the email but lost it?

Fear not: there’s an easy solution.

1. Login to your RateFast account.

2. Click your name in the upper right corner.

3. Click the “Users” link.

4. Search for the exact email address of the person whom you have previously invited. (Their “Status” should display as “Invited”.)

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5. Click the orange “Resend invitation” button.

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6. Your colleague should receive another invitation email!

Still having problems?

  • You will only see the “Resend Invitation” button if you are a RateFast admin. If you’re not a RateFast admin and you need to have an invitation re-sent, then show this article to the admin of your practice account.
  • Check alternate inboxes, such as “Promotions” or “Junk”.
  • Verify that your associate is checking the correct email address.
  • Still not working? Contact us at info@rate-fast.com

How to Invite New Users to Join Your RateFast Account

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Update for 2021: RateFast Express is an even easier alternative to the wonderful RateFast software. Try RateFast Express today!

This post is intended for RateFast users who want to invite other users to join their RateFast practice. Last updated on June 24th, 2022.

If you’ve just joined RateFast, then you may want other members of your staff to join your practice to help collaborate on writing and tracking workers’ compensation reports.

What You Need

  • A RateFast Organization Account. Don’t have your own Organization Account? Join for free by contacting us.
  • You need to be an “Admin” or “Superadmin” user. If you are the person who originally signed up for your own Organization Account, then you’re automatically a Superadmin.
  • The email address of one or more colleagues who want to join your Organization Account.

How to Invite Users

In order to bring your colleagues into your RateFast account, you need to invite them as new users. Here’s how it works:

1. Login to your RateFast organization account at https://app.rate-fast.com/login

2. Once you’re in, click the button in the upper right corner where your username displays, then click the “Invite Users” link.

 

3. Then, enter the information about the people you want to invite to join your practice. This is where you can assign their role and permissions.

To learn more about roles and permissions, check out our blog post about the different user levels.

4. If you want to invite multiple people, click the “Add Another” button.

5. To send the invitation, click the “Send” button.

This will send an email to your colleague inviting them to sign up for Ratefast. The email will contain a link. Ask your colleague to click the link, choose their username, password, and then login to the organization account.

If they already have a RateFast user account associated with the email you invited, then they will receive an email inviting them to login to your organization account using their normal username. In this case, there is no need to choose a new username/password.

6. Confirm that the email is received.

It may appear to your colleague that the invitation email hasn’t been received. There are two common reasons why this happens:

  • The email was mistyped. Try to invite the email address again by repeating step 3.
  • The email has been marked as junk mail. Ask your invited-colleague to check their Spam folder.
  • The email may have been directed to another folder. To find the invitation, ask your invited-colleague to search their entire email system for the keyword “ratefast”. This should pull up a list of all emails sent from RateFast, including the invitation email.

 

Sub Rosas in Workers’ Comp

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This article is for medical providers, insurance adjusters, and attorneys who want to better understand the process of a Sub Rosa within the context of a workers’ compensation case.

What is a Sub Rosa?

Sub Rosa is a fancy latin term that literally means “Under the Rose.” In workers’ compensation, however, it means secret investigation—surveillance. During a Sub Rosa investigation, usually an investigator is sent out to survey the injured worker. The investigator attempts to observe what level of physical activity the injured worker can or cannot perform. The second, and less common use of Sub Rosa in work comp is to investigate a doctor, an employer, work sites, and/or working conditions. 

What are the stakeholders looking for in a Sub Rosa?

When insurance adjusters, employers, or medical providers require a Sub Rosa investigation, they are normally looking evidence that an employee can perform observable physical activities that are in excess of what they claim they can do.

 For instance, an injured worker may report that they can’t lift anything, or can’t bend over, or can’t walk without a cane. The fundamental purpose of this surveillance is to verify or disprove the validity of what the person is claiming in regards to their physical or psychological conditions. 

Sometimes a patient may claim that they have good days and bad days. In these cases, their limitations ambiguous. It’s very important, therefore, that Sub Rosas span several, separate days, to provide an accurate view of the patient’s conditions.

What should the doctor do while viewing surveillance footage of a patient?

Most surveillance tapes are dead-boring. It is advisable for the doctor to dictate what she observes the patient doing while she watches the tape. It’s also important for the doctor to state whether she can clearly identify that the person being filmed is the patient in question, or whether she knows it is certainly not the patient, or whether she can’t tell.

When should an attorney consider requesting a Sub Rosa?

An attorney may consider a Sub Rosa to be useful if one or more of the following are present:

  • Is the patient off from work for a much longer time than is typical for their condition?
  • Does the patient have a history of workers’ comp cases where this has been a trend?
  • Do physical findings corroborate with the patient’s description of their symptoms?

Should a doctor confront the patient with apparent discrepancies before recommending a Sub Rosa?

Yes. There is a lot that can be gained from a frank discussion with the patient about their symptoms and physical findings. Here at RateFast, we are committed to remaining non-partisan—we believe the ultimate goal of a workers’ compensation claim should be to get patients safely back to work. Therefore, we recommend an open and honest discussion with the injured worker before considering surveillance.

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How to get RFAs approved for your patients using RateFast

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You want your patients to get the treatments that you’ve ordered for them. Quickly. With as little hassle as possible.

Unfortunately, in the world of work comp, getting an insurance carrier to authorize what you’ve ordered for your patient isn’t always simple.

This article is about how you, as a medical provider, can write medical reports and RFAs that get services authorized for your patient.

(If you want to learn more about RFAs, then click here).

What Utilization Review Wants to Know

When you send your request to your patient’s insurance carrier, then the insurance company’s Utilization Review team (UR) reviews the RFA and—the accompanying visit note—to determine whether or not the treatment should be authorized. Here’s what you can do to help your RFA get approved.

1. Complete the RFA as thoroughly as possible.

Each RFA should include diagnostic codes of the patient’s condition(s), the service/good/treatment that is being requested, and any supporting details. Failure to include any of this information may result in the insurance carrier sending the RFA back to the provider.

Also, ensure that the physician has signed the RFA. Nurse practitioners and Physician’s assistants should not sign RFAs.

2. Include the full medical report with the RFA.

An RFA is very difficult to authorize without context. Therefore, send the RFA and the workers’ comp report together, and make sure that the report supports the RFA. The information in the report should be consistent with the RFA and be crystal clear to the claims adjuster who reads teh report.

If you use RateFast to write your workers’ compensation reports (Doctor’s First, PR-2, and PR-4 reports), then RFAs will automatically be included at the end of the report as you select treatments, referrals, medical equipment, and other services for your patient while completing the RateFast report.

3. Include the medical history.

Include a list of all treatments used, the patient’s response to the treatment, self-care, home-exercise programs, and so forth.

Reports written in RateFast will always include this information, so long as you complete the “Subjective Complaints” and “Medical History” sections of each RateFast report.

4. Tell a convincing story.

Together, your RFA and workers’ comp report should make a persuasive case that the medication, therapy, equipment, or other treatment that you are requesting will benefit your patient.

For example, if you are requesting authorization for a treatment that the patient has already used, then your report needs to demonstrate that the treatment has helped the patient in the past.

To understand the full story, the UR department needs to know answers to the following questions:

  • Is the patient feeling better?
  • Has the patient improved functionally improved? In other words, is their range of motion, flexibility, and/or strength measurably improved?
  • Is the patient complying with the current treatments?
  • How are the current treatments affecting the patient’s activities of daily living?
  • If a patient stopped receiving a treatment, is the condition now worsening as a result of no longer receiving that treatment?

In order to answer these questions, it’s important to include information about all changes—or lack of changes—in the patient’s condition. This would usually be described in a PR-2 report (Physician’s Progress report). If you use RateFast to write your PR-2 reports, then you’ll be prompted by the software to make a note of all changes.

Conclusion

Answer these questions and your RFA will be a cut above the rest.

For real-life examples and details given by Dr. Alchemy, MD, QME, tune into our podcast on RFAs and Utilization Review.

Click here to learn more about how RateFast users can automatically fill out RFAs while writing reports.

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What’s an RFA, anyway?

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If you’re in workers’ compensation in California, then you probably know that an RFA (“Request for Authorization”) is a standardized form distributed by the Department of Industrial Relations. Click here to view the official RFA form on the DIR website.

Click here to download a copy of the RFA form.

Medical providers need to complete an RFA for every treatment they order for the patient. The Utilization Review department of the insurance carrier must then review the RFA, and either approve or deny the request.

Each RFA includes the following:

  1. Basic information about the patient and the claim
  2. Diagnostic codes of the patient’s condition(s)
  3. The actual service that is being requested—such as medication, therapy, referrals, equipment, etc.

Failure to include any of this information may result in the insurance carrier sending the RFA back to the provider.

The good news is that medical providers and office workers can create and manage RFAs for work-related injuries using RateFast. For free.

Click here to learn more about how RateFast users can automatically fill out RFAs while writing reports.

To get a more in depth description of how to get your RFAs approved by insurance carriers, click here.

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Frequently Asked Questions about Impairment Ratings

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This article is intended for RateFast users who have questions about the Whole Person Impairment ratings that come with each PR-4 Permanent & Stationary work injury report.

This FAQ contains answers to a few common questions that we’ve received regarding RateFast impairment ratings.

We pride ourselves in the accuracy of our impairment ratings, and would be happy to explain how they are being calculated. If your question isn’t answered here, then please contact us with questions about your PR-4 report.

Continue reading Frequently Asked Questions about Impairment Ratings