One Simple Tip to Improve How Your Practice Organizes Work Comp Claims

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Currently when patients come into a clinic, whether the clinic uses an EMR or paper charts, a chart is created. Notes are written- that works fine, as long as there’s only one injury being managed. The real problem comes up when patients get a second injury.

What can easily happen is that the notes for the two different dates of injury get shuffled together. Incorrect documents given to the provider can then further confuse the patient’s examination, and delay the claim being closed.

This is the problem with administering multiple claims in the clinic. So what’s the solution?

Patient’s injuries need to be organized around the date of the event. Unfortunately that’s not the way that we’ve created healthcare records. Traditionally you have a chart that is organized chronologically.

To solve this problem we have to re-organize the way we write and create our EMRs for Work Comp. Because in Workers’ Comp, each claim has it’s own universe, it’s own set of unique information. These need to be the drivers of the organization in the chart. All you really need to know is what date of injury is this patient here for? Once you know that then you know what the injured body parts are, and you can put your finger on the last, correct, and appropriate notes.

Once you’re working in a system that’s correctly organized by date of injury, it now presents an opportunity for everyone in the clinic to start contributing to the creation of the correct visit note. Now the front office has the opportunity to prepare the patient for an exam based on that specific date of injury. A medical assistant can open the EMR, verify the date of injury, and check-in about pending actions and RFAs.

This allows the doctor to focus on making medical decisions instead of doing clerical research. The patient’s visit goes really smoothly and the patient feels that the doctors are informed and the clinic cares about moving their claim forward.

Take a good look at how different members of the clinical team are helping as injured workers come into the office. It says a lot about the quality of care perceived by the injured worker.

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Understanding Disability: For Insurance Adjusters

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Question: Dr. Alchemy, Based on limited range of motion for the neck in the PR-4 exam, can the injured worker return to usual and customary work duties? (This worker was provided an impairment rating WPI value, but no work limitations were clinically indicated).  Sincerely, DS

Answer: Dear DS, Impairment and disability are two independent concepts. Impairment value is a loss of an organ system or function to which a number value is assigned, whereas, “disability” is an ability to meet social or occupational demands. An individual may have impairment but no disability, or the reverse may be true.

A great example here is a knee injury with a meniscus tear. If I choose to not have surgery, but have range of motion above the ratable guidelines, I have a non-ratable knee, BUT I may not be able to stand, squat or lift to the requirements of the job. So, no impairment, but disability (eg. work limitation).

Same knee example as above, but I have surgery this time and a partial meniscus debridement is performed. My knee is perfect post operatively and no pain. I return work no problems. My impairment, however, is 1% WPI based on DBE table rating in Chapter 17, Lower Extremity Table 17-33 etc.

Summary, when an impairment value is incorporated into the California Permanent Disability Rating  (PDR) calculation, true “disability” may or may not be present.

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Adjuster’s Corner: For Insurance Adjusters

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Introducing the RateFast “Adjuster’s Corner”.

Adjuster’s Corner is brought to you by, well, adjusters. This series of newsletters are based on real life letters and questions from insurance carrier adjusters seeking clarity and knowledge of the AMA Guides 5th Edition impairment rating situation in California.

Our responses are provided by Dr. John Alchemy, MD, DABFP, QME, CIME. Dr. Alchemy’s credentials include:

A) A current Qualified Medical Examiner (QME) for the State of CA

B) A certified educational provider for the State of CA DWC Medical Unit, specifically approved for content in the AMA Guides 5th Edition, Chapters 1,2,15, 16 and 17, in addition to advanced impairment report writing (12 hrs CME).

C) Currently certified by the American Board of Independent Medical Examiners (ABIME) as a Certified Independent Medical Evaluator (CIME) and have successfully passed a proctored written exam demonstrating competency in the AMA Guides 5th Edition rating system.

Got a great rating question? Send it in (info email link here)!  We love questions almost as much as answers.

Case Study #1 Submitted by adjuster DS:

Question: Dr. Alchemy, why did the cervical spine rating come out so high for a non-surgical neck?

Answer: Dear DS, Do not fall into the trap of responding to impairment values based on the result value. If one reads the rating criteria, surgery is only a subset of the DRE categories, and in no way, a single gateway for rating inclusion etc. Additionally, surgery plays only a subset in the rating determination when using the ROM spine rating.

Rather, I would urge you to focus on the data set that is presented, the validity of the measurements, and the application of the results to the tables and figures. The goal in providing AMA ratings is to provide the stakeholders a numeric value  based on statistical rigor, objectivity, and reproducibility.

If you have specific questions as to the validity of a number or the application of a table/figure, please let me know specifically which part of the data set is appears inconsistent and let’s have learning opportunity.

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Digitization of Workers’ Compensation

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The process of digitization is taking information from  the real world and overlaying it with a set of digital perimeters, which allows that information to be put into a system.

This allows for meaningful content to be created for consistent conclusions across large numbers of users.

Electronic Medical Records (EMRs) have gained wide popularity over recent years, but to what extent have Workers’ Compensation reports been digitized in a similar way?

There really hasn’t been a concerted effort to digitize WorkComp by any one group or entity.

There are some impairment reporting softwares out there that will give you the header of the section of the report you’re supposed to fill out. But in these cases, the user is left with a blinking cursor to ask the questions and perform their own physical exam, at their current level of understanding.

We’re talking about guiding the patient and medical provider through a very specific process to make sure reports are as complete and compliant with the law as possible.

Digitization of Workers’ Comp means getting every part of the WorkComp reporting process standardized, using computer technology.

With the rise of cloud computing and centralized and data repositories, the time is now to start this process.

This benefits everyone in the workers’ comp process, but most importantly, it benefits the injured worker. Injured workers get caught in a spiral of inefficiency and errors which draws their cases out much longer than they need to be.

Digitization means faster and more accurate reports; there is currently no penalty for turning in wildly inaccurate reports. Once this process does get digitized any missing information will become blatantly clear.

Has this happened elsewhere? Yes- take a look at the automobile industry. As soon as cars appeared on the market, both new and used, there needed to be a system for determining their value. This guy Les Kelley showed up, of Kelley’s Blue Book– he didn’t have a computer, but he used a specific set of questions that determined how much a car’s value was worth and how much its resell value was. Within a couple of years he took over, his system was an industry standard.

So what does this look like in an Impairment Exam? Let’s have an example:

A QME is doing an exam for a right shoulder injury. The QME took two measurements with the goniometer in all planes of motion. This report gets submitted, and the report is digitized, meaning that someone takes the information and places it into a standardized format to confirm the opinion of the QME. However, what the QME either forgot or wasn’t aware of, is that in upper extremity injuries, you need to measure both the injured and uninjured parts of the body. Therefore half of the functional measurement set is missing, as no measurements were taken on the left shoulder. With digitization the data that’s missing is made extremely clear. This will improve accuracy and consistency in monetizing work injuries.

A study from 2006 found as much as 79% of reviewed reports for the low back were incorrect. Hopefully with the process of digitization this number will significantly decrease. Questions or comments on digitization? Write us at info@rate-fast.com

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Stay Out of Fraud’s Way with RateFast

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Last year the California Department of Industrial Relations, Division of Workers’ Compensation (DWC) sent out a letter to the workers’ compensation community regarding fraud. You can read the full letter from 2014 here. But in order to keep things simple, RateFast has created an easy to follow guide for understanding regulations and making sure your practice isn’t making common mistakes.

Workers’ Compensation fraud can be committed by all parties in the workers’ comp process. This includes medical providers, attorneys, claims adjusters, and employers. Below are details and real-world examples of what fraudulent activity might look like for Medical Providers. For a full discussion and review of the 2014 Fraud warning notice, please listen to our podcast “Staying Out Of Fraud’s Way”, available on the iTunes store.

Fraudulent activity for medical providers includes:

  • Billing for services that weren’t performed/ billing for procedures that weren’t indicated.

  • This can occur if an office is not in the practice of correctly documenting the amount of time a provider has spent with the patient.

  • Employing Individuals to Solicit New Patients

  • Using another individual in the community to funnel cases to you.

  • Unnecessary treatment.

  • A patient is authorized for a cortisone injection, and it doesn’t work. If the doctor continues to provide cortisone injections, that may be viewed as unnecessary treatment.

  • Self-interested referrals.

  • If a provider has stock or ownership in a physical therapy group across the street and the provider sends their patients over there, then they make an additional profit on that patient.

  • Failure to report a work injury.

  • Employers are required to report work injuries. If a doctor is not reporting an injury then be in favor in employer, then insurance premium doesn’t go up.

  • If a doctor is aware that a work injury has occurred they have to report it whether or not the patient wants to continue treatment.

Let’s take a look at a fictional, but quite possible real-world scenario:

An employer brings in an injured worker and they have a laceration on their arm. The medical provider examines the wound and makes a determination that the wound needs to be closed with sutures. If sutures are used it becomes a reportable case. If it’s closed with surface tape, the injury falls under first aid. The employer states that they would like it to be closed with butterfly tape. They will pay the provider cash for this and also promise to send other injuries to the provider’s clinic.

If the doctor complies and places the butterfly tape, then fraud has occurred because the medical recommendation was for stitches. The doctor knowingly changed their medical treatment plan to provide a first-aid remedy as opposed to a reportable one. This can be very difficult to prove after the fact.

Bottom line for medical providers concerned about fraud? Simply remember to be careful about processes in the office:

  • How you assign medical codes

  • How you interact with employers

  • What something might look like to a third party

Understand the law, familiarize yourself with the annual fraud notice, and you’ll stay out of fraud’s way!

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What is MMI?

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Your patient or injured worker has reached MMI. But what does MMI mean when we’re talking about California workers’ compensation?

MMI is shorthand for Maximum Medical Improvement, defined on pg. 2 of the AMA Guides to the Evaluation of Permanent Impairment 5th Edition as the following:

An impairment is considered permanent when it’s reached Maximal Medical Improvement, meaning it’s well stabilized and unlikely to change substantially in the next year, with or without medical treatment.

The date of MMI is important: it’s the date when a patient is ready for an impairment rating, and for decisions about future care and permanent work restrictions.

How Do You Know if a Patient is MMI?

How can you tell when a work injury has “stabilized” and is “unlikely to change substantially in the next year, with or without medical treatment”?

To find out what goes into determining MMI, keep a few key questions in mind:

1. Is there any on-going medical treatment that will change the injured worker’s functionality?

For instance, imagine a case where a patient has a back injury, and can only lift 25 pounds.

Physical therapy helped improve the patient’s condition in the past, and they still have six more physical therapy visits authorized by the insurance carrier.

In this scenario, the patient may be able to lift more weight after completing all their physical therapy visits.

Why declare a patient MMI if they are in the midst of ongoing treatment that may improve their condition?

2. Is the impairment rating going to change?

Another example: a worker with a shoulder injury is improving their range of motion with physical therapy, but they cannot improve their ability to lift more weight.

Until their range of motion remains the same, they will not be eligible for MMI.

As soon as the claim is filed, MMI becomes the ultimate goal for treatment. Patients obviously want to get bet better after a work injury, but sometimes they continue to have pain. MMI does not mean that the patient is no longer experiencing pain. It’s the doctor’s responsibility to communicate this to the patient, and to everyone involved in the case.

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Assembling the Perfect PR-4 Report

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Your patient or injured worker has reached MMI and is ready for their final impairment rating: it’s time to complete the California PR-4 Report.

What goes into these reports, which are required for each reported work comp injury in California?   A summary of how the injury occurred, attempted treatments to date, how the patient is doing currently, future care and medications… to name a few items.

But perhaps most important to the PR-4 report is a detailed set of measurements which create a value for the injury (Whole Person Impairment or WPI%). These measurements are required by the AMA guides to be reproducible, and determine if the employee is eligible for a payment benefit based on permanent impairment findings.

We recommend using RateFast for fully reproducible findings on PR-4 reports. RateFast provides a digitized patient exam for correct prioritization of all data. But, whenever you’re performing a PR-4 report, keep these tips in mind:

  • For multiple body part claims remember to keep all injuries in mind when providing treatment.
  • Create a consistent system for collecting information for all patients.
  • Remember incorrect measurements lead to incorrect impairment ratings. Always measure twice for accuracy.

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Untangling the PR-2 Report: 6 Tips For Faster, Better Treatment

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You’re in the middle of a complex work injury claim. You, whether you’re a doctor, patient, or adjuster, are under a lot of time pressure. You want to get back to work, or to close the claim, or see your patient healed. This is where the  PR-2 Report comes into play.

What is it? Before the patient has reached permanent and stationary status, it’s a report which summarizes the active management of the claim. It helps the provider communicate to the insurance company how the patient is responding to their treatment. After the claim has closed, PR-2 reports are used to describe future care necessary for the continual functional rehabilitation of the injured worker.

We’ve got six simple tips to help you understand the PR-2 Report better, and avoid common mistakes which can cause major delays.

  1. Don’t try to do too much in one single PR-2 Report. Time is short in any doctor’s visit.
  2. Select a focus for the visit and stick with it. Listen to how the patient is doing and select a plan of care which addresses the most debilitating parts of their injury first.
  3. Remember to keep all injured body parts on the radar. Injured body parts can get left off of the claim because the pain has seemingly fizzled out, only to flare back up again. If dealing with a multiple body part case it’s vital (literally!) to continue providing care for each aspect of the injury.
  4. Clear next steps. Future care should be a major priority of the PR-2 Report. For example, if you exam only the neck of an injured worker in one visit, be sure to plan to assess the functionality of the fingers in the next.
  5. Review the charts of fellow providers on the case.
  6. Remember to see the patient every 45 days (6 weeks) until the patient reaches MMI. Longer time between visits creates a lapse in care which can lead to delayed recovery and return to work.

If you’re confused about new RBRVS questions and how they change billing for the PR-2 report, check out question two in this helpful post from our friends at DaisyBill.

Listen in on the conversation at our new Podcast, CA WorkComp Report, here.

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AMA Guides 5ed Glossary Definitions (Pages 599-603)

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AMA Guides 5ed Glossary Definitions (Pages 599-603)

Below is a common list of terms that help RateFast users better understand the basics definitions used for impairment ratings. You will find many of these terms used in RateFast to provide more consistent and reproducible reports.

Aggravation

A factor(s) (eg, physical, chemical, biological or medical condition) that adversely alters the course or progression of the medical impairment. Worsening of a preexisting medical condition or impairment.

Ankylosis

Fixation of a joint in a specific position by disease, injury or surgery. When surgically created, the aim is to fuse the joint in that position, which is best for improved function.

Apportionment

A distribution or allocation of causation among multiple factors that caused or significantly contributed to the injury or disease and existing impairment.

Assistive devices

Devices that help individuals with a functional loss increase function. Examples include reachers, extended grabbers, hearing aids, and telephone amplifiers.

Causation

An identifiable factor (eg. accident or exposure to hazards or disease) that results in a medically identifiable condition.

Chronic pain

Pain that extends beyond the expected period of healing or is related to a progressive disease. It is usually elicited by an injury or disease but may be perpetuated by factors that are both pathogenically and physically remote from the original cause. Because the pain persists, it is likely that environmental and psychological factors interact with the tissue damage, contributing to the persistence of pain and illness behavior.

Combined Values Chart

A method used to combine multiple impairments, derived from the formula A+ B(1-A) w combined values of A and B, which ensures that the summary value will not exceed 100% of the whole person.

Contracture

A permanent shortening (as of muscle, tendon, or scar tissue) producing loss of motion, deformity, or distortion.

Desirable weight

A range of optimal weight given an individual’s sex, age, height and body habitus.

Disability

Alteration of an individual’s capacity to meet personal, social, or occupational demands or statutory or regulatory requirements because of an impairment. Disability is a relational outcome, contingent on the environmental conditions in which activities are performed.

Effects of medication

Medication may impact the individual’s sign, symptoms, and ability to function. They physician may choose to increase the impairment estimate by a small percentage (1% to 3%) to account for effects of treatment.

Functional limitations

The inability to completely perform a task due to an impairment. In some instances, functional limitations may be overcome through modifications in the individual’s personal or environmental accommodations.

Handicap

A historical term used to describe disability or a person living with a disability or disabilities. A handicapped individual has been considered to be someone with a physical or mental disability that substantially limits activity, especially in relation to employment or education.

Impairment

A loss, loss of use, or derangement of any body part, organ system, or organ function.

Impairment evaluation

A medical evaluation performed by a physician, using a standard method as outlined in the Guides, to determine permanent impairment associated with a medical condition.

Impairment percentages or ratings

Consensus derived estimates that reflect the severity of the impairment and the degree to which the impairment decreases an individual’s ability to perform common activities of daily living as listed in Table 1-2.

Malingering

A conscious and willful feigning or exaggeration of a disease or effect of an injury in order to obtain specific external gain. It is usually motivated by external incentives, such as receiving financial compensation, obtaining drugs, or avoiding work or other responsibilities.

Maximum medical improvement (MMI)

A condition or state that is well stabilized and unlikely to change substantially in the next year, with or without medical treatment. Over time, there may be some change, however, further recovery or deterioration is not anticipated.

Normal

A range or zone that represents healthy functioning and varies with age, gender, and other factors, such as environmental conditions.

Pain

An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

Paresthesias

A sensation of prickling, tingling, or creeping on the skin, usually associated with injury or irritation of a sensory nerve or nerve root.

Permanent impairment

An impairment that has reached maximal medical improvement.

Prosthesis

An artificial device to replace a missing part of the body.

Radiculopathy

Any pathological condition of the nerve roots.

Recurrence

A return of the disorder or disease after a remission.

Reproducibility

Synonymous with reliability. Consistency in results when examinations (tests) are repeated.

Sciatica

Pain along the course of a sciatic verve, especially in the back of the thigh, caused by compression, inflammation, or reflex mechanisms.

Teleroentgenography

A radiographic method used to determine actual limb length.

Treatment

The action or manner of treating an individual, medically or surgically. Medical treatment is the action or manner of treating an individual, medically or surgically by a physician. Treatment may include modalities recommended by a health care provider.

Validity

An accurate measurement apart from random errors. Validity refers to the extent to which a test measures what it is intended to measure.

Whole person impairment

Percentages that estimate the impact of the impairment on the individual’s overall ability to perform activities of daily living, excluding work.

Workers’ compensation

A compensation program designed to provide medical and economic support to workers who have been injured or become ill from an incident arising out of and in the course of their employment.

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How to write a good Doctor’s First Report (DFR)

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Somewhere in California, a workers’ compensation injury is about to occur. The initial steps in a work comp claim are some of the most important, as they can determine the complexity and timeliness of an injured workers’ case. The Doctor’s First Report (or DFR) is the first step in determining care. What are these first steps?

          1. After a worker is injured on the job, the worker reports the incident to the employer.
          2. A medical provider examines the injured worker.
          3. The medical provider completes a Doctor’s First Report (DFR) that includes information about the patient and the history of the injury.

A DFR must be filled out for all on-the-job injuries according to the California Department of Industrial Relations.

Errors in the DFR can delay the patient’s ability to return to work or to receive treatment. Unfortunately, these errors are far too common.

How to make your Doctor’s First Report count

Here are some tips to keep in mind to ensure that your Doctor’s First Reports are as effective as possible.

  • The DFR should include a detailed description of the injury according to the injured worker. Get all the facts in the patient’s own words.
  • The physical exam taken for the DFR should be supported by the patient’s own story about the injury. The more consistent the patient’s account is with measurable findings, then there will be fewer complications further down the line.
  • List all injured body parts. Each individual body part will receive different types of treatment, and, ultimately, a different impairment rating.

So, if a patient comes in after injuring her cervical spine after falling off a ladder, but she also complains about a sore wrist, then you should make a note of both body parts in the Doctor’s First Report. This way, medical treatment for all aspects of the injured worker’s claim will be addressed. Further steps for reproducing the Doctor’s First Report are listed on the Division of Workers’ Compensation website, here.

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