RateFast founder and CEO, Dr. John Alchemy answers a question which comes up periodically with workers’ comp claims: How do I add a body part to an existing workers’ comp claim?
Dr. John Alchemy: Hello again, this is Dr. John Alchemy, founder of RateFast. Another mini podcast today on a question that came in from one of our clients. The topic is, what about adding body parts in a workers compensation claim?
So this particular client was wondering how to address when a patient, for example, comes in with an ankle injury, the injury has been accepted and receiving treatment, but the patient comes in and says, because of my sore ankle, I’ve been limping for a couple of months now, and now my knee is starting to hurt. The client has this question of what do I do, how do I appropriately include this into the claim, how do I get treatment or should they receive treatment?
The first thing that the provider needs to do is to back up a little bit and put on their medical probability hat. They need to take a decent history, they need to figure out when it started, they need to talk about any preexisting conditions that might be overlying it, and then they need to make a simple opinion. So for instance in the case I just described, let’s just say that there were no other complications, the patient’s knee started hurting after limping around for a few months on an industrial accepted ankle.
So in this case, the real responsibility of the primary treater is to put out their best medical opinion. So for instance this treater might state that the patient has a documented ankle injury, that they’ve been having some limping as a result, maybe there’s some soft tissue pain, or maybe some arthritis or maybe it’s a fracture. They’ve been walking and for the past three weeks, they’ve noted aggressive, persistent pain in the knee. And it’s okay to say that the patient believes it’s from that but what really matters is what the medical provider believes. If you do believe that the patient is credible and that from an anatomic standpoint this is a compensatory injury due to altered gate mechanics, go ahead and put that in. But next comes the big piece.
So what you don’t want to do is to start ordering all these tests for treatment and knee pain because the adjuster is not going to understand why all this is happening, they’re going to be denied all this stuff. So what you really want to do is put in a request for authorization to include treatment for the body part you want to add. So for instance you may say I am requesting authorization for evaluation and treatment of the compensatory left knee, secondary to altered gate mechanics due to the industrial index injury of the ankle. That’s the best way to do it.
Then, have the discussion with the patient, send that RFA into the adjuster, have a discussion with the adjuster if they need to and then wait and see what happens. If it comes back that it’s denied for whatever reason, you can tell the patient they have a couple of options. One is certainly to exercise their right in the qualified medical exam system in California. They can call, they can get a QME, the QME can listen to the story and can make a recommendation. If they are represented or have an attorney, they need to have that discussion with their attorney as well. As always they can seek to get healthcare through their plan and get it that way.
So in a nutshell, what you do is take a good history, make your best medical opinion, make a recommendation with RFA treatment if you do think it is medically indicated, with a 51% medical certainty that it’s related to the index body part of the accepted claim. Go ahead and send it off. Again if it is denied they can exercise their right to a qualified medical exam if they’d like, talk to their attorney or representative, or they can always choose to treat it in their health plan as well.
Alright, I hope that’s been useful, keep the good questions coming in. Again I’m Dr. John Alchemy, founder of RateFast. To learn more go to rate-fast.com. Click on our blog tab and send any questions you have at firstname.lastname@example.org. Thanks so much.