By: Mark A. Doyne, MD, Medical Director, Medical Consultants Network (MCN)
First, a disclaimer before risking making a total fool of myself. My only in-house claims management experience was the five years I spent with a large reinsurance company as an orthopedic consultant helping them manage long-term disability claims….something I really enjoyed. As we all know, workers’ compensation (WC) is a different organism.
In my mind the key to managing a WC claim is really understanding the injury(s) or condition associated with the claim. Every injury or condition has what is called a natural history, which it is the time from onset to resolution. That timeline, and the anticipated response to treatment, can be affected by a whole host of elements from co-morbid conditions to non-clinical circumstances.
Maybe the best way for this lead lemming to proceed is by using a case example. Just for fun, let’s take an industrial back injury. Earlier I mentioned evidence based medicine (EBM). Official Disabilities Guidelines (ODG), published by the Work Loss Data Institute, is the best WC EBM resource I’m aware of. As you know, it has been adopted by many state WC systems. Because it was adopted by the Texas Department of Insurance – Division of Worker’s Compensation in 2007, I have become very familiar with using and citing EBM.
A good way to think about low back conditions or injuries is divide them into two buckets, as ODG does: low back problems (LBP) without radiculopathy (90% of cases) and low back problems with radiculopathy (10% of cases). Believe it or not, LBP without radiculopathy is much more difficult to manage because only about 15% of the time do we know exactly where the pain is coming from. Sounds like blasphemy, but it’s true. It has lots of names such as lumbago, lumbar syndrome, lumbalgia and lumbar strain, and an ICD9 code must be assigned. I would place all WC low back injuries in at least category four – requiring vigilant claims management. I would move it to a higher category if any one of several clinical risk factors were at play: morbid obesity, age, a smoking status, or a history of prior back injuries and/or surgery. Non-clinical red flags that would move the claim to a higher risk category include things like patient non-compliance including gaps in treatment, frequent emergency room visits, polypharmacy (taking a number of drugs), polymedica (a term I made up meaning the claimant is seeing a number of providers), an unhappy work environment, and someone who simply doesn’t deal with life well. The more risk factors in play, the more likely I’d move the claim to category seven or eight.
My experience tells me that what happens in the first 6-8 weeks of a lumbar claim is critical. I’d prefer that a treating physician evaluate the claimant on a weekly basis early in the claims process than every four weeks. This is exactly what ODG recommends with the first visit at day one, and the second at day 3-10. Treatment recommendations at this time include referral to PT/OT if not yet returned to work, discontinuation of muscle relaxants, and consideration of screening for psychosocial issues (yes, this early). The third visit is recommended at day 10-17. By this time, 66-75% should be back to regular work. Physical therapy focus should be on active and not just passive treatment, and should be completed by four weeks. After that the claimant should continue with a self directed home exercise program. The emphasis should not be on symptom reduction, but improvement of function and return to work (RTW). As you can see, ODG recommends a very aggressive and proactive approach, something I strongly endorse.
Once initially stratified, each claim could be placed in one of the following sub-categories: A) Caution, B) Warning, C) Take Action, or D) Take Action and Refer to the Special Investigation Unit. In this case study, if the claimant had not RTW, was not responding to treatment, and/or demonstrated multiple risk factors and red flags, it should be placed in Category C – Take Action. That action step would be a peer review no later than 6-8 weeks post injury. Industrial back injuries, with all the attendant dynamics, can be very complex. A well done peer review early on can provide important direction and perspective for the claims manager. If the claimant is still not making functional improvement, the next action step would be an Independent Medical Evaluation by week 10-12. The evaluating IME/peer specialist can now, de facto, function as a virtual medical director in the claims process.
This, therefore, is claims triage, with corresponding management based on perceived risk. For higher risk claims, aggressive and proactive claims management is recommended. The application of EBM invokes the best science has to offer and can be thought of as a default clinical approach. Treatment guidelines are exactly that – guidelines, but there should be a well articulated reason for a clinician to deviate. Most claims will not require an external peer review or IME, but I feel they have their highest and best utility in the front end of the claims process….before we are chasing the problem. The outcome we are seeking – an excellent clinical result, more rapid RTW, and improved cost management, almost always go hand in hand.
About Dr. Mark A. Doyne
Dr. Doyne serves as Medical Director of Medical Consultants Network, Inc. He holds his M. D. from the University of Tennessee College of Medicine, having completed an Internship at the University of California, San Diego and his residency in orthopedic surgery at Vanderbilt University Medical Center. He is a Fellow of the American Academy of Orthopedic Surgeons, Fellow and past board member of the American Academy of Disability Evaluating Physicians, and Fellow and past president of the American College of Physician Executives. He is board certified in orthopedic surgery and is a member of the American Medical Association, Texas Medical Association, and the Texas Orthopedic Association.
Dr. Doyne currently serves the Texas Department of Insurance—Division of Workers’ Compensation as a Designated Doctor, member of its Medical Quality Review Panel, and has served as faculty for Designated Doctor and Physician Training Courses. He has also served as a Medical Expert for the Social Security Administration in the field of disability. He has held management and leadership positions in the health care industry including: Vice President, Medical Affairs Curative Health Services; Orthopedic Consultant, Swiss Re/Reassure America Life and Health Company; Medical Director of Conservative Care and Rehabilitation Services at the Texas Back Institute; and as Chief Medical Officer, St. Thomas Hospital, Nashville, Tennessee. He has extensive experience in the oversight of Independent Medical Evaluations (IMEs) and related services and has lectured extensively on disability and orthopedic topics to industry audiences.
MCN is a leading provider of independent medical evaluations, peer reviews, and cost management solutions. Through its national carve-out network of physician consultants, MCN serves workers’ compensation, auto, disability and liability insurers, self-insured employers, and the group health market. MCN operates twenty-one offices nationwide, performing over 80,000 ordered services annually. MCN was founded in 1985 and serves all fifty states and Canada.