At the 2022 Washington Self-Insurers Association Annual Conference, Liz Fischer, Vice President, Senior Claims Consultant at Marsh discussed Evidence-Based Disability Guidelines and Best Practices.
What Are Disability Guidelines?
Evidence-based guidelines for medical management and disability duration include nationally-recognized treatments and return-to-work guidelines used to evaluate the necessity and/or effectiveness of medical care. While there are different evidence-based guideline tools available, all rely on extensive data collection and analysis to benchmark disability, treatment and claim costs outcomes. Some of the most frequently used guidelines include the Official Disability Guidelines (ODG), American College of Occupational and Environmental Medicine (ACOEM) and state-specific guidelines, like Washington state. Not all states require utilization of evidence-based guidelines for workers’ compensation.
Why Are Evidence-Based Guidelines Important?
These guidelines help review treatment requests and compare them against evidence-based standards. Treatment decisions are then guided by recommendations that are supported by the best available evidence. These guidelines are regularly reviewed and updated based on claims data analytics, which assist in facilitating the delivery of the most appropriate, quality care to injured workers. They also assure that treatments are progressing and are effective in achieving medical stability.
Who Utilizes Evidence-Based Guidelines?
Users of evidence-based guidelines include:
- Medical providers
- Managed care organizations
- State agencies
- Nurse case managers
- Insurance carriers
- Claims administrators
- Employers/risk managers
Practical Applications for Claims Examiners
Is the attending physician’s recommended or requested treatment reasonable based on the diagnosis? Disability guideline tools provide recommended, reasonable treatments that can be expected based on diagnosis code. Claims examiners should ask:
- Is the diagnosis accurate?
- Is it time to discuss additional diagnostics?
- Is it time to evaluate for a second opinion?
- Would a peer review be appropriate?
- Could a nurse cases manager benefit?
Is the time loss authorized reasonable based on the worker’s diagnosis, job category and comorbidities? Disability guidelines can provide data-based targets for light-duty and full-duty return to work. Claims examiners should:
- Ask the provider why restrictions are not progressing.
- Identify if there are other factors contributing to excessive disability such as the lack of modified duty.
- Develop a strategic plan of action if the benchmark is anticipated to be exceeded.
- Not lose sight of the target date for full-duty, and ensure the attending physician doesn’t either. Often, once the modified duty release is obtained, there is a tendency to lose focus on progressing the case forward.
What can I expect this claim to cost? Examiners should leverage best practices for claim cost estimates to validate reserves, including:
- Evaluating claim costs versus best in class, claim typical and claim maximums.
- Identifying if reserves need to be re-evaluated for the most probable outcome.
Benchmarking Claims and Programs
Evidence-based data collected over a broad claim sample provides a wealth of data that can be used to benchmark individual claims and programs against industry best practice claim outcomes and industry claim typical claim outcomes.
Evaluating individual claim and program financial outcomes against industry best practice outcomes can help identify claims for priority reviews or round-tabling, and also target potential return-to-work program enhancements.
Establishing measurable program targets can drive continuous improvements in key performance indicators (KPIs) and performance goals.