Physicians’ Role in Workers’ Compensation

At the 2015 Harbor Health MPN Medical Director Meeting, Dr. Ted Blatt from Harbor Health discussed some of the best practices for physicians in the workers’ compensation system and how outcomes-based networks are changing workers’ compensation.

Some of his best practices recommendations included:

• Engage the patients in thinking about their recovery, not about disability.
• Focus on rehabilitation and not limitations.
• Look to establish a partnership with the claims administrator and the employer.
• Physicians need to accept accountability for the management and outcome of the case. They cannot wash their hands on the outcomes.
• Good communication must be maintained with all parties, including the injured workers, claims examiner and employers.
• Provide clear work status, respond to questions timely, request pre-authorization when appropriate.
• Explain that returning to work does not mean the claim is closed. Return to work is an essential component in the rehabilitation process.
• Put specific restrictions in writing and explain them thoroughly to the injured worker.
•  Workers’ compensation has specific regulatory requirements that must be met in the medical reports.  This includes addressing causation in the initial report and documenting physicial findings to justify work status. The reports must also be sent within the required time periods.
• Make sure your bills accurately reflect the services rendered and use appropriate diagnosis codes. If you are using an outside vendor for billing, monitor the quality of their efforts.
• Evaluation of clinical outcomes is based on objective measures. These must be clearly documented in the medical records.
• Make sure you clearly identify any co-morbid conditions that are impacting care and how these can be addressed.

There is an increasing focus on developing outcome-based networks for workers’ compensation. Some of the key objective measures of claim outcomes include:

• Claim duration.
• Incurred total expenses.
• TTD days.
• Litigation rate. If the litigation rate is high, you investigate whether the injured employee retained the attorney before seeing the physician or after. In other words, are attorneys referring a high volume of patients to a particular physician.
• Recidivism – the reopening rate of cases.

Outcome-based networks must be dynamic and adjusted constantly based on recent activity. It is also important that physicians see a minimum number of patients to ensure that the scoring of their services is statistically accurate and not skewed by one bad patient. With an outcomes-based network, physicians who produce better outcomes for injured workers are compensated at higher rates, usually with no discount below fee schedule and occasionally are paid higher than fee schedule. Outcome-based networks also reward higher-performing physicians with more patient referrals.