Sarasota, FL (WorkersCompensation.com) – Workers’ compensation stakeholders cite delayed medical treatment as one of their biggest complaints about the workers’ compensation system. That was one of the three top issues named by attendees during a nationwide Industry Summit in 2016 and it’s as much or more of a problem today.
Experts discussing the issue agree there is no single cause — or solution — to the problem. But they also concur that all parties in the workers’ compensation system have much to learn from one another and by sharing different perspectives and insights, injured workers can get quicker access to appropriate medical attention.
The Communication Problem
Waiting for days on end to see a medical provider, undergo diagnostic testing, re-see the physician and finally get the appropriate treatment does not benefit anyone. “We always look at the injured worker as really being injured by delays but employers are hurt too,” said Rosemary Eure, a Sarasota, Fla-based plaintiff’s attorney. “The employer has to find a way to work around the person’s position because they don’t want to replace the person. So everybody’s hurting from this.”
Eure spoke during Delays in Treatment For Compensable Workers’ Comp Claims, the latest WorkersCompensastion.com ‘Hot Seat’ webinar. Joining her was Robert Swisher, commissioner for the Kentucky Department of Workers Claims, along with hosts David Langham, Deputy Chief Judge of the Florida Offices of Judge of Compensation Claims, and Robert Wilson, president & CEO of WorkersCompensation.com,
All say communication breakdown is a major contributor to preventing expedited medical treatment.
“The problem we see is a lack of ability of adjusters and third-party administrators to communicate with medical providers. That’s the primary breakdown,” Swisher said. “There is not a good method to get people to talk to each other – treating physician to the utilization review physician, or to the adjuster. When they can talk to somebody on the phone, they more often than not get something get worked out. But a lack of communication with medical providers causes delays.”
Determining causation is one of the issues driving the communication problem. The aging workforce has led to more instances of employees with degenerative conditions that may appear to be caused by workplace accidents. Arguments over causation and reasonable necessity, and the time it takes to investigate the compensability of a claim cause delays in treatment.
“One issue we’ve heard about is delays from the review process,” Wilson said. “Treatment is ordered [by the treating physician] and put to review.”
The panelists noted that even in states where employers can direct medical care to their own network of physicians, the recommended treatment is often questioned and reviewed.
“There was a famous California story years ago where a case went to utilization review over a $10 bottle of Motrin,” Wilson added. “It doesn’t make a lot of sense. You wonder, when you have physicians approved but their recommendations get denied, what to do.”
Kentucky has addressed the issue by allowing carriers to waive UR in some cases, where they trust the physician. “It’s a valuable tool,” Swisher said. “Carriers pushed for that.”
That state is also trying to deal with the persistent problem of treating physicians not being able to communicate with other physicians by allowing the treating physician to set a date and time window for a call.
Too Many Cooks
The caseloads of claims adjusters was cited as a big reason they often fail to adequately communicate with medical providers and others involved in a claim. Some handle upwards of 300 claims or more at any given time. That just doesn’t allow them time to have a phone call with anyone.
“Thirty years ago adjusters met with people in their homes,” Wilson said. “Now they are in cubicles in centralized states and a lot of their functions are being outsourced.
“As you dilute responsibility for a file, you don’t have the continuity and somebody who’s on top of it; for scheduling an X-ray or making appointments,” Eure added. “Carriers abdicate their responsibilities to other companies, [then say], ‘the nurse case manager didn’t get this set,’ or ‘the MRI … doesn’t have the right documentation, the nurse case manager doesn’t have it,’ and they call an attorney. We’ve got to take it down to a more grassroots basis to expedite medical care.”
There is no single ‘fix’ for the problem of delayed medical treatment, the panelists agreed. But there are small steps that can help, such as looking beyond the fragmentation in the system.
“We’ve become so line driven-in-the-sand we’re not thinking about the big picture anymore,” Eure said. “It’s not about, ‘do I authorize this or not.’ We need consensus that everybody will benefit if this system is efficient and expedient.”
Wilson noted, for example, that the time spent reviewing recommended treatment and investigating claims not only delays medical treatment, it also adds costs. He cited a study from Lockton last year that said 67 percent of claims that were initially denied ended up being accepted and the overall cost for those claims was 55 percent higher than claims that had not been denied.
“I’d love a study where they authorize all claims and see the cost differential,” Eure said. “They may pay for things not covered in workers’ compensation … but I’m certain the numbers in cases where they pay would be far under the cost on claims that are litigated.”
Spending more money on treating physicians on the front end can also help expedite medical care — and reduce costs. It gets them more engaged and available in the workers’ compensation process.
“We make sure we fairly compensate physicians for the services we ask them to provide,” Swisher said. “Our comp rates are significantly higher than Medicare, and even private health insurance. We have a financial incentive for physicians to want to participate — even if it’s more onerous and burdensome.”
Getting physicians to reciprocate communications with other stakeholders can go a long way to getting appropriate treatment to injured workers as soon as possible. Paying physicians more, and implementing regulations to speed up claims processing help, but more is needed.
“We can only regulate, and legislate so far,” Swisher said. “People will either comply and talk [to one another] or they won’t. Carriers will reduce caseloads or not … It’s more of a cultural, systemic, endemic problem with providers to compel that communication or make that the first option and recognize the first goal is worker recovery.”
The panelists suggested a mini industry summit focused specifically on delayed medical treatment. “Find a company that is doing it right — limiting caseloads, or developing a culture of collaboration and engaging them to suggest best practices to see how somebody does it right more often than not. Look at that model to at least start there,” Swisher said. “
Part of the problem with getting quick access to medical care for injured workers is an overall problem with the healthcare industry in general. Patients often have long waiting times to see physicians, especially specialists.
“I think we’ll see more of that,” Eure said. “Physicians are tired. They’ve got adjusters, nurse case managers calling them. We’ve made it a very complicated, administrative-heavy job. A lot of physicians don’t want to deal with comp because of that. We’ve got to solve that problem to get the good physicians who don’t feel they’ve jumped in this rabbit hole.”
Talking through the issues is key, the speakers agreed. For example, at least two of the speakers suggested continuing the conversation at the upcoming Southern Association of Workers’ Compensation Administrator’ annual meeting July 29 – Aug 2.
“This problem is multi-faceted. We can’t wave a magic wand,” Swisher said. “But in my heart of heart I believe it comes down to talk … Hurdles disappear when people talk to each other.”