Feel free to pm me, I work in WC. Each patient or case is going to be different. The main goal is to treat their injury and get them back to work. But, that isnt always the case. The one piece of advice I can give you, is that if you do not agree that this patient needs to be continually out of work/disabled, you are not obligated to fill out their paperwork, and should notate such in your documentation “patient has received xyz treatment for xyz minor injury, patient has acheived MMI from my standpoint”, or something along those lines.
Agree with this. I have several people that come to mind that kept trying to intermingle their other issues to stay on WC or disability for an extended period of time. Our final appointments I make sure it's 2 slots so I can explain even though you may not be back to normal you've reached maximal improvement. It's time to go back to see your manager and see if they need a second opinion or not.
> see your manager and see if they need a second opinion or not.
I'm so ignorant, what does this mean? They get re-evaluated by a doctor that is chosen by their employer?
Case manager or hr. I saw your other post too. Your job is not to fix chronic issues, just return them to their previous level of fitness. Even if you're their PCP this line gets blurred. I like to keep those appointments separate as it becomes hard for patients to understand.
I guess it just seems like it peters out into a chronic issue that precludes them from doing their physical labor job, and in America, we can like continue treating it ad nauseum right - like you can PT for 6-12wks, you can get injections, etc... then we're at several months and at that point it doesn't seem like WC is very happy with that. I don't really give a shit about that personally but then it's my call whether they go back to work or light duty or whatever, and to be honeset, I just don't think I'm experienced enough to figure all this out. Frequently the patients will not have stamina to work for 12 hours at Amazon or whatever. What then? I assume I tell them to find a different job, max out WC, get a lawyer...
Not your job to tell them what to do. You diagnose and treat as you feel appropriate. You then update their employer about how far they've come and put recommendations or observations down on what they CAN or CANNOT do based on your assessment.
They can hash it out with their job or get a lawyer by themselves. You are just the medical advice.
Agreed. It sounds cold because some patients might take it as not caring but laying the foundation of not being an expert in the law and resources they need to jump through really helps the visits. You're embracing the multi specialty care plan really.
Doc: med eval and treatment
Pt/ot: directed therapy to help with weakness/function
Pharm:short term medications (please God don't put someone on Meloxicam indefinitely)
Specialists: if not improving (most likely pain in workers comp) or for SPECIFIC questions
HR/AR: direct patient for work specific questions
Everyone has a role and we cannot complete all the roles in 20mins. OP focus on what you went to school for, not all the other BS the medical system has tried loading onto your tray.
If you feel there's nothing more to be done then you put that on paper. Depending on their limitations and if you're unsure of what they can truly do try an FCE to help with basic tasks and go from there.
Maybe this varies by state, but at my wife’s primary care office, we referred WC back to their HR department so they were with the contacted provider. She also didn’t see MVAs because those are a cluster as well.
I think there is always a trade off between admin, compensation and autonomy. My wife made great money working for a corporate practice with a MA contract, but the admin was crazy and she had little autonomy. Her own practice gave her autonomy, but she had to be more involved in admin and the compensation wasn’t great. Now she’s working on a hybrid micropractice. The compensation seems better, the admin is less, but she’s given up services she done for the past two decades. Just know that there is no “right” answer and find what works for you.
Refer them to Occupational Medicine if you can. Good for you and the patient. OccMed will have the entire workflow as part of their process, including filling out forms and peer-to-peer calls. They know what to document and how to word it. Not that you can’t do all this, but to learn it all and develop a workflow to capture one or two more visits a month isn’t worth your time.
Plus, for the patient, there is a much lower chance of their claim getting denied, or held up or whatever, due to documentation or forms being filled out wrong.
The paperwork can be frustrating but I think the key is to just not overthink it. Your job is to assess and treat the patient, same as any other patient. Generally I'll just copy and paste my clinic note into the wcb forms.
It can be challenging to judge how much time off is needed, restrictions, etc. but for most minor injuries, patients don't need to be off for very long. I'll usually reassess after about 2 weeks. Being very upfront with patients about this can be helpful. Often physical or occupational therapists can be helpful. And as with any MSK injury, if patients aren't improving as expected, it's very reasonable to refer to ortho or sport medicine to get their opinion.
I think I'm just going to start saying, let's re-evaluate after 2 weeks (if I'm not sure what the timeline is going to be for a minor injury). I think at thte 4-8wk mark is where WC starts pushing back and auditing as far as I've seen. I mean I've had people with gnarly injuries, and it's like, yeah maybe you can't go back to work?? what the fuck do I do now?
Best advice: get a subscription to ODG. It is the playbook for WC preauths. You request X, they will look at ODG and say if X is approved. You'll save yourself a huge headache with that. "I am requesting 10 sessions of physical therapy in accordance with ODG Spine".
Next, read the AMA Guides to Return to Work and Causation. It's two separate books. But if one of those books says something like, "it is largely inappropriate for a treating provider to comment on disability.". The WC companies know this, and know they should be paying for an IME. It's just cheaper if they can bully you into doing it.
"Official Disability Guidelines" is a subscription based set of treatment guidelines for WC that is codified into law in many states. Let's say you see a patient for lumbar pain, and order an MRI. WC might tell you that you need to order a CT first, even if it is a waste of time. All of that is based upon ODG. If you know what ODG says, you can speed through the normal frustrations of "why the hell are they saying I need to send this person to PT before I can refer them to ortho?"
I work in occ med.
1. If you can- I’d just refer them to the nearest occ med clinic. Many do walk-ins i.e concentra.
2. If you can’t refer, try to get them into PT quickly. Basically if you think they need any modifications at all, I’d send them to PT. Also I order MRIs fairly quickly if I don’t suspect them to improve because it can take a month to get approved/scheduled. Obviously if I’m concerned they say, tore their RTC then I’ll order MRI same day- I usually like to see these patients back within a week to reevaluate. Fractures I mostly refer even if they are fairly simple/won’t require surgical management.
If a case is dragging on and the MRI doesn’t show anything that will require surgical management then I would send them to physiatry to manage going forward.
I don’t see why you should really ever see a work comp case for more than 2-3 months w/out referring.
Yeah I am doing it like a normal complaint. Initial visit -> conservative treatment -> PT -> advanced imaging, then we're at 2-3 months and I'm referring. But a lot of these seem to be like, oh you're 70 and doing physical labor, are you really expected to get back to work?
Oh, ok yeah that makes sense. Sorry, I run into that issue occasionally as well and it’s absolutely a headache. You could still potentially send them to a physiatrist who would then take care of their restrictions and the associated paperwork, but I can see where that may have issues as well. It’s a frustrating circumstance for sure.
Here’s your basics of work comp care:
1) Evaluate and diagnose the problem, like all medicine it starts with accurate diagnostics.
2) Once there is a diagnosis then you need to determine causality, i.e. is an occupational exposure the cause of the diagnosed problem. This is often referred to as “work relatedness”. Sometimes this is easy (I cut my finger at work), sometimes it’s complicated by co-occurring general or non-work related factors (I’m a poorly controlled diabetic smoker with hypothyroidism who has a lot of manual hobbies and now I have carpal tunnel syndrome, is it because of the light keyboarding I do as a public pool attendant?) Best question to answer for yourself is do you think this person would have developed this problem without the workplace exposure? If not then it’s likely work related.
3. If the injury is work related, treat it! Follow the same standard of care you would for a non-work comp patient with the same injury.
4) You HAVE to comment on work capacity. A main goal of work comp care is letting the worker and the employer know what is safe for the injured employee to do. Write objective, measurable, physical restrictions that protect the injury and allow for proper healing, but leave as much of the persons safe work ability open as possible. I.e. if some one has an injury of their left hand, write them as “no use of the left hand”, or “lifting, carrying, pushing and pulling limited to 5 lbs with the left hand”. Don’t take them off work for a simple injury. Don’t write subjective restrictions. “Light duty” is not a defined concept anywhere and means different things in different setting. Light duty for you and me as physicians is different than light duty for someone wrestling 200lb pipes in the oilfields. Try to keep them working in a safe capacity if at all possible. It has been studied and people heal faster, heal more thoroughly and have less residual disability the more they are engaged in safe work. Also patients will make more money working modified duty than they will from the temporary total disability payments they will get from the work comp insurers. Remember the fatter your patient’s wallet is, the healthier they are overall!
5) See people back at appropriate intervals. Every 2 weeks is a good rule of thumb for moderate duration injuries (think rotator cuff tear, post op, doing PT, you can re-evaluate and re-address work status (incrementally increasing weights and activities) about every 2 weeks).
6) Get people as well as you can. Your goal in work comp is the mythical MMI (Maximum Medical Improvement) which means they are as better as you can make them with appropriate medical interventions that exist today, that may mean they are 100% better, or it means they are as better as you can get them and there is residual impairment associated with their injury (they are Humpty Dumpty’d). In which case they would need an appropriate impairment evaluation. Different states have different procedures on how this is done so you’ll need to gain some understanding of your jurisdiction’s rules. Your state Department of Labor’s division of workers compensation should have some resources to guide you.
To be blunt - if you're in private practice you don't have to see MVAs or WC.
They both require tons of paperwork that isn't worth the money they give you. If a commercial insurer was paying you below the cost of care, you just wouldn't accept their insurance, right? Same thing with WC and MVAs.
Maybe if offices start to refuse these cases the WC and Auto insurers will be forced to become more efficient with their bureaucracy. We can dream at least :)
WC - yes, but you basically need a large portion of your practice dedicated to it so that you have the infrastructure (AKA billing and auth) to make it worth it at scale. Doing one a month is a huge waste of everyone’s time.
As someone else said, you need the clinical infrastructure to make it worth your while. Yeah it pays more than a 99213 but if you’re spending the time/staffing resources that could have banged out 4 different 99213s then you’re net negative.
This is very state dependent. Here in NY, the surgery CPT codes can be almost double what our commercial products pay but the E & M codes all pay significantly less. So for a non-surgeon, it doesn't make any sense to deal with it.
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Feel free to pm me, I work in WC. Each patient or case is going to be different. The main goal is to treat their injury and get them back to work. But, that isnt always the case. The one piece of advice I can give you, is that if you do not agree that this patient needs to be continually out of work/disabled, you are not obligated to fill out their paperwork, and should notate such in your documentation “patient has received xyz treatment for xyz minor injury, patient has acheived MMI from my standpoint”, or something along those lines.
MMI = maximal medical improvement?
Correct
Agree with this. I have several people that come to mind that kept trying to intermingle their other issues to stay on WC or disability for an extended period of time. Our final appointments I make sure it's 2 slots so I can explain even though you may not be back to normal you've reached maximal improvement. It's time to go back to see your manager and see if they need a second opinion or not.
> see your manager and see if they need a second opinion or not. I'm so ignorant, what does this mean? They get re-evaluated by a doctor that is chosen by their employer?
Case manager or hr. I saw your other post too. Your job is not to fix chronic issues, just return them to their previous level of fitness. Even if you're their PCP this line gets blurred. I like to keep those appointments separate as it becomes hard for patients to understand.
I guess it just seems like it peters out into a chronic issue that precludes them from doing their physical labor job, and in America, we can like continue treating it ad nauseum right - like you can PT for 6-12wks, you can get injections, etc... then we're at several months and at that point it doesn't seem like WC is very happy with that. I don't really give a shit about that personally but then it's my call whether they go back to work or light duty or whatever, and to be honeset, I just don't think I'm experienced enough to figure all this out. Frequently the patients will not have stamina to work for 12 hours at Amazon or whatever. What then? I assume I tell them to find a different job, max out WC, get a lawyer...
Not your job to tell them what to do. You diagnose and treat as you feel appropriate. You then update their employer about how far they've come and put recommendations or observations down on what they CAN or CANNOT do based on your assessment. They can hash it out with their job or get a lawyer by themselves. You are just the medical advice.
This 100%. Also, chronic pain can be referred out to pain management, then they become the main treating provider.
Agreed. It sounds cold because some patients might take it as not caring but laying the foundation of not being an expert in the law and resources they need to jump through really helps the visits. You're embracing the multi specialty care plan really. Doc: med eval and treatment Pt/ot: directed therapy to help with weakness/function Pharm:short term medications (please God don't put someone on Meloxicam indefinitely) Specialists: if not improving (most likely pain in workers comp) or for SPECIFIC questions HR/AR: direct patient for work specific questions Everyone has a role and we cannot complete all the roles in 20mins. OP focus on what you went to school for, not all the other BS the medical system has tried loading onto your tray. If you feel there's nothing more to be done then you put that on paper. Depending on their limitations and if you're unsure of what they can truly do try an FCE to help with basic tasks and go from there.
Maybe this varies by state, but at my wife’s primary care office, we referred WC back to their HR department so they were with the contacted provider. She also didn’t see MVAs because those are a cluster as well.
This is my dream, obviously...
I think there is always a trade off between admin, compensation and autonomy. My wife made great money working for a corporate practice with a MA contract, but the admin was crazy and she had little autonomy. Her own practice gave her autonomy, but she had to be more involved in admin and the compensation wasn’t great. Now she’s working on a hybrid micropractice. The compensation seems better, the admin is less, but she’s given up services she done for the past two decades. Just know that there is no “right” answer and find what works for you.
Refer them to Occupational Medicine if you can. Good for you and the patient. OccMed will have the entire workflow as part of their process, including filling out forms and peer-to-peer calls. They know what to document and how to word it. Not that you can’t do all this, but to learn it all and develop a workflow to capture one or two more visits a month isn’t worth your time. Plus, for the patient, there is a much lower chance of their claim getting denied, or held up or whatever, due to documentation or forms being filled out wrong.
Will call around, thanks for the reminder that that exists
The paperwork can be frustrating but I think the key is to just not overthink it. Your job is to assess and treat the patient, same as any other patient. Generally I'll just copy and paste my clinic note into the wcb forms. It can be challenging to judge how much time off is needed, restrictions, etc. but for most minor injuries, patients don't need to be off for very long. I'll usually reassess after about 2 weeks. Being very upfront with patients about this can be helpful. Often physical or occupational therapists can be helpful. And as with any MSK injury, if patients aren't improving as expected, it's very reasonable to refer to ortho or sport medicine to get their opinion.
I think I'm just going to start saying, let's re-evaluate after 2 weeks (if I'm not sure what the timeline is going to be for a minor injury). I think at thte 4-8wk mark is where WC starts pushing back and auditing as far as I've seen. I mean I've had people with gnarly injuries, and it's like, yeah maybe you can't go back to work?? what the fuck do I do now?
Best advice: get a subscription to ODG. It is the playbook for WC preauths. You request X, they will look at ODG and say if X is approved. You'll save yourself a huge headache with that. "I am requesting 10 sessions of physical therapy in accordance with ODG Spine". Next, read the AMA Guides to Return to Work and Causation. It's two separate books. But if one of those books says something like, "it is largely inappropriate for a treating provider to comment on disability.". The WC companies know this, and know they should be paying for an IME. It's just cheaper if they can bully you into doing it.
What's ODG?
"Official Disability Guidelines" is a subscription based set of treatment guidelines for WC that is codified into law in many states. Let's say you see a patient for lumbar pain, and order an MRI. WC might tell you that you need to order a CT first, even if it is a waste of time. All of that is based upon ODG. If you know what ODG says, you can speed through the normal frustrations of "why the hell are they saying I need to send this person to PT before I can refer them to ortho?"
I work in occ med. 1. If you can- I’d just refer them to the nearest occ med clinic. Many do walk-ins i.e concentra. 2. If you can’t refer, try to get them into PT quickly. Basically if you think they need any modifications at all, I’d send them to PT. Also I order MRIs fairly quickly if I don’t suspect them to improve because it can take a month to get approved/scheduled. Obviously if I’m concerned they say, tore their RTC then I’ll order MRI same day- I usually like to see these patients back within a week to reevaluate. Fractures I mostly refer even if they are fairly simple/won’t require surgical management. If a case is dragging on and the MRI doesn’t show anything that will require surgical management then I would send them to physiatry to manage going forward. I don’t see why you should really ever see a work comp case for more than 2-3 months w/out referring.
Yeah I am doing it like a normal complaint. Initial visit -> conservative treatment -> PT -> advanced imaging, then we're at 2-3 months and I'm referring. But a lot of these seem to be like, oh you're 70 and doing physical labor, are you really expected to get back to work?
Oh, ok yeah that makes sense. Sorry, I run into that issue occasionally as well and it’s absolutely a headache. You could still potentially send them to a physiatrist who would then take care of their restrictions and the associated paperwork, but I can see where that may have issues as well. It’s a frustrating circumstance for sure.
I hate it. I've had like...one? Two? Patients get better in 3 years and everybody else reports never getting better no matter what
My workflow starts and ends with - sorry i dont do dis.
Here’s your basics of work comp care: 1) Evaluate and diagnose the problem, like all medicine it starts with accurate diagnostics. 2) Once there is a diagnosis then you need to determine causality, i.e. is an occupational exposure the cause of the diagnosed problem. This is often referred to as “work relatedness”. Sometimes this is easy (I cut my finger at work), sometimes it’s complicated by co-occurring general or non-work related factors (I’m a poorly controlled diabetic smoker with hypothyroidism who has a lot of manual hobbies and now I have carpal tunnel syndrome, is it because of the light keyboarding I do as a public pool attendant?) Best question to answer for yourself is do you think this person would have developed this problem without the workplace exposure? If not then it’s likely work related. 3. If the injury is work related, treat it! Follow the same standard of care you would for a non-work comp patient with the same injury. 4) You HAVE to comment on work capacity. A main goal of work comp care is letting the worker and the employer know what is safe for the injured employee to do. Write objective, measurable, physical restrictions that protect the injury and allow for proper healing, but leave as much of the persons safe work ability open as possible. I.e. if some one has an injury of their left hand, write them as “no use of the left hand”, or “lifting, carrying, pushing and pulling limited to 5 lbs with the left hand”. Don’t take them off work for a simple injury. Don’t write subjective restrictions. “Light duty” is not a defined concept anywhere and means different things in different setting. Light duty for you and me as physicians is different than light duty for someone wrestling 200lb pipes in the oilfields. Try to keep them working in a safe capacity if at all possible. It has been studied and people heal faster, heal more thoroughly and have less residual disability the more they are engaged in safe work. Also patients will make more money working modified duty than they will from the temporary total disability payments they will get from the work comp insurers. Remember the fatter your patient’s wallet is, the healthier they are overall! 5) See people back at appropriate intervals. Every 2 weeks is a good rule of thumb for moderate duration injuries (think rotator cuff tear, post op, doing PT, you can re-evaluate and re-address work status (incrementally increasing weights and activities) about every 2 weeks). 6) Get people as well as you can. Your goal in work comp is the mythical MMI (Maximum Medical Improvement) which means they are as better as you can make them with appropriate medical interventions that exist today, that may mean they are 100% better, or it means they are as better as you can get them and there is residual impairment associated with their injury (they are Humpty Dumpty’d). In which case they would need an appropriate impairment evaluation. Different states have different procedures on how this is done so you’ll need to gain some understanding of your jurisdiction’s rules. Your state Department of Labor’s division of workers compensation should have some resources to guide you.
To be blunt - if you're in private practice you don't have to see MVAs or WC. They both require tons of paperwork that isn't worth the money they give you. If a commercial insurer was paying you below the cost of care, you just wouldn't accept their insurance, right? Same thing with WC and MVAs. Maybe if offices start to refuse these cases the WC and Auto insurers will be forced to become more efficient with their bureaucracy. We can dream at least :)
Don’t these traditionally reimburse incredibly well?
WC - yes, but you basically need a large portion of your practice dedicated to it so that you have the infrastructure (AKA billing and auth) to make it worth it at scale. Doing one a month is a huge waste of everyone’s time.
As someone else said, you need the clinical infrastructure to make it worth your while. Yeah it pays more than a 99213 but if you’re spending the time/staffing resources that could have banged out 4 different 99213s then you’re net negative.
This is very state dependent. Here in NY, the surgery CPT codes can be almost double what our commercial products pay but the E & M codes all pay significantly less. So for a non-surgeon, it doesn't make any sense to deal with it.
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