Mar 29, 2022 | Insights
It has become well understood that a broad range of biological, psychological and social factors impact an injured worker’s recovery. Recent shifts in the industry – especially in light of the pandemic – have heightened focus on how we can better identify and address psychosocial issues in particular.
Unlike physical ailments like bruises, psychosocial setbacks are usually invisible, but their impact on an injured worker’s recovery as well as healthcare utilization costs are prominent. That’s why claims organizations are working to adapt to help practitioners identify these factors – the earlier the better. Unless someone asks questions and makes observation as a part of the intake process of a claim, these factors will continue to go unnoticed and workers’ time to recovery will continue to suffer.
In this white paper – in partnership with Risk & Insurance – Brian Peers, VP of Clinical Services & Provider Management, MedRisk, and Jean Feldman, RN, BSN, Director of Managed Care, Workers’ Compensation Claims for Sentry Insurance, discuss the critical role physical therapists play in not only treating physical injuries but also identifying biopsychosocial factors that could impact recovery.
PTs are well-equipped to make a difference in this area for two key reasons:
- Physicians do not spend enough time with injured workers to develop a close enough connection with them to identify and address psychosocial issues.
- PTs do – they have the opportunity to build trust and engage in meaningful conversations about how the injured worker is doing, not just as a patient, but as a person, during appointments.
“If someone’s feeling like, ‘I don’t want to move because I think it’s going to hurt,’ who better to help them through that than someone who’s an expert in recovery?” explained Peers. “So not a psychologist, not an orthopedic surgeon, but someone whose specialty is recovery.”
Peers and Feldman also provide insights on bridging the mind-body connection and the importance of compassion for an injured worker’s circumstances – and, simply put, doing the right thing.
As Feldman said: “If we do the right things, it will help that individual get back to work, recover faster, recover safely. It’ll help our employers decrease their costs. We’re all in this together.”
To read the full white paper, click here
Mar 29, 2022 | Legislative Update
Here is a summary of legislative and regulatory developments and challenges for the first quarter of 2022 and their practical implications:
Texas WC Network Regulation: In January, the Texas Division of Workers’ Compensation proposed revisions to existing WCN regulations, explaining that changes were needed to clarify the provisions and to implement legislative amendments to the Insurance Code. These proposed changes are extensive and bear attention of WC system participants.
Among the prominent proposed provisions are the following:
- Location and service type identification requirements for WCN participating providers have been made much more specific.
- Networks must give prior notice to TDI of any proposed change of ownership.
- Networks must give prior notice to TDI regarding modifications to network configurations involving telehealth services.
- Network contracts and subcontracts with providers must include a statement that a carrier contesting compensability may not deny payment prior to the issuance of a notice that the injury was not compensable.
- Carriers and employers must have a documented procedure for determining which is responsible for obtaining signed employee acknowledgements of the employer’s network participation as well as signed copies of the employee acknowledgements.
- By September 23, 2022, networks must have a documented credentialing process that meets NCQA or URAC standards.
- Networks may only use Texas-licensed doctors to perform in-network utilization reviews.
Implications: Payers, certified WCNs and specialty networks should review their policies and procedures in preparation for TDI’s enforcement efforts based on these proposed regulations.
California MPN Legislation:
In January, a revised AB 399 was unanimously passed by the Assembly and sent to the Senate. In its current state, the measure requires payers to provide employees, within five business days of their request, with the MPN’s name and identification number. The payer may satisfy this requirement by providing the information in writing or an explanation of benefits or by posting the information on a website.
Implications: Through a concerted effort, the revised version of AB 399 now ensures employees are given timely and useful information. Without any discernable opposition, the measure is very likely to be enacted and signed into law.
Mar 29, 2022 | Legislative Update
Here is a summary of legislative and regulatory developments and challenges for the first quarter of 2022 and their practical implications:
Texas WC Network Regulation: In January, the Texas Division of Workers’ Compensation proposed revisions to existing WCN regulations, explaining that changes were needed to clarify the provisions and to implement legislative amendments to the Insurance Code. These proposed changes are extensive and bear attention of WC system participants.
Among the prominent proposed provisions are the following:
- Location and service type identification requirements for WCN participating providers have been made much more specific.
- Networks must give prior notice to TDI of any proposed change of ownership.
- Networks must give prior notice to TDI regarding modifications to network configurations involving telehealth services.
- Network contracts and subcontracts with providers must include a statement that a carrier contesting compensability may not deny payment prior to the issuance of a notice that the injury was not compensable.
- Carriers and employers must have a documented procedure for determining which is responsible for obtaining signed employee acknowledgements of the employer’s network participation as well as signed copies of the employee acknowledgements.
- By September 23, 2022, networks must have a documented credentialing process that meets NCQA or URAC standards.
- Networks may only use Texas-licensed doctors to perform in-network utilization reviews.
Implications: Payers, certified WCNs and specialty networks should review their policies and procedures in preparation for TDI’s enforcement efforts based on these proposed regulations.
California MPN Legislation: A once-onerous bill has been brought back to life, but in a much-diminished form. As originally proposed Assembly Bill 399 would have mandated that MPNs pay participating providers at California’s Official Medical Fee Schedule and would have prohibited negotiated rates below the regulatory fee. The measure would also would have restricted MPNs’ ability to review provider bills for mistakes, fraud and abuse. Through intense opposition by WC payers and employers, the bill was held in the Assembly Insurance Committee without being voted on and, as a consequence, is ineligible for further consideration until the next legislative session.
In January, a revised AB 399 was unanimously passed by the Assembly and sent to the Senate. In its current state, the measure merely requires payers to provide employees, within five business days of their request, with the MPN’s name and identification number. The payer may satisfy this requirement by providing the information in writing or an explanation of benefits or by posting the information on a website.
Implications: Through a concerted lobbying effort, the earlier version of AB 399 was converted into a reasonable provision giving employees timely and useful information. Without any discernable opposition, the measure is very likely to be enacted and signed into law.
Mar 10, 2022 | Insights
Chronic pain is complex, costly and widespread – especially for injured workers. In fact, workers’ compensation patients in the U.S. generally experience poorer outcomes compared to those not covered by workers’ comp.
Not to mention the economic impact of chronic pain: direct and indirect costs total about $650 billion. This has prompted clinical practice guidelines and the U.S. Federal Pain Research Strategy to prioritize research on reducing the public health impact of low back pain (LBP) – and physical medicine researchers have begun to analyze the predictors of chronic pain in response. The goal: prevent acute pain from becoming chronic.
In this WorkersCompensation.com article, MedRisk’s VP of Clinical Services & Provider Management Brian Peers discusses key takeaways from a mapping review of 20 studies that have investigated the acute-to-chronic LBP transition. From this review, the authors described a standardized predictive framework to improve prediction of chronic LBP.
The structure used five predictor domains, adding elements in some areas that emerging evidence has revealed impactful on chronic pain:
- Demographics: income, marital status, household size and living arrangements
- Pain
- Health status
- Psychosocial: negative mood and copying styles, and positive coping skills like self-efficacy
- Individual context: perceptions of receiving care, expectations and treatment preferences
“There’s a lot to unpack in this research and much work left to be done. However, this analysis and previous studies have told us a lot,” said Peers. “Early and accurate prediction of the development of chronic pain can guide claims representatives in securing the appropriate physical and behavioral healthcare services in the beginning of the claim.”
Among other key takeaways, Peers pinpointed the importance of patient education in accelerating recovery, addressing psychosocial factors and treating chronic LBP. This is pertinent as psychosocial factors can delay recovery and return to work – and potentially lead to the development of chronic pain. Ultimately, this research supports a rising theme from the past couple of years: early physical therapy (including initial consult and education) produces better outcomes for all patients – but especially workers’ compensation patients.
To read more about the framework for predicting chronic pain, click here – or review the full study here.
Jan 5, 2022 | Legislative Update
Here is a summary of legislative and regulatory developments and challenges in the fourth quarter of 2021 and their practical implications:
New York: Amendments to the Workers’ Compensation Board Medical Billing Disputes regulation became effective on November 1. These amendments require all objections to medical bills be filed with the Board simultaneously rather than sequentially. As amended, 12 NYCRR 325-1.25 now provides that the Board will deny any objections to payment of a health care provider’s bills that are not raised simultaneously in Form C-8.1, including objections based on legal, valuation or Medical Treatment Guideline grounds. The regulation is further amended to require payers, if the objection relates to the provider’s failure to obtain prior authorization, to provide with the filing evidence that the prior authorization request was actually denied.
Implications: The New York State WCB, in adopting these revisions, cited the need to expedite the resolution of medical payment disputes in the interest of administrative efficiency. The new requirements, however, appear to place the burden of improved timeliness primarily on insurers, employers and TPAs. The revisions may present challenges for payers’ claim staff in compiling and presenting all potential objections to medical bill payment within New York’s 45-day prompt payment timeline.
