Oct 7, 2022 | Legislative Update
Here is a summary of legislative and regulatory developments and challenges for the third quarter of 2022 and their practical implications:
Revisions to Texas HCN Regulations: The Texas Department of Insurance has adopted many revisions to the regulations governing WC Health Care Networks (HCNs). Many of these changes are more administrative than substantive, as TDI noted in July 29, 2022, issue of the Texas Register, but there are a number of amendments that will require compliance efforts by Texas WC stakeholders.
Among the material revisions are those that:
- require HCNs to provide detailed information about telehealth providers in their provider rosters
- require HCNs seeking certification to provide provider location maps for 21 specialties
- require TDI prior approval before HCNs change their service areas or merge with other networks
- add newly mandated language to HCN provider contracts
- tighten requirements for notifying employees they are subject to HCN rules
- require HCNs to show evidence of their provider recruitment efforts in non-qualifying geographic areas
- increase HCN recordkeeping requirements relating to provider complaints and appeals
Implications: The new HCN regulations recognize the growing prominence of telehealth services and represent an increased commitment by TDI to the proper functioning of HCNs. Nevertheless, Texas WC stakeholders will need to work diligently to ensure their compliance by the January 1, 2023 deadline, at which point HCNs are required to attest to their compliance.
Ohio Statute Defining Compensability of Work-From-Home Injuries: Ohio has enacted HB 447, which sets standards for WC compensability for injuries incurred by work-from-home employees.
Three criteria must be met:
- The employee’s injury or disability arises out of the employee’s employment.
- The employee’s employment necessarily exposes the employee to conditions that substantially contribute to the risk of injury.
- The injury or disability is sustained in the course of activity that is taken on by the employee for the exclusive benefit of the employer.
Implications: With a substantial proportion of the workforce working remotely and likely not returning to the office fulltime, legislatures are grappling with work-relatedness issues that at one time were self-evident, or at least settled law. WC stakeholders can expect lawmakers, regulators and jurists to continue to address these questions for the foreseeable future. The Ohio statute became effective on September 23, 2022.
California Study Law on Prompt Medical Treatment: California Governor Gavin Newsom has signed into law AB 2848, which requires the Division of Workers’ Compensation to contract with an outside independent research organization to evaluate and report on the impact of the delivery of medical treatment within the first 30 days after a claim is filed. The measure requires the report to be provided to the DWC Administrative Director, the Senate Committee on Labor and Industrial Relations and the Assembly Committee on Insurance before July 1, 2023.
Implications: This legislation can be seen as part of a continuing discussion in California regarding the function and value of registered Medical Provider Networks (MPNs) in delivering timely and accessible health care to injured workers. It is generally recognized in the workers’ compensation community that prompt delivery of health care services improves work-related injury outcomes and independent research has shown this to be the case.
Sep 8, 2022 | Insights
Some days, we’ll come across a certain event – one that isn’t too rare, but also isn’t too common – and simply brush it off. “It probably doesn’t mean anything,” we say to ourselves. But what if it does?
This was the exact case with David. He had a diagnosis of right shoulder strain after complaining of injuring his shoulder while carrying heavy boxes. Following initial medical diagnosis, he was initially prescribed 12 sessions of physical therapy. He attended his first session, seemingly eager to play his role in the journey to recovery. And then he missed the second session… and the third… and the fourth.
On the first instance of David missing his PT session, the adjuster didn’t think much of it. Something probably came up, but it probably isn’t too serious. This initial miss would generally not be alarming as some data suggest that 5-15% of musculoskeletal injuries resolve within 24-72 hours post-acute injury. But after David remained on limited duty and missed two more sessions, his adjuster knew this was concerning behavior – perhaps there’s something else behind it.
Eventually, the claim went into litigation, and it was found that David was in fact moonlighting. It turns out he had another job that made it impossible to attend his PT sessions. If it weren’t for his adjuster noting his lack of attendance as a red flag, his current employer wouldn’t have known this fraud was going on.
Attendance can be such a basic thing that it’s easily overlooked. But as seen with David’s case, if an adjuster knows when and where to look, there’s more to attendance than meets the eye.
It’s all in the communication
While one might think that you would need AI or machine learning or some fancy tool to unlock key insights from attendance, the answer really lies in good communication with the treating provider. Open dialogue with a provider, access to notes, and specifically, access to scheduling and attendance data, can be used to monitor claims.
In schools, for example, an attendance record is kept for each student. This record is then evaluated by their teachers and sent home for their parents to review. While there are exams to test a student’s knowledge, their attendance is also another indicator of their performance and essentially, their readiness to move on to the next grade.
For claims, things are no different – a patient’s readiness to return to work must be measured not only by their performance in the actual therapy sessions but also by their attendance. After all, erratic attendance (or none at all), will hinder their recovery progress.
In David’s case, the attendance report from the treating provider was the important information his adjuster needed to sound the alarm. With a look at this shared information, it’s seen when he should be going for sessions, the actual dates that he showed up, and the dates that he didn’t.
Getting the most out of your communication
While good provider communication can provide the data you need, it won’t be of much use without a benchmark.
Going back to our school example, it’s likely that at the start of the year, a standard is set for both the students’ test scores and attendance. If halfway through the term, it seems like a student is falling below these standards, his teacher will likely want to speak with him and his parents. In this conversation, they start to ask important questions to both uncover the drivers of poor performance and come up with a plan that will help the student perform better for the rest of the term.
In claims, it’s a similar case – an overall standard must be set for patient attendance. This standard may vary from organization to organization and can be informed by previous claim data. Combining this attendance standard with additional medical evidence modeling a standard “report card,” an adjuster would know when a patient’s attendance record is “alarming,” and when it’s time to double-check on a case.
Additionally, communication must be timely, and shared data must be easy to interpret. A simple tool like a shared calendar, for instance, can be used not only to schedule therapy sessions but also to evaluate attendance. As much as possible, this should be created so that in one look, an adjuster can effortlessly make initial inferences about a patient’s status.
Making it a strategic partnership
None of the above will be possible without a strong relationship across the key stakeholders in a claim. When providers, vendor-partners, and adjusters work seamlessly together, they’re able to unlock the power of data and harvest important insights. And when constant communication is in place, the right steps can be taken at the right time.
In a nutshell, attendance, while seemingly simple, should not be taken for granted. While it can tell the basics of when a patient is scheduled to attend and when they actually do, it can also be a gateway to uncovering deeper insights such as a patient’s lack of motivation or like in David’s case, a bigger red flag. Moreover, clear and concise communication with providers throughout treatment is crucial to ensuring claims are caught before they go off track.
Beckett, Kathy. “How Pt Attendance Can Tell You More than You Think It Does.” WorkersCompensation.com, Workerscompensation.com, 15 Aug. 2022, https://www.workerscompensation.com/news_read.php?id=41713.
Sep 8, 2022 | Insights
MedRisk’s team of experts is leading the way to methods of stronger, faster recovery while avoiding the expense and trauma of surgeries and addictive painkillers.
In a sense, the precepts of good workers’ compensation risk management are simple and straightforward, at least compared to some parts of commercial property/casualty insurance.
Employers and their insurers strive to help injured workers get better and get back to work, without subjecting them to unnecessary procedures and medications that might stall their recovery progress and diminish their quality of life.
Of course, keeping workers’ compensation medical costs and indemnity payments down is a laudable aspiration. But all of that comes in second to the goal of helping people who got hurt at work heal and reengage with the careers that earn them their living.
Although the goals of good workers’ compensation risk management will always be the same, the methods of achieving those goals are ever evolving.
According to Sri Sridharan, the Chief Client Officer at MedRisk, his company stands at the portal of being able to use data and connective technology to provide more focused care for workers, particularly in the area of physical therapy.
For starters, Sridharan is a big believer in the capacity of physical therapy to help workers and physicians manage the musculoskeletal injuries that are big drivers of lost time and medical costs. Back injuries, knee injuries and shoulder injuries together account for the majority of workers’ compensation medical costs.
Physical therapy (PT), applied in a timely and focused manner, can help workers manage and heal an injury, and hopefully help them avoid expensive and traumatic surgeries.
“Physical therapy is an excellent conservative treatment option and one that can yield quick, cost-effective results,” Sridharan said.
In just one example out of dozens, a patient with a knee problem can gain better utility, alignment and flexibility out of their knee while lowering pain if they work with a physical therapist to strengthen the muscles around the joint.
MedRisk is investing considerable time and money into the human resources and technology to make physical therapy an even more targeted and efficient experience. “Rather than relying largely on the treatment benefits of surgery and pain medication, a greater number of physicians are seeing the value of physical therapy for helping injured workers regain their pre-injury abilities,” he added for emphasis.
The MedRisk Process
The first step in getting an injured worker appropriately oriented to the rehabilitation process is in MedRisk’s PTConsult. In this process, licensed physical therapists reach out to an injured worker to prepare them for the rehab experience and identify any potential barriers to recovery. They develop a rapport with patients and learn more about not only their injury, but details about their overall health and lifestyle.
PTConsult also provides the space for the patients to ask questions and learn about their condition from an experienced physical therapist.
“We’re engaging with the injured workers to explain to them what to expect and help them navigate the episode of care, which is very helpful,” Sridharan said.
MedRisk then marries the information from the PTConsult with decades of patient outcome data that it has amassed over the years.
The provider-scoring information MedRisk infuses into the process matches the injured worker to the medical provider best positioned to help the patient recover, based on their past performances.
“Our platform is always learning. We are constantly modeling and sequencing data for risk stratification and outcomes,” added Aubrie Cunningham, SVP of Pricing and Business Intelligence for MedRisk.
“The more we analyze our data, the more definitively we can say, “Oh this is what’s different about this patient. This is why matching to providers is such an important piece of the puzzle,” she added.
MedRisk’s investment in their technology and analytics has been substantial in recent years.
“Data is most effective when you can aggregate it across multiple sources, collect it, combine it and have a unified layer,” Sridharan said, in explaining why MedRisk places so much emphasis and is devoting so many resources to that part of its approach.
Progress, Engagement and Compliance
Beyond better matching an injured worker to a provider, MedRisk is in the process of eyeing and implementing another technology-aided advancement that should make its efforts even more efficient and productive.
The gap this evolution will address is in the way that patients adhere to the treatment and guidance given to them by physical therapy professionals. Let’s face it, coming back from an injury, not to mention surgery, can be discouraging if not downright depressing. Anyone who has ever taken their repaired shoulder out of a sling to have it manipulated and strengthened can attest to that fact. The pain one endures and the days and weeks needed to get back to full usage can feel like a slog. That experience might lead an injured worker to shirk the strengthening and flexibility exercises they’ve been assigned by their physical therapist.
Physical therapists can provide the best tools and guidance available, but if the injured worker can’t steadily and devoutly comply with that guidance, they may never recover properly.
This is where the latest technological advancements can play an important part.
Using Internet of Things (IoT) capabilities, including sensors that can be worn by the recovering worker, Sridharan and his colleagues are exploring the ways they can use the data collected by wearables to better direct care and ensure compliance.
“In the musculoskeletal recovery process, pain is a limiting factor that is perceived by claimants differently. Utilizing additional measurement tools to collect objective data allows a therapist to quantify pain level and support claimant throughout the recovery cycle,” Sridharan said.
Say, a patient was only able to lift their arm 75% of the way overhead in week four of their recovery, but due to physical therapy, and using information collected by sensors, a physician or physical therapist will be able to gauge that the recovering worker, exercising from home, is able to fully lift their arm overhead in week five.
That’s vital information that may relate directly to their ability to return and be productive in their job.
Sridharan said MedRisk is currently undergoing pilot projects with its physical therapists to see how the use of sensors and the data they collect can be applied consistently and with good results.
The technology advancements Sridharan and his colleagues are implementing are exciting and bear watching. But his colleague Aubrie Cunningham reminds us that a clear understanding of the mindset and environment of the injured worker are still central to the process.
She said the highest result is when the humanity of each worker is placed at the forefront of the entire process.
“They’re not data points, they’re people,” she said.
22, MedRisk. “How Data, Focused PT and Wearables Can Yield Better Patient Engagement and Superior Outcomes in Workers’ Comp.” Risk & Insurance, Risk & Insurance, 22 Aug. 2022, https://riskandinsurance.com/sponsored-how-data-focused-pt-and-wearables-can-yield-better-patient-engagement-and-superior-outcomes-in-workers-comp/.
Jul 26, 2022 | Insights
A recent assessment evaluated the impact of receiving physical therapy and the timing of physical therapy initiation on downstream health care utilization and costs among patients with acute low back pain (LBP).
Nearly 1 of 55 patients with LBP are referred for physical therapy by physicians. The study took patients who had a new onset of LBP between January 1, 2009, and December 31, 2013, in New York State and grouped them into different cohorts based on whether they received physical therapy and the timing of physical therapy initiation over the course of 1 year.
The results found that among 46,914 patients with acute LBP, 40,246 patients did not receive physical therapy and 6,668 patients received physical therapy initiated at different times. After examining these findings, researchers found that health care utilization and cost measures were the lowest among patients that did not receive physical therapy followed by patients that received immediate physical therapy treatment (within 3 days).
The conclusion? When a referral for physical therapy is warranted for patients with acute LBP, immediate referral and initiation (within 3 days) may lead to lower health care utilization and LBP-related costs.
Liu, et al. “Immediate Physical Therapy Initiation in Patients With Acute Low Back Pain Is Associated With a Reduction in Downstream Health Care Utilization and Costs | Physical Therapy | Oxford Academic.” OUP Academic, Oxford University Press, 16 Apr. 2018, https://bit.ly/2L4GbDx.
Jul 11, 2022 | Legislative Update
Here is a summary of legislative and regulatory developments and challenges for the second quarter of 2022 and their practical implications:
New York WCB Clarification regarding Payer Objection Notices: The Workers’ Compensation Board has clarified its earlier guidance, stating that Form C-8.4 notices to providers and the Board need not be sent if the reasons for lower payment are standard bill review adjustments, including PPO network reductions. Specifically, the bulletin states:
Payments may be appropriately reduced, but objections should not be submitted by the insurer to the Board in the following scenarios:
- The amount billed for the particular CPT code is in excess of the amount designated by the applicable medical fee schedule and the insurer pays the bill at the appropriate medical fee schedule amount.
- The insurer reduces the amount of the bill to 12, 15 or 18 relative value units for evaluation services and modalities, as set forth in the applicable medical fee schedule.
- The insurer reduces the amount of the bill pursuant to a contractual agreement with the provider (e.g., network or PPO discount).
- There is a duplicate bill.
Implications: This revision should greatly reduce the voluminous paperwork burdening claim organizations doing business in New York. On a related topic, the WCB is in the midst of a multiple-year move to electronic submission of filings, a key feature of which is the OnBoard application.
Telehealth Compliance with HIPAA: The Office of Civil Rights (OCR) within the US Department of Health and Human Services has recently issued guidance broadly endorsing the use of audio-only telehealth services to increase access to health services by patients who have limited financial resources or who live in rural areas with limited broadband availability. The guidance can be found here: https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/hipaa-audio-telehealth/index.html.
Implications: OCR enforces federal privacy regulations (e.g., HIPAA) that generally don’t apply to WC payers, but health care providers and payers’ third-party service providers don’t enjoy those same exemptions, so this clarification comes as a welcome relaxation of regulatory constraints.
On a related telehealth topic, a new study from physical therapy quality analytics firm Focus on Therapeutic Outcomes (FOTO) found that, for telerehabilitation for low back pain, telerehab (a) was equally effective in improving functional status outcomes for patients with low back pain compared to traditional in-person office visits, (b) usually involved significantly fewer visits, and (c) had roughly equal patient satisfaction ratings (82% for telerehab versus 86% for in-person office visits.
