Surviving WC/ Utilization

Review

Lesley J Anderson MD

COA WC Chair

San Francisco, CA

Disclaimers

Consultant/ Advisory Panel/Stock

Trainer-RX

What’s the best option in today’s environment?

The Problem

No payment for outside time

P and S

AOE/COE

Requested reports

NCM Visits

“Consults” still being requested

The Problem

UR has gotten more aggressive with

denials- NSAIDS, slings

Break up PT visits

80% requests are sent to UR by some

carriers

$1000 Motrin article

IMR- upholds denials 89% of the time

2016 on average (160,000)

>50% are for meds

So what to do?

So what to do?

What you CAN do

Know the rules of the game

Be efficient and be better

Tips from a respected Ortho

Reviewer California providers make the most

unreasonable requests compared to other states

They add body parts

Issue several and excessive RX for opiods

(#100)

Bad players are small, but everyone suffers

Reviewers do have some discretion

Tips from an Ortho Reviewer

If FP or PMR reviewer - ask specifically on

appeal for orthopedic surgeon.

Postop issues/PT should be reviewed by

an orthopedic surgeon

Tips from an Ortho Reviewer

PT visits- document “measurable

functional improvement” and be specific

(ROM, fewer pain meds, ADLs);

Clarify also number of visits remaining from

prior auths (ask for 12 but 6 are remaining)

Quote ODG allowable visits

ODG and PTRotator cuff syndrome/Impingement syndrome:Medical treatment: 10 visits over 8 weeksPost-injection treatment: 1-2 visits over 1 week

Post-surgical treatment, arthroscopic: 24 visits over 14 weeksPost-surgical treatment, open: 30 visits over 18 weeksSprained shoulder; rotator cuff tear:Medical treatment, sprain: 10 visits over 8 weeksMedical treatment, tear : 20 visits over 10 weeksPost-surgical treatment, arthroscopic: 24 visits over 14 weeksPost-surgical treatment, open: 30 visits over 18 weeksMassive rupture of rotator cuff:Post-surgical treatment, arthroscopic: 30 visits over 18 weeksPost-surgical treatment, open: 40 visits over 18 weeks

ODG and PT

Intervertebral disc disorders without myelopathy:Medical treatment: 10 visits over 8 weeksPost-injection treatment: 1-2 visits over 1 weekPost-surgical treatment (discectomy/laminectomy):16 visits over 8 weeksPost-surgical treatment (arthroplasty): 26 visits over 16 weeksPost-surgical treatment (fusion, after graft maturity): 34 visits over 16 weeks

Tips from an Ortho reviewer

Shoulders- surgery request

Document cervical spine exam including

Spurlings, motor, reflexes

Quoting the guidelines or a checklist are

helpful

Steroid injections- document if done and if

not, why not…even if controversial

Low yield procedures (lumbar fusion) get

added scrutiny; so document…

What you CAN do

Use of evidence based medicine

What is being routinely denied?

Preempt their denial with specifics

COA Check lists –

www.coa.org/education/ur-checklists

Automate your RFA to be complete

COA checklistRC repair example

Criteria for Rotator Cuff Repair Check if

documented

Full thickness Rotator Cuff Repair- r/o Cervical

and adhesive capsulitis

Pain

Inability to elevate arm

Tenderness over Greater tuberosity

PLUSMay be Weakness of Abduction

May have Atrophy

Full passive ROM may be present

PLUSX-rays AND MRI, UTZ, or arthrogram show

deficit in RC

COA Checklist- CTSI. Severe CTS, requiring ALL of the following: A.

Symptoms/findings of severe CTS, requiring ALL of the

following:

II. 1. Muscle atrophy, severe weakness of thenar muscles

III. 2. 2-point discrimination test > 6 mm

IV. B. Positive electrodiagnostic testing --- OR ---

Not severe CTS, requiring ALL of the following:

A. Symptoms (pain/numbness/paresthesia/impaired

dexterity), requiring TWO of the following:

1. Abnormal Katz hand diagram scores

2. Nocturnal symptoms

3. Flick sign (shaking hand)

Carpal Tunnel

B. Findings by physical exam, requiring TWO of the following:

1. Compression test

2. Semmes-Weinstein monofilament test 3. Phalen sign

4. Tinel's sign

5. Decreased 2-point discrimination

6. Mild thenar weakness (thumb abduction)

What you CAN do

Make sure add how long from from injury

Injection and results;

Number of PT visits -document

If you are denied after supplying all this

information:

COA wants your redacted cases!

Send to “badUR@coa.net”

Develop your own “No Fly List”

Develop your own non-negotiable list of issues-individual decision

UR

Meds, Imaging, Injections, Surgery, PT

Lack of payment or delay in payments

Delay in care for patient- does it put you in a vulnerable position?

Consider doing consults, provide an opinion and then refer back

If they will not negotiate, I will not play.

They need our P and S reports – do not do

unless approved in writing- consider QME

Upcoming Changes

UR bill requires UR companies to be

accredited

Collect data- of unreasonable denials

Drug Formulary coming- July 1 2017

2017- MC bringing back code to bill for

outside time.

2017- Medicare/DWC changes“Document, Document, Document”

99358-99359 billable and reimbursable

Non face to face time

Must document in report what you reviewed,

how long-

>30 minute - less than 30 min not

reimbursable

Can be on a different day from encounter-

Additional hospital time

2017- Medicare/DWC changes“Document Document Document”

99354-99355 billable and reimbursable

Prolonged service FACE TO FACE

Must document nature of prolonged time

30 minute intervals-

99358 = $149.40 for the first hour

99359 – >1 hr $71.97 for each 30

minutes

www.daisybill.com- Free webinar

Unreasonable denials

If UR denies a medication/sling/ etc. have patient request an IMR-

Costs about $400 per IMR to the employer

Peer to peer

Call the adjustor if UR denies; often they are able to approve

Resubmit RFA after

addressing reason for

denial

Injection

6 visits of PT

Use the COA checklist

Use a prenegotiated

formCOA website

How to get around PT delays/

improve outcomes?

Online PT programs- Trainer RX

WC will pay

You can track the patient’s

progress online

Engage the patient preop

Expectations of RTW-modified

and full duty

Summary

Develop relationships with your payors

5-10% of abuses in orthopedics punish the

other 90% by over regulation

Look at successful models that are saving

costs and rewarding docs

My opinion; this will not be fixed by DWC

or legislature- need to work with the

employers and unions and access to care

has to be an issue before they pay

attention.

Who is missing from this equation???