Comparing Claims Information to Treatment and RTW Guidelines

Saturday, June 30, 2007 | 1

By Julie Shank

How will the Division of Workers' Compensation's (DWC) adopted treatment guidelines and return-to work guidelines impact claims management and the medical care of Texas injured employees?

Are the medical treatments, which are usually provided to injured employees, based on evidence-based medicine and recommended as appropriate by the Official Disability Guideline Treatment in Workers' Comp (ODG), the DWC adopted treatment guideline? Does the 'usual' time off work for certain injuries correspond with the disability durations in The Medical Disability Advisor (MDA), the DWC-adopted return-to-work guideline? What is the cost impact of all of these changes? How will the use of guidelines in non-network settings impact the decision to join a network?

In a December 2006 meeting, these were some of the questions that the City of Dallas discussed with their cost containment vendor and utilization review agent, Injury Management Organization, Inc. (IMO). During the meeting, IMO was instructed to examine 25 lost time claims and compare the length of lost time with the disability duration for the same injury listed in the MDA. In addition, the ODG would be used to compare the type and duration of treatment provided to the 25 injured employees with the recommended treatment in the treatment guideline. This study would not only compare disability durations and appropriate treatment, but also the cost difference for both temporary income benefits and medical care.

In order to accomplish this project, TRISTAR Risk Management, the third party administrator for the city of Dallas, furnished IMO with a random sampling of 25 lost time claims. The dates of injury for all 25 claims were within the past 12 months. The sample included the length of disability and the amount of temporary income benefits paid to each of the injured employees.

IMO used the Explanation of Benefits (EOBs) for treatments and services provided on these 25 claims. The EOBs on reviewed medical bills were compiled on the 25 claims to identify the diagnosis (ICD-9) codes and description as well as the treatment or service codes (CPT or HCPCS) used to describe the health care rendered. Other information gathered from the EOBs included the date of the service, the provider name, and the payment for each treatment or service.

After compilation of this information, IMO reviewed each treatment (at the line item level on a medical bill) according to the ODG to ascertain if it was a recommended treatment. If it was a recommended treatment, the number of services, length of service, and other factors specific to the treatment or diagnosis were considered. The length of disability was compared to the MDA. The difference in days off work and the cost of temporary income benefits (TIBs) was calculated.

The diagnosis codes were reviewed to determine the most descriptive code or codes to use when reviewing the MDA. One or two codes were used. If two codes were reviewed in the MDA, the code with the highest disability duration was applied to the calculation. The optimum disability duration with a medium job classification was used in the review.

The following paragraphs define the sample and describe some of the points gleaned from it when the diagnoses and treatments are compared and contrasted with the ODG and the MDA.

The 25 claims included:

* Nine injuries (36%) to the back, including seven listed as 'sprain/strain of the lumbar spine' * Six knee injuries (24%) including three claims for 'tear to the medial meniscus' * Five shoulder injuries (20%), including three 'sprain/strain of the shoulder' * Five other injuries including three fractures of the arm or wrist, a sprain/strain of the ankle, and one diagnosis of complex regional pain syndrome.

Comparison with ODG: The EOBs included over 3700 lines of treatments and services that had been billed for health care provided for the 25 claims. The following comments are some of the findings from the review and analysis of those 3700 treatments and services in relation to the ODG:

* If the ODG had been strictly followed in these 25 claims the medical expenses would have been 25% less than what was actually reimbursed.

* Out of the 3700 lines, over 800 lines of treatments and services were listed as 'not recommended' by the ODG or had exceeded the treatment guideline.

* Over 500 of the 800 lines were for physical medicine services.

* Greater than 50% of the 500 physical medicine services were for four passive modalities: ultrasound, diathermy, electrical stimulation, and mechanical traction. These modalities are not recommended, and hence considered not effective care, for most diagnoses in the ODG. (Even though these four services only account for 3% of the total direct medical costs on these 25 claims, there are obvious operational and indirect costs including processing the medical bills, reviewing the treatments, sending the EOBs, and possible disputes, in regards to handling these medical bills).

* Therapeutic procedures are recommended in many areas of the ODG, but with a limit to the number of treatments. There were almost 200 lines of therapeutic procedures that either were not recommended or exceeded the number of treatments. The CPT code describing therapeutic exercise has historically been the costliest service in Texas workers' compensation. In fact, in this study of only 25 claimants, therapeutic procedures (including exercises and neuromuscular reeducation) constituted 23% of the total amount that would not have been reimbursed if the ODG had been strictly followed.

* There were over 100 lines of medications that were not recommended or exceeded the length of time as stated in the ODG. Within that list were approximately 30 narcotic prescriptions, as well as other pain medications used for moderate to severe pain. And, even though the cost per prescription for many generic narcotic is not very expensive (i.e., $30 for 30 days of a hydrocodone prescription), when not properly used, there are other long term consequences for narcotic pain medication. Ambien, a sleeping medication was listed as not recommended 12 times on the list of 100 lines of medications. In contrast to the cost of generic narcotic medications, the cost of Ambien was on average $122 for a 30 day supply. Other medications included on the list were skeletal muscle relaxants, anti-convulsants used for neuropathy and compounding medications with numerous inert substances. The list of over 100 lines of medications constituted over 10% of the total amount that would not have been reimbursed if the ODG had been strictly followed.

* Some of the other issues presented by this study included the frequency of x-rays and imaging, the number and frequency of office visits provided to the injured worker, nonspecificity in diagnoses, and the use of nerve conduction velocity studies.

* Interestingly, the list of over 800 'non-recommended or exceeded' did not include any surgical procedures other then injections. The assumption is that the preauthorization process screened some of the possible surgeries that may not have been appropriate according to the ODG.

Comparison with MDA: As noted previously, to calculate the return-to-work parameters, the job classification of 'medium' and the 'optimum' time off work was utilized from the MDA disability duration tables.

* Using those points on the disability duration tables, only two of the twenty-five injured workers returned to work in the time listed for their injury. (Interestingly, those two injured workers were recovering from back injuries).

* According to the MDA, the claims should have generated 808 days off work, whereas the total number of days off work (from the first temporary income benefit check to the last) for all twenty-five cases combined was approximately 2500 days. It should also be noted that out of the 808 days allowed by the MDA for these specific injuries 273 days of the 808 days is allowed for one of the 25 injuries (described as 'surgical treatment for the anterior cruciate ligament of the knee'). In other words, for all the other twenty-four cases combined, the MDA states that 535 days are the appropriate benchmark for time off work. (This includes 14 days as disability duration for the most popular diagnosis in the sample: sprain/strain of the lumbar spine).

* Using the temporary income benefits (TIBs) paid in the twenty-five reviewed claims compared to the length of disability recommended by the MDA disability duration tables, there is an approximate 64% decrease in TIBs. With this percentage, it must be noted again that this small study did not take into consideration the difference in job classification, comorbidities and other factors that could make the injury unique. But, even with that caveat, the appropriate use of the MDA will impact the direct and indirect cost of income benefits.

To be truly effective, all parties in the system must begin to learn and understand the two guidelines adopted by the DWC. Physicians and therapists should, not only review the ODG regarding evidence-based guidelines, but also the MDA for appropriate benchmarks on return-to-work issues when helping the injured employee and their employer. Utilization review agents and providers alike must re-think what services must be preauthorized since it is now not only the spelled out treatments and services listed in DWC Rule 134.600 that mandates the need for preauthorization. (Treatments and services on the preauthorization list must also be scrutinized, (for example, physical and occupational therapy) in relation to the evidence-based guidelines).

It is assumed that certified network providers will be more educated in the networks' guidelines. This education and appropriate management by the certified networks and their providers may be hindered if Designated Doctors and DWC Hearing Officers are not also appropriately trained on the guidelines. Insurance carrier adjusters may need to consider the issues more before quickly saying to a provider that they will pay 'reasonable and necessary' health care costs, if they know the services to be rendered are not recommended by the ODG.

The question posed by the City of Dallas almost six months ago was 'how will the guidelines impact the management of claims and medical care of Texas injured workers'. It is apparent, even with this small retrospective study of twenty-five claims, that the use of medical evidence-based guidelines and disability duration (return-to-work) guidelines will and should significantly impact and change the handling of claims and medical management in the Texas workers' compensation system. Time and knowledge will be needed to gauge the true impact to the system.

Julie Shank, RN, BSN, is an advisor for the Injury Management Organization and president of J Shank Consulting. Injury Management Organization is a comprehensive cost containment, medical management company that facilitates return-to-work through the integration of disability and disease management. Further information regarding IMO can be found at the following Web site link: www.injurymanagement.com. This column first appeared in the Insurance Council of Texas' newsletter.

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The views and opinions expressed by the author are not necessarily those of workcompcentral.com, its editors or management.