Eli's Rehab Report

Learn how to avoid sending red flags to your worker’s comp payers.

Do you have honest worker’s comp cases that take extra time to resolve, but you feel like you’re walking on thin reimbursement ice? Learn from the experts what you can do to minimize questioning payers and keep your reimbursement flowing smoothly.

The facts: Worker’s comp can be a double-edged sword. The extra revenue stream is a welcome bonus, but a scrutinizing payer can add a damper to it all. Factor in the notorious employer assumptions that worker’s comp patients milk their benefits to the max and more, and you have extra-wary payers when a treatment episode lasts longer than usual.

Focus on the Following 3 Pillars

When you have a case that’s slow to resolve (or any worker’s comp case, for that matter), keep in mind 1) documentation, 2) function, and 3) communication, says Robert Kroll, BS, PT, account supervisor, ergonomic consultant, and medical case manager for Encore Unlimited in Stevens Point, WI.

1) Documentation. “Probably one of the biggest red flags is poor or lack of documentation,” Kroll says. “The adjusters may get an initial evaluation, but subsequent follow-up progress notes from the treating therapist may be sporadic or non-existent. Documentation that relies on generic references such as, ‘shows improvement’ or ‘continues to progress’ will alert a payer as well.”

2) Function. So, kicking it up a notch to good, objective documentation of progress, including strength, stability, and ROM will suffice, right? Not necessarily. “These [elements] are important,” Kroll says, “but the adjuster is most concerned about how these will relate to function and the injured worker’s ability to return to modified or full duty.”

It goes without saying to provide legible, consistent, and specific documentation regarding the injured worker’s status, treatment plan and goals, and how these are changing to meet the changing needs of the patient. However, “remember that the ultimate goal is a safe, timely, and cost-effective return to work and function,” Kroll says. So, “make sure your treatment plan reflects how you can assist in this process.”

3) Communication. To best incorporate function into your notes, you need to have regular conversations with your patients about their real-world tasks. Translate their clinical activities to their work activity potential.

Also communicate with the adjuster or case manager handling the injured worker’s claim — “not just to determine initial coverage, but on an ongoing basis,” Kroll recommends. “A phone call to relay the need for ongoing care, a change in treatment plan to address slow progress, or to alert the adjuster or case manager of concerns regarding non-compliance with appointments or home programs, can help highlight a proactive physical therapy approach and avoid a reactive response from a payer.”

In fact, there’s a lot you can discuss with the adjuster. As you do so, you are developing a trust relationship that could mitigate unnecessary denials.

“Ask about individual concerns they may have, e.g., symptom magnification, poor employee/employer relationships, or availability of transitional work,” Kroll suggests.

Hidden opportunity: You may even strike a nice business relationship along the way. “Utilize [the adjuster] as a resource for obtaining physical job demands, and offer to perform a job site visit to assist in transitional work if you are able to,” Kroll says. Not only will you get a more tailored and effective treatment plan out of it, but also you are establishing relationships that could become great referral sources.

Avoid These Red Flags

Meanwhile, there are several practices to avoid that will automatically put you in a worker’s comp payer’s crosshairs, according to Kroll:

• Cutting and pasting of treatments, goals and recommendations. (This is oh-so-easy to do with electronic medical records but can make the treatment program appear overly general and not tailored to the specific needs of the injured worker, Kroll explains.)

• Poor documentation of follow-up regarding missed appointments

• Treatment that is dominated by passive modalities. 

• Treatment that continues for prolonged periods without change.

• Treatment that goes for periods beyond recommended guidelines or best practices.

• Multiple providers with lack of distinction of services.

A note on multiple providers: More and more, facilities are taking a multidisciplinary approach to patient care. Even hospital systems are integrating chiropractic, acupuncture, and nutritional counseling into the more traditional model of work injury management, Kroll observes. While each practitioner adds a unique part to the injured worker’s recovery, now more than ever, you must identify in your documentation what you are uniquely providing to the patient’s care.

Example: A patient is receiving treatments from a chiropractor, who is providing spinal adjustments, and a physical therapist, who is providing muscle energy techniques to specifically address an SI joint issue. In this case, you would need to “identify specific deficits and goals that are being addressed, and that these have been communicated to the other members of the treating team,” Kroll says. “If the adjuster just sees ‘manual therapy’ as a current or recommended treatment, it’s easy to assume there may be a duplication of services.”

Stay on Top of Your State Regs

Always remember that each state has its own rules, regulations, and guidelines regarding worker’s compensation, and they can vary significantly.

“Some state worker’s compensation rules the maximum number of timed sessions per date of service regardless of the number of different providers,” points out Marvel J Hammer RN CPC CCS-P ACS-PM CPCO, with MJH Consulting in Denver, CO. “For example, if the state worker’s compensation jurisdiction limits time therapy services to four 15-minute units, it doesn’t make any difference if it is one PT, two PTs or a PT and OT from the same group that provide the one hour of therapy services.”

Blind spot: “Just because a patient is being seen in your practice doesn’t mean that the local state worker’s compensation rules apply,” Hammer says. “The patient’s injury may be filed with another state worker’s compensation jurisdiction. The other state worker’s compensation rules may, in fact, be different from what the therapy practice routinely follows.”

If you know your state regs like the back of your hand, be sure to check each year for any updates, as well. Although each state has its own guidelines, three basic rules of thumb to keep in mind, according to Kroll, are:

1. Is the injured worker’s pain decreasing?
2. Is ROM improving?
3. Is function improving?

“Wisconsin says that if two out of the three areas above aren’t improving, then the treatment plan should be altered,” Kroll says.