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Difficulties of Surgery in Workers’ Compensation
#1
Difficulties of Surgery in Workers’ Compensation
As the medical costs of workers’ compensation claims have risen sharply in recent years, the importance of understanding the role surgery plays in a claim has grown. This session at WCI’s 2016 Workers’ Compensation Educational Conference discussed various delays and pitfalls related to surgeries in workers’ compensation.
Speakers included:
– Cheryl Gulasa, Vice President, AmeriSys
– Dr. Steven Weber, Board Certified Orthopedic Surgeon, Orlando Orthopedic Center
– Michael Costello, Regional Director, Tenet Healthcare
– David Anderson, Vice President of Operations, Orchid Medical

Continuum of Care
Because you are working with various stakeholders, there is a big barrier to getting surgery approved and it causes delay in care for the injured worker. Some approves are more conservative than others. Attitude is a large contributing factor in healing and, if there is a big delay, the patient often feels slighted and enters the surgery process with a chip on their shoulder.
From a doctor’s standpoint, the physicians and reporting mechanisms can help move the needle towards approval. A risk calculator can be utilized to show a risk profile to help show if the person is a good surgery candidate. They can also expedite delivery of information to the adjusters to help get authorization.
Litigation and Settlement
Sometimes litigation and settlement is the motivation for an injured worker to have the surgery. Sometimes it is a road they take to get the settlement. Anytime a claim goes into litigation, it slows everything down. The nurse case manager can no longer talk to the client. It does nothing but delay care.
Selecting a Surgeon
You have to get to know your local community to uncover who works well within the system. Conservative care should often take precedence before surgery, but you have to know the right doctors that make the right decisions. You should also get to know your local imaging centers to get good, quality, honest reads. Where you send your people is going to matter.
Ask questions. If a surgeon isn’t willing to take the time to meet with nurse case managers, fill out required forms or follow fee schedules, they are not good candidates to accept workers’ compensation patients. Not every surgeon is made to work in this system, so these are good questions to ask.
Fee Schedules
Fee schedules are a large challenge because they vary by state. They can also be limiting and they need to evolve so that doctors can accept patients sooner. There recently have been codes added related to the spine, which has help to changed the landscape, but there is more that can be done.
Outcomes
There are many items that lead to negative results. Often, there are secondary gains to be had in the workers’ compensation arena, which is a large impediment to healing and return to work. In addition, patients are often not compliant with post-opp recovery recommendations
 
Found @ https://www.safetynational.com/conferenc...pensation/
 
Reply
#2
(08-23-2016, 12:10 PM)bugmann Wrote: Difficulties of Surgery in Workers’ Compensation
As the medical costs of workers’ compensation claims have risen sharply in recent years, the importance of understanding the role surgery plays in a claim has grown. This session at WCI’s 2016 Workers’ Compensation Educational Conference discussed various delays and pitfalls related to surgeries in workers’ compensation.
Speakers included:
– Cheryl Gulasa, Vice President, AmeriSys
– Dr. Steven Weber, Board Certified Orthopedic Surgeon, Orlando Orthopedic Center
– Michael Costello, Regional Director, Tenet Healthcare
– David Anderson, Vice President of Operations, Orchid Medical

Continuum of Care
Because you are working with various stakeholders, there is a big barrier to getting surgery approved and it causes delay in care for the injured worker. Some approves are more conservative than others. Attitude is a large contributing factor in healing and, if there is a big delay, the patient often feels slighted and enters the surgery process with a chip on their shoulder.
From a doctor’s standpoint, the physicians and reporting mechanisms can help move the needle towards approval. A risk calculator can be utilized to show a risk profile to help show if the person is a good surgery candidate. They can also expedite delivery of information to the adjusters to help get authorization.
Litigation and Settlement
Sometimes litigation and settlement is the motivation for an injured worker to have the surgery. Sometimes it is a road they take to get the settlement. Anytime a claim goes into litigation, it slows everything down. The nurse case manager can no longer talk to the client. It does nothing but delay care.
Selecting a Surgeon
You have to get to know your local community to uncover who works well within the system. Conservative care should often take precedence before surgery, but you have to know the right doctors that make the right decisions. You should also get to know your local imaging centers to get good, quality, honest reads. Where you send your people is going to matter.
Ask questions. If a surgeon isn’t willing to take the time to meet with nurse case managers, fill out required forms or follow fee schedules, they are not good candidates to accept workers’ compensation patients. Not every surgeon is made to work in this system, so these are good questions to ask.
Fee Schedules
Fee schedules are a large challenge because they vary by state. They can also be limiting and they need to evolve so that doctors can accept patients sooner. There recently have been codes added related to the spine, which has help to changed the landscape, but there is more that can be done.
Outcomes
There are many items that lead to negative results. Often, there are secondary gains to be had in the workers’ compensation arena, which is a large impediment to healing and return to work. In addition, patients are often not compliant with post-opp recovery recommendations
 
Found @ https://www.safetynational.com/conferenc...pensation/

Great post.The only disagreement I would have is that a patient would undergo surgery to increase settlement. I cannot see this happening at least for 99.9999% of the population, unless someone had a mental disorder. I do think there are unwarranted surgeries being done on patients who trust their doctors advice.
I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.
 
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#3
these ideas/suppositions on surgery represent only the view of the medical vendor side of the system.

In many states TTD benefits often expire. Opting for surgery before that happens is often a less expensive choice then delaying the surgery.
That is often the "secondary gain" many workers have to consider.
In a fee for service system the monetary incentive for physicians and/or the medical community is often greater then that for the workers.
I also think the idea that "surgery is a road to settlement" idea reflects a very primitive understanding of the complex motivations involved in workers compensation decision making.

this group is representative of very powerful special interest groups sponsoring legislative changes to workers compensation systems in many states.

In my opinion these "observations" are not balanced by the views from either carriers, the legal community, or especially the workers themselves. maybe they can lead to dialogue that can moderate any changes to local work comp legislation.
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
THANKS FOR POSTING.
 
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#4
TO Cal Help.  I've never been to the West Coast but here in the East Coast we are full of wackos wanting to beat the system.  Some are forced onto a corner by a vindictive employer where is in many states the employer selects the first primary care Dr who does what the employer wants; just this cost me a 2nd injury that disabled me for life, I lost everything I worked all my life for except the best womn in the world as she was the only one who stood by my side qs she knew me and knew how much I love my job and also knew my manager who wanted more than a employee/employer relationship and didn't like being told no and used the WC system as a weapon that denied me the care needed until I got SSDI then in 24 months got Medicare (A 6 YR Wait) by then the pain was so bad I was bed ridden.  This my be an extreme case but if it can happen to me all are potential victims. Now back to the wackos who knows what fuels their desire to have surgery as  in nj it will not improve an IW'S settlement very much. maybe they like the drugs who knows or it keeps them out of work longer?? Maybe they knew the system better than I as I was nievie and thought all Drs stood by the oath they swore b4 GOD to uphold boy did I get a wake up smack in the chops!!!!!. I ended up having conservative experimental procedures once I move back home OUT OF NJ!! then 3 back surgeries and I am walking again I guess everyone has their motivations. Some Drs are greedy some employers are greedy and some workers look 4 a free ride. When I am in doubt I follow the money and in NJ it goes to the Drs and lawyers all I get is ssdi and 2nd Injury Fund no medical so I need my wife to work for good ins. The system is simply messed up

As for 1171 you have a very wise head on your shoulders I always follow your opines just to see where you are coming from. You seem well educated in many areas and that's a wonderful gift. See you around

BUG
 
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#5
Thanks for the kind words.
Be well.
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
THANKS FOR POSTING.
 
Reply
#6
(08-28-2016, 07:32 PM)1171 Wrote: Thanks for the kind words.
Be well.

1171 thanks and your right . MY State was NEW JERSEY. I wish there was a way where we can have 50 sections each representing one state and we could start new threads in the State we are selecting??
 
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#7
(08-30-2016, 08:01 PM)bugmann Wrote:
(08-28-2016, 07:32 PM)1171 Wrote: Thanks for the kind words.
Be well.

1171 thanks and your right . MY State was NEW JERSEY. I wish there was a way where we can have 50 sections each representing one state and we could start new threads in the State we are selecting??
yup. or better yet a way to require a location before you could post and then allow you to search on it.
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
THANKS FOR POSTING.
 
Reply
#8
(08-23-2016, 01:19 PM)1171 Wrote: these ideas/suppositions on surgery represent only the view of the medical vendor side of the system.

In many states TTD benefits often expire. Opting for surgery before that happens is often a less expensive choice then delaying the surgery.
That is often the "secondary gain" many workers have to consider.
In a fee for service system the monetary incentive for physicians and/or the medical community is often greater then that for the workers.
I also think the idea that "surgery is a road to settlement" idea reflects a very primitive understanding of the complex motivations involved in workers compensation decision making.

this group is representative of very powerful special interest groups sponsoring legislative changes to workers compensation systems in many states.

In my opinion these "observations" are not balanced by the views from either carriers, the legal community, or especially the workers themselves. maybe they can lead to dialogue that can moderate any changes to local work comp legislation.

Thank you for your explanation. 

It is too bad that ALL sides in the California workers' compensation system cannot come together to make a better system so some of these " difficulties of surgery" can be resolved.

If I could make a list:


 Difficulties of Surgery in Workers’ Compensation

1. California removed the 2nd opinion for spinal surgery process in 2013 and patients now only have a paper review system with UR/IMR and not an in person evaluation.

Outcomes

2. The UR/IMR paper review system in CA WC should not be used for complex surgeries and spinal surgeries. Doctors who are well versed in the paperwork aspect of the CA WC system will be the ones who will be able to get surgery approved for their patients. 

3.Continuum of Care

 California has capped physical therapy at 24 sessions (more may be allowed after a surgery but that also has a cap). By capping physical therapy for ALL patients it is causing patients to turn to surgery as they have no other alternative.  There are also caps after a patient has surgery.This cap is causing patients not to return to their best function, further disability, the need for more surgeries, increased medications and cost shifting to taxpayers (SSDI/SDI).

4. California has capped TTD at 104 weeks or when a patient reaches MMI/P&S. They should extend this especially if the patient has surgery and needs more time to recover. This TTD cap is also causing cost shifting to taxpayers via SDI and SSDI. The CA TTD cap has caused many California injured workers and their families to be harmed financially.

5. Selecting a Surgeon

MPN issues:

-Some MPN's do not have enough skilled surgeons for patients to chose from.
- Many of the MPN's still contain doctors who do not take WC patients.
-MPN's can be confusing to navigate online.
-Some patients are having extreme difficulties getting to a surgeon even after a consult is approved by UR. After a consult is approved often times the surgeons office wants a letter from the claims adjuster to allow the visit. This is easier said than done and I have seen many CA injured workers get stuck just because they cannot get this letter.
- Language contained in SB863 stated there would be a gate keeper to help injured workers with MPN issues and this was watered down to their claims adjuster is responsible.



The Blob Of Fraud 


Insurance company industrial clinics vs applicant friendly hacks

IC industrial clinics -insurance friendly doctors:This may or may not be the first pace your employer sends you to after your injury. You will know you are at one of these clinics as they will have you return every week, and you have been going for months. These clinics are known for limiting medical treatment/under treatment and minimizing the patient injury to save IC money.  Under treatment can cause harm to patients. This is not a good place to receive proper medical treatment.(not all industrial clinics or first place an employer sends their IW are bad, this is an extreme example)

Pill Mills and Surgery Hacks: These doctors are known for over treating patients to make themselves money. They may request testings, treatment, medication and even surgery that may not be medically necessary or good for the patient. These clinics can also be known to overstate the patients injury. Over treatment can cause extreme harm to patients.This is not a good place to receive proper medical treatment.


Litigation and Settlement: 

6.Sometimes the insurance company can offer a lump sum payment before a patient has returned to work or best function. Sometimes settlement is offered before a surgery is done. I have seen patients who agreed to this instead of having the approved surgery out of financial desperation or just wanting out of the horrible CA WC system.
I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.
 
Reply
#9
(08-23-2016, 01:19 PM)1171 Wrote: these ideas/suppositions on surgery represent only the view of the medical vendor side of the system.

In many states TTD benefits often expire. Opting for surgery before that happens is often a less expensive choice then delaying the surgery.
That is often the "secondary gain" many workers have to consider.
In a fee for service system the monetary incentive for physicians and/or the medical community is often greater then that for the workers.
I also think the idea that "surgery is a road to settlement" idea reflects a very primitive understanding of the complex motivations involved in workers compensation decision making.

this group is representative of very powerful special interest groups sponsoring legislative changes to workers compensation systems in many states.

In my opinion these "observations" are not balanced by the views from either carriers, the legal community, or especially the workers themselves. maybe they can lead to dialogue that can moderate any changes to local work comp legislation.

I agree that the delay in surgery is a big part of the problem.. I got no help towards surgery until well over 6 months of sitting in pain,,, not because I did not want a remedy but because the IC pretty much ignored me
 
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