What you need to know to develop a successful and rewarding practice
By Snehal Dalal, M.D.
Successfully diagnosing, treating and returning workers’ compensation (WC) patients can be a rewarding part of a physician’s practice. However, not all of us are meant to take care of these type of cases.
There must be a commitment on the part of the provider to give extra time, fill out paperwork and handle specific issues. One must be comfortable in treating not only clear-cut cases but also those patients with vague symptoms without a specific injury.
We are usually accustomed to dealing with only patients and their families. With workers’ comp cases, correspondence from adjusters, case managers and even attorneys must often be handled. Sometimes communication is required to resolve conflicts in opinions.
As professionals, we must not only treat but also educate employers, insurers and case managers as well as help prevent injury in the workplace.
For patients with a workers’ compensation-related medical issue, having to take time off due to injury is quite distressing. The fear of losing one’s job due to an inability to keep up with what the position demands can cause anxiety. It may also put the patient at risk of further harm in their attempts to continue working while injured.
As an orthopaedist and sports medicine physician, I approach the injured worker as an athlete. I want to return the patient back into the game as soon as possible. Getting a patient back to gainful employment can be equally rewarding as getting an athlete back to their sport.
HOW IS THE INJURED WORKER DIFFERENT?
As the Authorized Treating Physician (ATP) in Georgia, we must diagnose and present a treatment plan for the injured worker that determines:
Causation: Is the injury due to direct trauma or overuse from job duties?
Work status: Is it safe for the patient to return to full or restricted duty and how soon?
Treatment Course: What is the anticipated time frame to Maximal Medical Improvement (MMI)?
Legal issues: What is the anticipated permanent impairment and functional limitations once the patient is deemed to be at MMI?
MAXIMIZING GOOD OUTCOMES
As we establish the doctor-patient relationship, it is paramount to be impartial and ensure that you have the best interest of your patient. After all, you are the patient’s best advocate. It is important to emphasize active patient participation and set expectations from the beginning. One a treatment plan is devised, it is important to educate the patient, case manager, adjuster, attorney and your Workers Compensation Coordinator.
Closer follow-up is a good idea to ensure patient compliance and insurance approval. This also allows changes to job restrictions as the patient’s symptoms improve or regress. If the patient is not improving, reconsider treatment options and/or diagnosis. Keep in mind that the importance should be placed on injury healing for functional restoration over subjective pain relief. This is critical when determining surgical intervention.
Prior to deciding on a procedure, ask why and how you have come to the conclusion to intervene. It is very important that the mechanism of injury, history, symptoms and exam positively correlate.
RETURN TO WORK
When determining when an injured worker may return to their job, the provider should emphasize return to work, even with restrictions, within 2-3 weeks from injury or surgery. This will keep the patient in his/her routine. Patients can return to work even if in chronic pain as long as they are functional and the job duties do not increase risk of further injury. It has been shown that patients out of work more than 6 months are unlikely to return.
Understand the demands of the workplace or job of the patient. Show interest, evaluate the job description and familiarize yourself with in-house occupational health staff. The patient will appreciate that you understand their perspective and understand that you aren’t with the employer “just to get them back to work.”
Illness behavior resulting in secondary gain can lead to prolonged perceived disability by patient. To deter avoidance behavior, encourage normal behavior and function. Involve case management or consider secondary gain if patient does not progress as expected in a 6-12 week timeframe.
Be aware of the many factors that may cause the patient to fail to return to pre-injury work status:
- Some legitimate patients cannot return to work safely due to the nature of injury or high demands of job
- Employers are not willing to accommodate restrictions
- Malingering/secondary gain
- Psychological issues
- Worker dissatisfaction with employer
- Symptom magnification
Recognize that many injuries, particularly those that arise from “overuse” happen insidiously and only are recognized or manifested at work. These are not necessarily related to work.
The concept of contralateral injury due to ‘overcompensation’ is a red flag and should be approached with caution.
Give the patient benefit of the doubt. There is a tendency to find fault with the treating physician in the private pay sector and a tendency to find fault with the patient in the workers’ compensation arena. There are times that the physician may have had the wrong diagnosis, resulting in the patient having protracted symptoms. Leave judgement at the door, and keep an open mind when evaluating second opinions or IME.
Evaluate each patient thoroughly, objectively and honestly. Be impartial.
KEEP GOOD RECORDS, and COMMUNICATE!
Documentation is more important here than anywhere else. Workers’ compensation cases are highly litigated, and you may be asked to give testimony based on your medical records.
In general, keep clean, concise documentation in your practice. Electronic medical records (EMR) can be cumbersome, but these are very helpful in keeping track of phone calls, visit status reports(VSR), and work status forms and other correspondence.
Be proactive in communication with the case managers and adjusters. Avoid situations where someone must read your mind because they have to rely solely on your clinic notes. Identify problem cases, and bring them to their attention. With early communication, case managers may help expedite the treatment process. Provide timely notes to the adjuster with work restrictions.
Getting the patient to MMI is helpful, as their functional status may improve after settling a case. Get out Permanent Partial Disability (PPD) ratings as soon as possible to facilitate this.
Market yourself to get yourself on panels. Panels can change quickly and often, so stay in touch with the insurance carriers and employers.
Use other peers on the panel for second opinions to help reinforce the treatment plan.
Never belittle or criticize other medical providers. This will only adversely affect your credibility.
Although Georgia law allows the authorized treating physician (ATP) to dictate treatment, it is good practice to seek pre-approval through the WC insurance provider. Also try to use the insurance-preferred providers. Of course always have the best interest of the patient, and deviate if necessary. Early and clear communication is important so you can present your case and the carrier can see why you have made specific recommendations.
Pain management may be helpful, but put a limit on the course of treatment to discourage chronic treatment.
As your WC practice grows, your time will become increasingly limited. Therefore, I recommend employing a Workers’ Compensation Coordinator to help streamline the treatment and communication process with all involved parties.
Many physicians shy away from a workers’ compensation-focused practice because the process is misunderstood or appears too time consuming. Realize that the vast majority of injured workers are eager to return to work and carry good outcomes.
With a little more understanding of the process and the willingness to put in the appropriate time, hopefully more highly qualified physicians will take on the task of helping our injured workers.