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No one likes preauthorization/utilization, review/physician peer review, or whatever term your specific jurisdiction uses to establish the process where the treating provider must seek the endorsement of their patient treatment plan, through the workers' compensation system. To attempt to control costs, many jurisdictions have adopted a process where healthcare interventions are reviewed prior to the application of said care. Fortunately, as an initial arbitrator, the concept of evidence-based medicine has been applied to this process. The phrase “evidence-based medicine” has been in the medical lexicon for approximately 25 years. The original definition has been amended and expanded to fit a revolving healthcare culture. Evidence-based medicine does not represent the most current medical practice; it represents the best-established practice in the application of healthcare. It is designed to present the most effective and cost-efficient healthcare available to address a specific problem.  Critics claim that evidence-based medicine and other “guidelines” are “cookbooks” that limit medical practice. The utilization of such guidelines has been declared to be dogmatic, inflexible, and too uniform. However, applying the standards of evidence-based medicine and utilizing the adapted guidelines specific to any particular jurisdiction is anything but a limitation on appropriate/effective medical application. A combination of [...]

A medical link that should raise red flags for employers and workers' compensation managers. Research linking burnout to heart health issues, strokes, blood clots, and other potentially deadly illnesses exposes the risk employees under excessive amounts of stress and exhaustion face. The WHO went so far as to deem burnout an occupational phenomenon. A study conducted by the European Journal of Preventative Cardiology (Jan 2020) looked at the effects of “vital exhaustion” (burnout) on the human body by focusing on a number of factors including anger, antidepressant use, and other factors that influence the condition’s development.   The study extracted a couple of key findings: inflammation and increased stress hormones are possible links between burnout and heart issues. Burnout increased the risk of developing atrial fibrillation by up to 20% —atrial fibrillation can cause blood clots and is associated with an increased risk of stroke, heart failure, and death. It is difficult to detect; many don’t know they have it. Researchers documented a total of 2,200 cases of atrial fibrillation.   Inflammation, high amounts of stress hormones, and heart conditions are all potential comorbidities for workers’ compensation claims for burnt-out employees. In addition to comorbidities, employee burnout [...]

In this article, I am going to discuss the calculation of the impairment rating for a COVID claim. But first, I must, once again, do all that I can do to encourage each of you to get vaccinated. I get that this is a politicized disease process. There are educated health care professionals refusing this intervention; however, after reading numerous articles as to why vaccination should not be pursued, NONE rise to the level of competent, peer-reviewed evidence-based medicine establishing why you should not.  I can not condone passing up getting the vaccine unless there is a specific clinical indication not to.   Now for the good stuff. As previously reported, COVID can be an accepted compensable injury from a clinical perspective and a legal (presumption) perspective. If the diagnosis has been established as a compensable injury, then you need to develop a specific checklist of noted symptoms and actual sequelae of the disease. Track and make note of symptoms, the findings upon physical examination, and the laboratory values reported with the subsequent clinical assessment of the disease process.  COVID has been linked to brain injury (such as anoxia after pulmonary or cardiac complications, heart disease (atrial fibrillation), pulmonary disease (such as changes associated with pneumonia, congestive heart failure, or pulmonary edema), kidney disease (acute kidney injury, avascular tubular necrosis), and there are some who believe that the [...]

Presumption in workers compensation typically requires that an employer accept full responsibility for certain diagnoses, with presumption laws varying by jurisdiction. And, with the recent pandemic and national healthcare emergency in the United States, presumption in workers compensation can often mean accepting responsibility for the contraction of a highly communicable virus that carries a multitude of implications both for the employee and the employer. In several jurisdictions, the increasing prevalence of COVID-19 has led to modifications of the workers compensation statute to factor in other circumstances that might heighten an employee’s risk of exposure to disease. By this new standard, certain workplace illnesses are presumed to be secondary to occupational issues. For example, some presumption laws assert that certain cancers are a function of occupational exposure regardless of what evidence-based medicine may indicate. With the recent national healthcare emergency in the United States, presumption in workers compensation can often mean accepting responsibility for the contraction of a highly communicable virus that carries a multitude of implications both for the employee and the employer. This broad, vague definition of presumption in workers compensation has made it even more difficult to distinguish between ordinary disease of life and occupational [...]

Earn continuing education credits for free without ever leaving your desk! To help foster the growth and success of our adjusters, C3 is offering complimentary professional development courses for Texas state credit. These courses are fully remote and taught via webinar, so you can brush up on your knowledge of topics such as ethics, impairment ratings and file review all without leaving your desk! Below is a 2021 fall schedule of professional development courses offered by C3 that are available for registration. *Please note: if you are a continued education or HR coordinator who needs additional dates for groups of adjusters between 6-50, please email avillalba@comp-consultants.com to schedule a webinar for your group.  Thursday, August 26th 12PM-1:00PM Pain Concepts for the Comp Adjuster - 1 Credit Hour Since perception and tolerance of pain vary widely from individual to individual, pain is difficult to define and describe. This course will go over the types of pain and how it is defined and considered in workers compensation claims, and why. Register Now Thursday, September 9th 12PM-1:30PM Cost Containment Strategies for Workers Comp Adjusters - 1.5 Credit Hrs A return to basics for adjusters that refreshes what the statute in your [...]

Statistically the most commonly filed workers comp claim, strains and sprains account for nearly half of all reported workplace incidents (according to the BLS). Although these two injuries vary significantly, oftentimes workers are clinically diagnosed with a combination strain/sprain injury, which can cause confusion when it comes to determining appropriate treatment and compensation. To clarify, a sprain is an injury to a specific ligament while a strain is an injury to a muscle. Ligament injuries such as sprains involve a stretching or tearing of the tissue, whereas strains occur in a muscle or tendon and can range from a simple overstretch to a partial or complete muscle/tendon tear. Both sprains and strains are most likely to occur in the manufacturing, moving, transportation, and warehouse industries, however they can happen in virtually any job or industry. Since the treatments, interventions and length of injury for a sprain and strain vary widely, it is imperative that the distinction be made between these two pathologies when accepting a compensable diagnosis for a workers comp claim. Statistically one of the most commonly reported workplace incidents, strains and sprains account for over 30% of all workers comp claims (according to the BLS). Since [...]

Back Injuries What Adjusters Should Know Statistically one of the most common compensable injuries in the workplace, back pain accounts for over 20% of workers compensation claims in the U.S. With half a million employees making back injury claims a year, the cost to employers is continuing to increase significantly. Recent data shows that the cost for an employee back injury can be anywhere from $40,000-$80,000, but the average payout from employers is $24,000. While many of these workplace injuries occur in more physically demanding industries such as construction, there are also a surprising number of back pain claims made by employees that spend the majority of their work day sitting at a desk. This is why it is important for adjusters to understand the various elements of back injuries and how they are treated and compensated in workers compensation claims. Cost containment tools such as Early Compensability Assessments and Diagnostic Re-reads can also offer much-needed clinical insight into these complex claims and help identify key components of a workplace injury to determine what the exact compensable injury is and how it should be treated. Because back injuries can occur in virtually any workplace situation - and [...]

Physician Pre-Authorization One of C³'s most crucial containment tools, our pre-authorization services rely on the expertise of medical specialists to answer specific questions related to utilization of care and claimant treatment plans in workers comp claims. During the pre-authorization process, C³'s board-certified physician reviewers provide medical, evidence-based determinations on medical necessity and assess the appropriateness of the: Proposed treatment Level of care Length of stay Treatment setting C³'s pre-authorization services are quick and efficient, giving adjusters the results they need in less time. And our expert panel of board-certified physicians can provide accurate, thorough reports on a wide array of claims to help adjusters successfully contain costs. The above video features one of C³'s physician panelists Dr. Steven Thornton as he discusses the importance and benefits of utilizing expert pre-authorization services. Call us today at (512) 519-9069 to learn more about C3's superior cost containment services. Learn More