Case Study 1 – Administrative PR-4
Recordable workers’ compensation claims in California often needlessly result in delayed case closure, or no case closure at all. Open cases pose unnecessary expenses and delays for all stakeholders, as the claims remain ambiguous with regards to future treatment or the ongoing status of the injured worker. Cases that remain open without a closing PR-4 report are in danger of complication due to subsequent injuries after being lost to follow-up, and cause unnecessary risk exposure to the stakeholders. Sometimes offices close cases administratively, assigning a zero percent impairment rating without supporting data or analysis. In addition to being incorrect, this behavior also causes confusion in liability and subsequent injuries, as the case has not been properly documented and closed.
Medical providers and stakeholders do not have access to a digital timeline tool to identify cases at risk for delayed closure. Providers do not understand their responsibility to close cases with a PR-4 impairment rating for every recordable case. Adjusters and carriers managing large volumes of cases and may have trouble timely identifying the case status when patients fail to return, or when the medical office fails to deliver a PR-2 report within 45 days.
A 37-year-old female has filed for low back pain and right radiculopathy. She undergoes physical therapy; X-Ray and a trial of conservative care management are completed. At 8 weeks post injury she remains on modified duty, and fails to attend her PR-2 follow up appointment. The doctor’s office attempts to contact her with several phone calls, and is unsuccessful. She is not scheduled and the case remains open for six months. During this time, the provider receives multiple letters from insurance carriers requesting MMI or claim status. These go unanswered because the physician doesn’t understand how to proceed. The patient continues to receive partial temporary disability payments. The insurance company has no recourse but to now request a QME for a summary update on the injured worker adding additional cost and time delay.
Kura MD’s digital case management platform, allows users to track and follow PR-2 status. When the patient fails to return for a visit, an administrative PR-4 can be created with a single click, importing the ratable elements of the case, and creating an impairment rating value based on the data set. This allows stakeholders to have closure on the claim, thereby remaining compliant with labor codes that specify the need for delivery of an impairment rating in a timely fashion with accurate analysis of the data to support impairment value delivered.
In our stated example above, an administrative PR-4 report was created on our software platform. The following ratable data set and apportioned items were noted:
- BMI of 32.5 kg/m2
- A lumbar analog pain score of 4/10, with a 75% frequency.
- No leg pain at last clinical visit.
- No decreased activities of daily living.
- Mild degenerative changes documented on plain film X-Rays at the L2-S1 levels.
A 3% WPI rating was returned using the range of motion method, which best described the individual’s condition. A 23% apportionment was provided for non-industrial degenerative changes, and another 23% apportionment was provided for non-industrial obesity (according to World Health Organization weight scoring). A final non-industrial apportionment value of 41% was delivered. Future care was recommended for ongoing symptoms that included access to therapy, medications, and diagnostic testing. Functional limitations, that include no lifting over 15 pounds and no bending more than ten times per hour, were converted to permanent limitations. A comment was included that the patient may return to the clinic for functional measurement if she chose to do so. This claim was subsequently closed.
When stakeholders have access to a systematic approach for the creation of administrative PR-4 reports, cases can be adjudicated and/or closed in a legally compliant and transparent method for stakeholders. In the case above the insurance company receives a fully complete and legally compliant report and the injured worker can be notified that her claim has been made permanent and stationary. Partial disability payments can now be stopped, and the employer can make a determination on their ability to meet permanent functional limitations in the workplace. For these critical reasons, access to a comprehensive digital workers’ compensation injury mapping tool such provided by Kura MD, saves money, time, confusion, and risk of litigation.
Case Study 2 – Case Management
Cases are managed unpredictably between doctors practicing in the same medical group as well as across different medical practices. This leads to inconsistency, delay, and a varied experience for the stakeholders who pay for the system and consume the reports. A single identifiable problem is that there is no assigned “policeman” to ensure that workers’ compensation cases in California are moved forward using a standardized approach.
- Medical provider individual experience.
- Varied understanding of legal requirements for compliance of timelines.
- The lack of a digital tool/platform to properly format, interview, and systematically track treatment recommendations and requests for authorization (RFA) in a time-sensitive way.
A forty-two year old right-hand dominant labor worker injures his left shoulder. He is seen for his Doctor’s First Report (DFR), and physical therapy is ordered. He returns to the clinic two weeks later and the insurance company has been unresponsive. He has been treated with over the counter anti-inflammatories and a home exercise program. The provider and patient are frustrated that there’s been no response on the RFA for physical therapy. The patient has been scheduled to follow up in 4 weeks or sooner if there are updates on the request. The patient returns one month later, but there has been no response from the stakeholder. The provider’s office makes continued attempts to reach the adjuster without success. Another eight weeks pass and the injured worker and the employer become frustrated with the system. The injured worker seeks legal counsel to advocate treatment. He has remained out of work the entire time.
The California Workers’ Compensation system is set-up with a system of checks and balances to ensure treatment is authorized in a timely fashion. Additionally, there are medical treatment utilization guidelines (MTUG) that are adopted by law to guide the physician through evidence based diagnostic testing and treatments. Understanding timelines offers an opportunity to move these cases sequentially forward and request ongoing staged treatment regardless of authorization, denial, or unresponsiveness. Using this method, the claim can move forward and be documented as to treatments and responses to those treatments. This is called “developing the chart”. When workers’ compensation judges review cases, they judge on the level of case development and documentation of timelines attempts for treatment. If timelines of the cases are not well documented, the judge may have to return the injured worker to the doctor and/or assign the injured worker to another provider in the community better develop the chart.
Performing Case Management using Kura MD
When cases are created in a digital timeline environment, using Kura MD’s rating tool software platform, treatment requests and authorizations may be tracked using the RFA tracker feature. This tool allows the users to automatically create cards and document when an RFA is created, and to which PR-2 it belongs. In California a RFA requires a response within five business days. If treatment is denied, the patient may be brought back in 5 days to document a response (or lack thereof) and the next step of the treatment guidelines can then be ordered. This process can be repeated until all treatment options have been exhausted, or until the patient has recovered from their injury given authorized treatment at maximal medical improvement (MMI).
Kura MD’s rating software is a tool that allows stakeholders the ability to create and monitor treatment recommendations from the Primary Treating Physician (PTP). This allows cases to move quickly in a predictable timeline, and advance to the next steps of recommended treatment when treatment requests are either denied or not responded to by utilization review and/or the insurance carrier. Using this tool in the context of our example, the case study patient could have been brought to MMI status eight times faster, increasing the chances of treatment and/or administrative development of the chart for final claim adjudication. Using Kura MD this claim could have been accelerated and closed without frustration using Kura MD’s time-sensitive case management platform.