Labor Day: Near and Dear to Those in Workers’ Comp Industry

| | Technology & Integration, Utilization Review

Jaelenes Sept Labor Day Message Sept 2016

Labor Day. What does it mean? I like the definition on the US Department of Labor’s website: “a yearly national tribute to the contributions workers have made to the strength, prosperity, and well-being of the country.”

Labor Day is a great opportunity for workers’ compensation stakeholders to reflect on how American workers contribute to the well-being of the country. I think of American workers as our country’s greatest “assets.” Quite simply, in our business, these “assets” are people who “labor” and are injured on the job. This hasn’t changed since the first workers’ compensation laws were adopted. But today’s workforce provides new opportunities and new challenges.

Recently, the WCI Conference Panel, “Managing Workers’ Compensation Claims in a Diverse Workforce”, succinctly outlined the current and emerging changes in workforce diversity. These include a multilingual workforce, various comorbidities, an aging workforce, and with the Millennial generation, a younger workforce. The panel also discussed the injured workers’ experience, reminding us that every injured worker is an individual. Every injured worker is a person, like you or me, who wants to get better.

The same week as the WCI Conference, California Department of Industrial Relations Director Christine Baker released a statement on SB 1160 titled, “Speeding Care to Injured Workers.” Director Baker said, “We all agree that the sooner an injured worker is treated in the critical first month of injury and the sooner the worker returns to work is the best outcome for the worker and the employer.”

We all agree that every injured worker is an individual and that providing the appropriate medical care is important. Determining the appropriate care, especially for those employees in the “aging workforce” and those with comorbidities, requires coordination among several stakeholders. Here are few of my thoughts on how we can make sure we are doing the best job possible to protect America’s greatest “assets.”

Let’s start with the health care provider who is treating the injured worker and documenting SOAP notes (an acronym for Subjective, Objective, Assessment and Plan). During the patient/provider encounter, the SOAP notes may not distinguish between medical care needed to treat conditions directly related to the injury versus care needed to treat comorbidities.

After the patient/provider encounter, the health care provider may submit a “prospective” request to determine the appropriateness of the requested medical care. Or the provider may deliver the care and the medical necessity of the care will be reviewed “retrospectively.” It is critical during these steps that the person reviewing the prospective request and/or medical bill considers what is appropriate for the individual AND that the reviewer is considering all available medical records. This is as opposed to just looking at each utilization request and/or medical bill in isolation.

Another essential step is the opportunity for the treating doctor and the reviewer to have a real “conversation” to discuss the individual worker’s medical condition. Ideally, both the requester and reviewer will have access to the same medical records so that prior treatment requested and rendered is considered. I firmly believe that a good workers’ comp system is one where both a provider and reviewing physician are looking at substantially similar information. These records should include medical bills and prospective utilization requests and decisions, along with supporting documentation provided by the treating provider.

The integration of medical records with prospective and retrospective medical necessity requests and determinations is critical if we truly want to achieve timely delivery of appropriate medical care. If not, our employee “assets” will not return to work as expeditiously as possible to continue contributing to the strength, prosperity and well-being of our country.

Jaelene Fayhee

Jaelene Fayhee

Jaelene Fayhee, AVP, Client Solutions for UniMed Direct, is a regulatory expert who works hand-in-hand with clients and the technology department to deliver technology and medical solutions to clients. Jaelene is focused on using technology to ensure compliance with current and upcoming regulatory requirements and delivering prompt and appropriate decisions to expedite medical decisions for injured workers.