Happy Thanksgiving From UR Nation

| | Utilization Review

Thanksgiving Graphic from RS
At this time of year, we reflect on things that we are thankful for. This usually includes family, friends, our home, our jobs, etc. We don’t normally think about workers’ comp as something to be thankful for in our lives – unless we’ve had an on the job injury or illness and the system worked for us, helping get us safely back to work.

Let’s think for a minute about our lives without workers’ comp:

  • History shows us that before workers’ comp, an injured worker was often out of luck. It was common for an injured worker to be out of work and unable to pay for his treatment.
  • With no workers’ comp, workers often had to litigate against their employers for benefits. Because workers’ comp today is a no fault system, if you’re injured on the job, you get the benefits.
  • With no workers’ comp, many workers may not give the job their best efforts. After all, if your employer is not going to help with your injuries, why would you risk injury?
Is the workers’ compensation system perfect? Most would say no. But, it is an important benefit. Individual states set the requirements for workers’ comp coverage and establish rules surrounding what that coverage provides, rates and processes. Each state controls the costs (fee schedules), processing times and rules surrounding complaints, appeals and hearings.

Whether you are a first responder or work on a dairy farm, coverage can prove critical to getting the medical treatment needed at the time of the injury. Additionally, as a claimant, you want to ensure that the treatment that is being recommended is evidence-based to ensure every possibility of successful recovery. Workers’ comp regulations in most states help ensure appropriate care in most states.

Have you heard of stories of bad outcomes to medical services? One of the most common situations surrounds failed back syndrome. This is a problem in which, post surgery, the injured worker experiences subsequent degeneration, scarring or other reason for chronic back pain. The treatment for back injuries can be extensive, and often a worker will just want aggressive care in order to be “done” with the pain and suffering. This is especially true as we have become a nation of instant gratification. But, what if:

  • Conservative care improves the injury?
  • Conservative care strengthens the worker and allows him to return to work in some capacity?
  • Conservative care ensures unnecessary surgeries are not being performed?

All of the above could help avoid a potential failed back syndrome. This is why applying commercial and/or state guidelines, utilization review has become an effective tool in managing the claim/injury. The workers’ compensation industry intends to provide the coverage that is needed and appropriate in a manner in which the outcome of the injury is recovery and not continued pain. The industry’s focus is in managing the pain and the medical conditions with the treatment most favorable for a positive outcome.

Recognizing it’s not perfect in any state, the system has improved and will hopefully continue to improve. I believe, as we sit down at our tables for Thanksgiving, we should be thankful for workers’ comp and those in the industry who give their best for injured workers.

Happy Thanksgiving!

Karen Atkins

Karen Atkins, Chief Operating Officer with UniMed Direct, is leading the conversation, and the industry, on how to make the utilization review process more efficient for all stakeholders: physicians, insurance companies and, most importantly, patients.