Cumulative Trauma Claims, whether stemming from keyboard entry or repetitive lifting, require a very specific and thorough investigation. It is important not to settle for the kind of routine investigation that may be performed on an undisputed claim. Cumulative Trauma claims should always be considered questionable. In our experience, not only did the claimant usually have the injury before employment, but we have found numerous instances in which surgery for the same injury had been recommended before as well.
Listed below are important investigative tips for cumulative injury claims. In these types of situations, we recommend obtaining the following information:
- Medical restrictions keeping the claimant from working
- Offending job duties and tasks being alleged as harmful
- Medical history, including the name of the family physician
- Prior medical records including Trace America search, if necessary
- Sports, hobbies and special interests and other activities of the claimant
- Job description for regular and transitional duty
- Prior employment history and records, if possible
- Comparison of prior medical records with current records to establish if the condition has changed, or if it is truly an aggravation. Additionally, you can determine when any such alleged aggravation had been resolved bringing the claimant back to the pre-injury status.
- Ask the doctor to comment on causal relationship after all the information is in on prior medical and the job description is available
It is important to understand that the employer’s obligation is only to bring the employee back to their pre-injury status. If their pre-injury status was not 100%, the employer is not expected to make the employee 100%. That is why it is extremely important to uncover as much prior medical history as possible in order to ferret out an unknown pre-existing condition and/or to benchmark the claimant’s condition prior to the alleged aggravation. Only then can you determine when the alleged aggravation has been resolved and the employee is brought back to his or her pre-injury status.
A return-to-work (RTW) program is an important part of workers compensation management, second only to accident prevention. The success of RTW programs has been shown to reduce workers compensation costs by 10% to 30%.
A comprehensive program involves having a systematic approach for returning injured employees back to meaningful work in a timely fashion. To be successful, an RTW program needs:
- Management commitment and support
- Job descriptions for temporary and/or modified work assignments
- Policies and procedures for each step of the RTW program
- Supervisory communication and training
- Employee training and understanding of responsibilities
- Follow-up and evaluation
While medical cost containment, utilization review, and preferred provider networks can help reduce unnecessary treatment and costs, RTW is an additional way for an employer to control and reduce workers compensation costs and help reduce litigation.
Strategies to Minimize PPO Costs While Enhancing PPO Savings
When a third-party administrator (TPA) or carrier is responding to an RFP, the preferred provider organization (PPO) aspect of the proposal should be carefully reviewed. In some instances, the fees earned on the PPO program by the PPO vendor and the carrier or TPA can exceed the cost of the carrier or TPA’s claims quote.
Below are six items to keep in mind when negotiating a PPO program:
- The goal is to reduce provider charges that are in excess of the fee schedule for usual and customary charges. Interestingly enough, many PPO vendors charge a fee as a percent of savings for reductions that the state already guarantees. PPOs should only charge for savings that are higher than the state’s fee schedule for usual and customary charges.
- Header charges and per-line minimum fees should always be avoided.
- Per-line charges are more cost-effective than percent of savings. It is not unusual for the PPO vendor to pay a percent of savings back to the TPA or carrier. This, however, is generally, not disclosed.
- All CPT codes with a modifier of 3 or greater should be reviewed by a medical professional to ensure that the amount billed for the CPT code matches with the services rendered.
- Unbundling of services or procedures. A common type of unbundled services is nerve conduction studies. The CPT code defines “each nerve,” not each site tested on a nerve, which increases the cost. Spinal ultrasounds are ordered frequently by chiropractors for soft-tissue injuries. Although the value of this testing is questionable, it is frequently unbundled into multiple segments of the spine or billed as an ultrasound of the head and neck, a spinal ultrasound and a pelvic ultrasound for the lumbar spine. The CPT code "76800" describes an ultrasound of the entire spine and should only be billed one time.
- Proving unnecessary services or tests. These can easily be identified by a medical professional.