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Communicate with physicians to reduce claim costs

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DANA POINT, Calif. — Better communication between payers of workers compensation claims and physicians can improve outcomes for injured workers and decrease employer costs, experts say.

“Physicians are the most critical component to a successful health care experience,” said Dr. Teresa Bartlett, Troy, Michigan-based senior vice president and medical director of Sedgwick Claims Management Services Inc. “Their communication skills often set the stage for recovery and the expectation of the healing process.”

When physicians tell employers whether injured workers should or shouldn't return to work rather than what they functionally can or cannot do, employers have a harder time matching workers with appropriate light-duty jobs, said De Ann Wagner, assistant vice president of claims at York Risk Services Group Inc. in Inland Empire, California.

Payers also dislike when physicians engage in aggressive or unnecessary medical testing, and when they render medical care outside evidence-based guidelines without clearly documenting why, Dr. Bartlett said.

Meanwhile, submitting untimely utilization review responses or not conveying the covered conditions within a claim are examples of payer behaviors that can lead to contentious relationships with physicians, she added.

Dr. Bartlett, Ms. Wagner and other experts in attendance at the 2015 California Workers' Compensation & Risk Conference in Dana Point, California, earlier this month stressed that effective communication requires participation from both parties.

Health care providers want to know if an employer has a formal return-to-work program in place, Ms. Wagner said. She told risk managers to make it clear that “you want them to embrace (the program) and you want them to partner with you” by offering work restrictions instead of temporary disability, for example.

Having physicians tour the worksite provides a greater understanding of workers' functional requirements, Dr. Bartlett said, adding that supplying pictures, videos and job descriptions is also helpful.

Payers and physicians should at least feel comfortable enough with each other to pick up the phone and call regarding questions or issues, experts said, noting that utilization review tends to be a big point of contention.

“I never, after (33) years in my practicing time, had (a treatment) denied when I offered to pick up the phone and speak with an adjuster,” said Dr. Bernyce Peplowski, senior vice president of national medical strategy and innovation at U.S. HealthWorks Medical Group in Los Angeles. Health care providers can't “be afraid to pick up the phone,” Dr. Peplowski added.

At Sedgwick, “there is a higher degree of scrutiny and UR” with physicians who don't obtain good claim and medical outcomes, Dr. Bartlett said. “Doctors definitely need to know they are being watched and held accountable.”

It is the workers comp industry's responsibility to drive the use of evidence-based care, which is “based on the latest research and ensures physicians are staying current with new technology and medical practice,” she added.

California's medical treatment utilization schedule “provides medical treatment guidelines for utilization review and an analytical framework for the evaluation and treatment of injured workers,” according to the state's Department of Industrial Relations.

Dr. Rupali Das, executive medical director of the California Division of Workers' Compensation, said “a big part of our focus now is educating physicians” that there is a medical treatment utilization schedule and “how to apply it to patients, how to apply it to practice, and to encourage them that this is something they should do.”

Evidence-based care isn't an excuse to deny care, Dr. Das said. “It is the application of the best scientific evidence that's out there, but it has to be tailored to the individual patient ... Physicians are the ones who start the treatment process, and if we can get the message to them to do the right thing, we can avoid a lot of problems later.”