surviving wc/ utilization review - coa
TRANSCRIPT
Surviving WC/ Utilization
Review
Lesley J Anderson MD
COA WC Chair
San Francisco, CA
Disclaimers
Consultant/ Advisory Panel/Stock
Trainer-RX
What’s the best option in today’s environment?
The Problem
No payment for outside time
P and S
AOE/COE
Requested reports
NCM Visits
“Consults” still being requested
The Problem
UR has gotten more aggressive with
denials- NSAIDS, slings
Break up PT visits
80% requests are sent to UR by some
carriers
$1000 Motrin article
IMR- upholds denials 89% of the time
2016 on average (160,000)
>50% are for meds
So what to do?
So what to do?
What you CAN do
Know the rules of the game
Be efficient and be better
Tips from a respected Ortho
Reviewer California providers make the most
unreasonable requests compared to other states
They add body parts
Issue several and excessive RX for opiods
(#100)
Bad players are small, but everyone suffers
Reviewers do have some discretion
Tips from an Ortho Reviewer
If FP or PMR reviewer - ask specifically on
appeal for orthopedic surgeon.
Postop issues/PT should be reviewed by
an orthopedic surgeon
Tips from an Ortho Reviewer
PT visits- document “measurable
functional improvement” and be specific
(ROM, fewer pain meds, ADLs);
Clarify also number of visits remaining from
prior auths (ask for 12 but 6 are remaining)
Quote ODG allowable visits
ODG and PTRotator cuff syndrome/Impingement syndrome:Medical treatment: 10 visits over 8 weeksPost-injection treatment: 1-2 visits over 1 week
Post-surgical treatment, arthroscopic: 24 visits over 14 weeksPost-surgical treatment, open: 30 visits over 18 weeksSprained shoulder; rotator cuff tear:Medical treatment, sprain: 10 visits over 8 weeksMedical treatment, tear : 20 visits over 10 weeksPost-surgical treatment, arthroscopic: 24 visits over 14 weeksPost-surgical treatment, open: 30 visits over 18 weeksMassive rupture of rotator cuff:Post-surgical treatment, arthroscopic: 30 visits over 18 weeksPost-surgical treatment, open: 40 visits over 18 weeks
ODG and PT
Intervertebral disc disorders without myelopathy:Medical treatment: 10 visits over 8 weeksPost-injection treatment: 1-2 visits over 1 weekPost-surgical treatment (discectomy/laminectomy):16 visits over 8 weeksPost-surgical treatment (arthroplasty): 26 visits over 16 weeksPost-surgical treatment (fusion, after graft maturity): 34 visits over 16 weeks
Tips from an Ortho reviewer
Shoulders- surgery request
Document cervical spine exam including
Spurlings, motor, reflexes
Quoting the guidelines or a checklist are
helpful
Steroid injections- document if done and if
not, why not…even if controversial
Low yield procedures (lumbar fusion) get
added scrutiny; so document…
What you CAN do
Use of evidence based medicine
What is being routinely denied?
Preempt their denial with specifics
COA Check lists –
www.coa.org/education/ur-checklists
Automate your RFA to be complete
COA checklistRC repair example
Criteria for Rotator Cuff Repair Check if
documented
Full thickness Rotator Cuff Repair- r/o Cervical
and adhesive capsulitis
Pain
Inability to elevate arm
Tenderness over Greater tuberosity
PLUSMay be Weakness of Abduction
May have Atrophy
Full passive ROM may be present
PLUSX-rays AND MRI, UTZ, or arthrogram show
deficit in RC
COA Checklist- CTSI. Severe CTS, requiring ALL of the following: A.
Symptoms/findings of severe CTS, requiring ALL of the
following:
II. 1. Muscle atrophy, severe weakness of thenar muscles
III. 2. 2-point discrimination test > 6 mm
IV. B. Positive electrodiagnostic testing --- OR ---
Not severe CTS, requiring ALL of the following:
A. Symptoms (pain/numbness/paresthesia/impaired
dexterity), requiring TWO of the following:
1. Abnormal Katz hand diagram scores
2. Nocturnal symptoms
3. Flick sign (shaking hand)
Carpal Tunnel
B. Findings by physical exam, requiring TWO of the following:
1. Compression test
2. Semmes-Weinstein monofilament test 3. Phalen sign
4. Tinel's sign
5. Decreased 2-point discrimination
6. Mild thenar weakness (thumb abduction)
What you CAN do
Make sure add how long from from injury
Injection and results;
Number of PT visits -document
If you are denied after supplying all this
information:
COA wants your redacted cases!
Send to “[email protected]”
Develop your own “No Fly List”
Develop your own non-negotiable list of issues-individual decision
UR
Meds, Imaging, Injections, Surgery, PT
Lack of payment or delay in payments
Delay in care for patient- does it put you in a vulnerable position?
Consider doing consults, provide an opinion and then refer back
If they will not negotiate, I will not play.
They need our P and S reports – do not do
unless approved in writing- consider QME
Upcoming Changes
UR bill requires UR companies to be
accredited
Collect data- of unreasonable denials
Drug Formulary coming- July 1 2017
2017- MC bringing back code to bill for
outside time.
2017- Medicare/DWC changes“Document, Document, Document”
99358-99359 billable and reimbursable
Non face to face time
Must document in report what you reviewed,
how long-
>30 minute - less than 30 min not
reimbursable
Can be on a different day from encounter-
Additional hospital time
2017- Medicare/DWC changes“Document Document Document”
99354-99355 billable and reimbursable
Prolonged service FACE TO FACE
Must document nature of prolonged time
30 minute intervals-
99358 = $149.40 for the first hour
99359 – >1 hr $71.97 for each 30
minutes
www.daisybill.com- Free webinar
Unreasonable denials
If UR denies a medication/sling/ etc. have patient request an IMR-
Costs about $400 per IMR to the employer
Peer to peer
Call the adjustor if UR denies; often they are able to approve
Resubmit RFA after
addressing reason for
denial
Injection
6 visits of PT
Use the COA checklist
Use a prenegotiated
formCOA website
How to get around PT delays/
improve outcomes?
Online PT programs- Trainer RX
WC will pay
You can track the patient’s
progress online
Engage the patient preop
Expectations of RTW-modified
and full duty
Summary
Develop relationships with your payors
5-10% of abuses in orthopedics punish the
other 90% by over regulation
Look at successful models that are saving
costs and rewarding docs
My opinion; this will not be fixed by DWC
or legislature- need to work with the
employers and unions and access to care
has to be an issue before they pay
attention.
Who is missing from this equation???