Category Archives: Claim referral

Best Practices, Claim referral, New Jersey

Workers’ Compensation’s Costly Psychosocial Issues (2)

Yesterday, we described the challenges confronting claims adjusters and injured workers when psychosocial issues are present in a workers’ compensation claim. These issues impede recovery and exacerbate costs. Whistling a happy tune, we  picked up our saw and confidently walked out on the proverbial limb to suggest this thesis:

Our nation’s current system for treating injured workers with mental health issues is uncoordinated, overly fragmented, highly wasteful and does not focus enough on speedy return to work. There is a critical need for a more systemic approach as well as an integrated coterie of clinicians and practitioners, trained in workers’ compensation, whose goals are to provide compassionate treatment with a steady return to work trajectory. 

Taking a large gulp after writing this, we listed the serious factors that make finding a solution to this looming crisis tremendously difficult.

But early in 2015 in New Jersey two Neuropsychologists, Mary Ann Kezmarsky and Richard Filippone, had an idea. Over a couple of decades, they’d treated a number of workers’ compensation claimants and had been appalled by what appeared to be the lack of a coherent system to deal with the issues they saw in their patients. They weren’t exactly sure what to do about it – they didn’t know much about workers’ compensation – but they saw it as a business opportunity. Well, they are “we,” and here’s what we did with that idea.

We contacted Tom Lynch, of Lynch Ryan, a nationally recognized consultancy in workers’ compensation, and over the next year and a half created a company, Workers Compensation Psychological Network (WCPN), and built a systemically organized and integrated specialty network of workers’ compensation clinicians and therapists to treat injured workers in New Jersey who might have behavioral health issues delaying recovery. With Tom’s help, here’s how we did it:

  1. During the the last half of 2015, we recruited, credentialled and vetted 44 mental health professionals covering 55 offices throughout New Jersey’s 21 counties. Providers within WCPN’s network include psychologists and neuropsychologists, as well as cognitive rehabilitation and biofeedback specialists. All of the clinicians and therapists gave up a weekend to attend Lynch Ryan training in workers’ compensation. They learned about the New Jersey law, as well as the way workers’ compensation works – how a premium is constructed and  what indemnity and medical benefits are. They now understand experience modification, maximum medical improvement and the law regarding injuries “arising out of and in the course of employment.” Further, they have been educated regarding early return to work and have agreed to work with employers, adjusters and nurses to effectuate modified duty wherever possible.
  2. We built (with difficulty, because it wasn’t easy) the nation’s first electronic Claimant Intake & Referral Portal that allows claims adjusters, nurse case managers and attorneys to refer a claimant instantly. The paperless portal’s referral system is geographically and specialty based, meaning that referrers are assured that claimants will not have to travel far to reach their assigned clinician. In the past, referrals and appointments took weeks, even months, to arrange, but now they can be finalized within minutes. In Beta Testing from May through October, 2016, the longest time from referral to Provider scheduled appointment was 27 minutes.
  3. We built (with even more difficulty) the nation’s first mental health Electronic Health Record system for workers’ compensation. The EHR is set up as a roadmap for all WCPN clinicians to follow, meaning reports have a consistently structured form. The EHR is paperless, HIPPA-compliant and cloud-based. Initial Psychological Evaluations and subsequent treatment reports reach claims adjusters in pdf form within five business days.
  4. Our clinicians are all highly qualified and experienced; they know how to treat workers with mental health issues delaying recovery. But to make the system work we needed to understand the needs of adjusters and defense attorneys who would be referring the injured workers the clinicians would treat. Consequently, we conferred with experienced adjusters and defense attorneys. After doing so we decided that every referral would begin with a thorough Initial Psychological Evaluation (IPE), which, although not technically an IME, would be done at the IME level (we priced the IPE at $450, and, since nobody’s complained, we now think that’s too low, but we’re sticking with it). If the Initial Psychological Evaluation determines the presence of one or more mental health issues which are deemed to be work-related and requiring treatment, the treatment prescribed is initially authorized for up to 12 sessions unless medically justified, extraordinary circumstances are present. Additional treatment requires the approval of the referring party.

We officially launched in November, 2016. Over the intervening three months  we’ve learned two things (among a lot of others): First, our solution works extremely well; referrers have been highly receptive and pleased. They appreciate the ease of referral, the EHR reports and the fact that claimants do not have to travel far to see a qualified clinician. Even more, they appreciate that our clinicians and therapists have been trained in workers’ compensation.  Second, this could be a national solution.

So, our solution is working in New Jersey, but every state workers’ compensation system is grappling with how to deal with psychosocial issues that frequently hobble recovery. This may be work comp’s final frontier. Time will tell whether our template and software could help others. Regardless, we will continue to improve our solution at Workers Compensation Psychological Network, as well as report on our outcomes.

It’s taken us nearly two years to get to this point, but, for the sake of the many injured workers suffering psychosocial comorbidities, as well as the claims adjusters who work tirelessly to help them, we think it’s been worth it.

Claim referral

Psychosocial Issues And How To Deal With Them

Workers’ compensation claims adjusters are busier than the Ed Sullivan Plate Spinner. Running around with one or two hundred lost time claims would make anyone dizzy, but at the recent National Workers’ Compensation & Disability Conference (NWCDC) in New Orleans, presenters tossed the frazzled spinners a few more plates to shoot up on the sticks.

The issue? Psychosocial factors delaying claim resolution.

At one well-attended session, Marco Iglesias, Medical Director for The Hartford, and Robert Hall, Corporate Medical Director for Optum went into great detail about how psychosocial factors rear their heads in the claim process and how they impede recovery.

For example, consider these research statistics based on a study of 75,000 claims:

Time out of work increases 30% for a musculoskeletal claim with one co-morbid complication;

Duration increases 57% if the claim co-morbidity is depression;

According to The Hartford’s Dr. Iglesias, 10% of claims, the ones with all those psychosocial issues, cause 60% of claim costs;

At another presentation, attendees learned that Mental Health, Addiction and Obesity are the three comorbidities causing the greatest cost and time away from work.

Also, according to an AETNA presentation, 97% of depressed patients have a second co-morbid condition.

Research aplenty; solutions, not so many.

The pitch at the conference seemed to be two-phased. First, here are a number of factors, which, if present, can significantly delay recovery (see our Predictive Triggers post for more on this). Second, if you’re an adjuster or nurse case manager and you recognize any of these factors in one of your claims, put on your sensitive side psychology hat and provide gentle guidance and counsel to help the injured worker overcome the problems delaying recovery.

At the breaks after the sessions adjusters were talking in small groups about how this was all well and good, but it required increased time on claim, time they didn’t have. Also, many of them admitted that their claim resolution approach, honed over many years, veered more to the cut and dried than the touchy feely.

So, what should overworked adjusters and nurse case managers do with this  fast-approaching, ever-enlarging, dead-ahead iceberg?

Well, there are three critical things to know when one suspects the presence of psychosocial triggers:

First, are they real?

Second, are they work-related?

Third, are they truly impeding recovery?

The only way to know with credibility the answers to those three questions is to have a qualified clinician conduct a thorough Initial Psychological Evaluation.

So, with all due respect to the excellent doctors who presented at the NWCDC, we suggest logging in to our claimant Intake & Referral Portal and referring these difficult claims with their thorny issues for a highly-reliable, speedy and comprehensive Initial Psychological Evaluation. The cost is only $450, and you’ll be glad you did it.

That’s all part of our pledge to you: Recovery – Sooner, Faster, Smarter!

 

Claim referral, Testing

Predictive Psychosocial Triggers For Workers’ Compensation Claims

There are a number of factors, which, if present, provide accurate prediction of who will benefit from early psychological evaluation. Current research is conclusive that the two most predictive psychological factors regarding who will file a non-traumatic occupational injury claim are:

  • Job task dissatisfaction; and,
  • Distress as reported on Scale 3 of the Minnesota Multiphasic Personality Inventory (MMPI). The MMPI Scale 3 was created using patients who exhibited some physical complaint for which no general medical explanation could be established.

However, employers rarely sense job dissatisfaction in one of their workers and claims adjusters don’t administer the MMPI to claimants before or even after they file claims.

So, when we attend claims association meetings in New Jersey, we are often asked what psychosocial factors, if present in a claim, should prompt a speedy referral for an Initial Psychological Evaluation. With that in mind, and drawing on the best evidence-based scientific research available, we’ve put together a list of specific Predictive Triggers for workers’ comp claims, Triggers which, if three or more are present, indicate early referral for an Initial Psychological Evaluation  is important. Keep in mind that our Initial Psychological Evaluation, although not technically an IME, is done at the IME level.

In no particular order, here are the Triggers:

  • History of abuse, sexual and/or physical
  • Excessive alcohol consumption
  • History of narcotics abuse
  • Depression, or a history of it
  • Coping inadequacy
  • Two or more prescriptions for narcotics
  • Perception of poor health in general
  • Passive attitude
  • Widowed or divorced
  • Tendency to catastrophize and make a referral
  • Blue collar, physically demanding job
  • Complaints of headaches, with no head injury
  • PTSD complaint, without traumatic experience
  • Age over 40
  • Low non-work activity levels
  • History of Somatization (Somatization is the conversion of anxiety to physical symptoms)
  • Driving distance from home to work greater than  30 miles
  • History of filing workers’ comp claims, or other legal claims
  • Poor performance in high school

If you’re a claims adjuster, a nurse case manager or an attorney handling workers’ comp claims, you’ve seen many claims where a number of these Predictive Triggers are present. And you’ve probably been frustrated because the claims have not closed when they should have; they drag on; MMI seems elusive. Workers Compensation Psychological Network can help. Give us a chance. Create an account and login at www.wcpn.net to Make a Referral: Sooner – Faster – Smarter.

Best Practices, Claim referral

When Should Adjusters Refer Claims For Mental Health Evaluations?

As we roll out Workers Compensation Psychological Network to New Jersey’s insurers, third party administrators, self-insured employers and defense attorneys, we are often asked how to tell if a claim needs referring, as well as how to how to decide where to send the referral.

Well, in order to provide the best possible service, we believe whoever you send claimants to for psych evaluations and/or treatment should understand a few things. Here’s what we understand:

  • We understand MMI, and we know you want your claimants to reach it as soon as possible. We do, too. In a limited number of sessions we can achieve MMI sooner, faster, and smarter.
  • We understand Permanency Benefits, credits and the importance of a deeply detailed patient history. In our first session we will dig down to discover in as much detail as possible the background of the person we are seeing. This information is vital to bringing the claim to a fair and reasonable outcome for you and the claimant.
  • We understand that there is an epidemic of head injuries in New Jersey today and that most head injuries can reach MMI satisfactorily and quickly given the right treatment.
  • We understand that you need information in real time, which is why we’ve built New Jersey’s first online Claimant Referral and Electronic Health Record system for mental health issues.
  • We understand that most claimants who need mental health treatment can return to work in some modified duty capacity as they recover. That’s why our clinicians have been trained in how to work with you, the claimant and the claimant’s employer to find the right modified duty, thus lowering the cost of indemnity payments immediately.
  • Finally, we understand that, although claimants may benefit from mental health treatment, in many cases the cause of their distress is not work-related. In our Initial Psychological Evaluation we are expert in determining if a mental health issue “arose in the course of employment.”

When should you make a referral to us? The answer is when you notice in the claim any of the following:

  • Complex head injury
  • Concussion diagnosis
  • Chronic and/or continuing acute pain
  • Severe depression
  • High anxiety
  • Fear of returning to work
  • PTSD diagnosis

We understand that therapy has to fit the person. We are expert in:

  • Cognitive Rehabilitation
  • Biofeedback
  • Psychotherapy
  • Neuropsychology

We would welcome the opportunity to explore all of the ways Workers Compensation Psychological Network can work for you. Your time is precious. We won’t waste it.

This is our pledge to you ­– Recovery: Sooner, Faster, Smarter.