Employers are required by federal and state laws to carry workers' compensation (WC) insurance, provide comprehensive occupational medical services for work-related injuries and record certain work-related injuries for the Occupational Safety and Health Administration (OSHA).
The best way to substantially reduce the number of WC claims and OSHA recordable events is to develop a comprehensive medical management system. A medical management system is designed to prevent, treat and manage occupational injuries. This systems-based approach to medical management should not be confused with a "band-aid trailer" or a "first aid station." And if your medical management system is operating effectively, it should provide a demonstrable return on your investment in its implementation and maintenance.
Objectives
The objectives of a medical management system are to:
- Manage all patient encounters
- Deliver nationally-accepted standard of care
- Earn employee respect and comfort level
- Create a partnership in the prevention and treatment of injuries
- Provide specific management oversight to ensure an effective system
Case Management
An effective medical management system requires the hands-on case management of all patient encounters, both those treated onsite and those referred to offsite providers. The first step in this management approach is to treat the injuries according to the accepted standard of care. Next, identify injuries that fall under the first-aid determinations established by OSHA. Many times injuries treated offsite fall under the definition of medical treatment rather than first-aid because of certain treatments rendered at an emergency room or clinic.
A primary goal in case management is to keep injured employees onsite. If the worker goes to an offsite care facility, they will still be paid while in the waiting room, and if accompanied by a supervisor, this doubles the indirect cost of waiting. And, every time an employee visits an offsite clinic, the clinic is going to send the employer a bill, which will increase WC costs and increase your Experience Modification Rate (EMR).
A large number of injuries that would be generally considered OSHA recordable can be managed onsite. For instance, simple lacerations that receive one or two sutures can be treated onsite with a sterile wound adhesive (the same product used in hospitals)
If it is determined that a case should be referred to an offsite provider, the onsite medical management representative will control the situation and function as the patient's advocate to return them to duty in a healthy, cost-effective manner.
Any clinic or physician visit should be pre-qualified, and referrals should be with the most appropriate facility or clinician. For example, a worker with a particle in his/her eye should not be sent to the emergency room or a clinic, but referred directly to a pre-qualified ophthalmologist. This will prevent an unnecessary bill. It could also save a recordable report since the ophthalmologist was pre-qualified. (The pre-qualification of a provider is very detailed and too complex and lengthy to be included in this article.)
The medical management department should be attentive to any medical treatments or modalities that appear excessive, for instance, physical therapy or chiropractic treatment are notorious for abuse. In addition, the medical department should assertively manage all WC cases. This might necessitate involving investigators early and aggressively in suspected malingering cases. The medical management department should:
- Communicate daily with injured employee for the first week. Bi-weekly after the first week.
- Communicate with offsite provider after each visit.
- Communicate early with corporate WC in questionable cases.
- Communicate with third-party administrators (TPA) and/or carrier for reserves that seem too high.
- Have TPA/carrier close out claims as soon as employee is back to full duty (as allowed by state laws).
Standards of Care
The medical management department should deliver the accepted national standard of care every time. This results in fewer offsite referrals, and fewer referrals mean fewer workers' compensation claims, lessening the chance of needless OSHA recordables. A high standard of care and treatment also helps employees get right back to work with minimal
