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OWCA Medical Treatment Guidelines

OWCA Medical Treatment Guidelines. Christopher J. Rich, MD, MBA Medical Director Office of Workers' Compensation. OWCA Medical Treatment Guidelines. Goals of Clinical Practice Guidelines: IOM 2008 S ustain or improve health outcomes Improve the patient experience

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OWCA Medical Treatment Guidelines

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  1. OWCAMedical Treatment Guidelines Christopher J. Rich, MD, MBA Medical Director Office of Workers' Compensation

  2. OWCAMedical Treatment Guidelines • Goals of Clinical Practice Guidelines: IOM 2008 • Sustain or improve health outcomes • Improve the patient experience • Reduce high or escalating costs • Reduce exposure to risk of harms

  3. OWCAMedical Treatment Guidelines • Development of the MTG • La RS 1203.1.C: • The schedule shall be developed by the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients,………

  4. OWCAMedical Treatment Guidelines • Development of the MTG • La RS 1203.1.C: • ……integrating clinical expertise, which is the proficiency and judgment that clinicians acquire through clinical experience and clinical practice, with the best available external clinical evidence from systematic research.

  5. OWCAMedical Treatment Guidelines Best Evidence Available Clinical Experience Patient Values

  6. OWCAMedical Treatment Guidelines • The Medical Treatment Guidelines • Medical Advisory Committee (MAC) • In 2010 the initial MAC committee reviewed and approved the MTG • Medical Director was Larry Ferachi , MD

  7. OWCAMedical Treatment Guidelines • The Medical Treatment Guidelines • Chapter 20 Spine MTG • Cervical • Low Back • Chapter21 Pain MTG • Chronic Pain • CRPS

  8. OWCAMedical Treatment Guidelines • The Medical Treatment Guidelines • Chapter 22 Neurological and Neuromuscular Disorder MTG • CTS • TOS • Chapter 23 Upper and Lower Extremities MTG • Lower Extremity • Shoulder

  9. OWCAMedical Treatment Guidelines • Review of the MTG • La RS 1203.1.H: • The director, with the assistance of the medical advisory council, is authorized to review and update the medical treatment schedule no less often than once every two years.

  10. OWCAMedical Treatment Guidelines • The Medical Treatment Guidelines • Medical Advisory Committee (MAC) • MTG changes and recommendations • Any change MUST be accompanied by evidence based literature that supports the change requested, and if available, another published guideline that supports it. • Discussions with Colorado OWCA

  11. OWCAMedical Treatment Guidelines • Review Process • Chapter 20 - Spine Public Hearing • From 2013 Session In Process • E/M Codes • PT Visits • General Principles Public Hearing

  12. OWCAMedical Treatment Guidelines • Review Process • Bibliography Review Ongoing • Pharmacy / Medication WCAC • Elbow / Hand Disorders 2014 • Closed Head Injury 2014

  13. OWCAMedical Treatment Guidelines • Utilization Review - Old Process: • All companies dictated their own process • Medical disputes were adjudicated by the LWC hearings division, which took several months to more than a year

  14. OWCAMedical Treatment Guidelines • Utilization Review - Current Process: • Workers Comp Advisory Council • The process and forms, and other utilization review parameters are reviewed and approved by this group

  15. OWCAMedical Treatment Guidelines • Form 1010 • UR - Process Improvement: • Now everyone has to do this the same way. • No phone calls, no sitting on unending hold, and no need for several different company forms to be filled out.

  16. OWCAMedical Treatment Guidelines • Form 1010 • Used for any request for service over $750, and is available on line as a fillable pdf • The OWCA has announced the launch of a "Training Courses" on their website. • Currently includes courses on the 1009 and 1010 Forms

  17. OWCAMedical Treatment Guidelines • Form 1010 • Should be a provider staff function. • Save the form on the computer desk top • The data can be typed directly onto the form • Print the form, date and stamp signature, attach the appropriate and pertinent records, and submit to the carrier by fax or email

  18. OWCAMedical Treatment Guidelines • Form 1010 • Carrier has 5 days to make a decision and submit it back to you by fax or email • Peer Review • Approve, Deny, or Approve with modification • Tacit Denial

  19. OWCAMedical Treatment Guidelines • Form 1009 • Should be a provider staff function. • Save the form on the computer desk top • The data can be typed directly onto the form • Print the form, date and stamp signature, attach the appropriate and pertinent records, and submit to the carrier by fax or email along with the Form 1010

  20. OWCAMedical Treatment Guidelines • Form 1009 filed to Medical Services • Data from Inception • Estimated 1010 85.0% • Total 1009 Filed 4392 15.0% • Rejected 1342 30.6%

  21. OWCAMedical Treatment Guidelines • Form 1009 filed to Medical Services • Data from Inception • Rejected - March 2013 38.1% • Rejected - Current Total 30.6% • Data from Last 3 months • Rejected 25.8%

  22. OWCAMedical Treatment Guidelines • Medical Grievance Decisions: • Data from Inception • MGD Filed3050 • No Decision 204 6.7% • Approved 954 31.3% • Denied 1892 62.0%

  23. OWCAMedical Treatment Guidelines • Medical Grievance Decisions: • Data from Inception • Approved 31.3% • Denied 62.0% • Data from Last 3 months • Approved 34.2% • Denied 60.6%

  24. OWCAMedical Treatment Guidelines • Medical Grievance Decisions: • Top 1009 filers - Total MGD’s Min # % MGD’s • Top 5 ( > 120) 831 27.3% • Top 10 ( > 48) 1119 36.7% • Top 15 ( > 40) 1334 43.8%

  25. OWCAMedical Treatment Guidelines • Medical Grievance Decisions: • Data from Top 10 - 1009 filers • Total MGD 1119 • Approved 19.31% • Denied 80.69%

  26. OWCAMedical Treatment Guidelines • Medical Grievance Decisions: • Data from The #1 - 1009 filer • % MGD Denied 93.4% • % of Total Denials 9.6%

  27. OWCAMedical Treatment Guidelines • Medical Grievance Decisions: • Medical Treatment Guideline • Low Back 56% • Chronic Pain 22% • Cervical 11% • Upper Extremity 08% • Lower Extremity 03%

  28. OWCAMedical Treatment Guidelines • Medical Grievance Decisions: • Reason for Denial • Maximum Duration of Treatment has been exceeded • Clinical indications have not been met • Positive patient gain, improved pain scale, or functional improvement from prior treatment not noted

  29. OWCAMedical Treatment Guidelines • Medical Grievance Decisions: • Reason for Denial • Conservative measures have not been initiated or documented • Results of testing must be known prior to procedure or additional testing approval • The clinical findings, the natural history of the disease, the clinical course, and diagnostic tests do not correlate to support the requested service

  30. OWCAMedical Treatment Guidelines • Medical Grievance Decisions: • Reason for Denial • Therapy records do not note dates of prior treatment, duration, frequency, and specific functional improvement • Criteria for the minimum documentation submission has not been met • Other

  31. OWCAMedical Treatment Guidelines • LAC 40:I.2715.C • Minimum submission by a health care provider requesting care • Documentation to the level of the condition and as provided in the medical treatment schedule • History • Physical findings / clinical tests

  32. OWCAMedical Treatment Guidelines • LAC 40:I.2715.C • Minimum submission by a health care provider requesting care • documented functional improvements from prior treatment • test/imaging results • treatment plan including services being requested along with the frequency and duration.

  33. OWCAMedical Treatment Guidelines • LAC 40:I.2715.C • Subsequent clinical updates must demonstrate the patient’s current status to document the need for diagnostic testing or additional treatment.

  34. OWCAMedical Treatment Guidelines • LAC 40:I.2715.C • Subsequent clinical updates : • a brief history • changes in clinical findings such as orthopedic and neurological tests • measurements of function with emphasis on the current, specific physical limitations are necessary for approval.

  35. OWCAMedical Treatment Guidelines • The Medical Treatment Guidelines • Care not covered by the Treatment Schedule • Must follow the same prior authorization process • Submit with Form 1009 the scientific medical literature which supports approval of the variance. • House Bill 450 by State Representative Barry Ivey • REMOVED: Utilize a guideline that meets the requirements of the statute

  36. OWCAMedical Treatment Guidelines • The Medical Treatment Guidelines • Variance Request The requested care, services, or treatment is : • not recommended by the MTG although the diagnosis is covered by the MTG • is recommended by the MTG, but for a different diagnosis or body part. • requested care, services, or treatment involves a medical condition of the claimant that complicates recovery of the claimant that is not addressed by the MTG

  37. OWCAMedical Treatment Guidelines • The Medical Treatment Guidelines • Variance Request • Shall state the reason for review is that a variance from the medical treatment schedule is warranted • Submit with Form 1009 the scientific medical literature which supports approval of the variance.

  38. OWCAMedical Treatment Guidelines • Medical Grievance Decisions: • My Comments • Read and understand the General Principles • the determination of the need to continue treatment is based on functional improvement; and • the patient’s ability (current capacity) to return to work is needed to assist in disability management.

  39. OWCAMedical Treatment Guidelines • Medical Grievance Decisions: • My Comments • Examine the patient and document the exam • See every 3 to 4 weeks minimum • Submit appropriate and relevant records for Form 1010 / 1009 • Aggressive Conservatism

  40. OWCAMedical Treatment Guidelines • Medical Grievance Decisions: • My Comments • Cessation and/or review of treatment modalities should be undertaken when no further significant subjective or objective improvement in the patient’s condition is noted. • If patients are not responding within the recommended duration periods, alternative treatment interventions, further diagnostic studies or consultations should be pursued.

  41. OWCAMedical Treatment Guidelines • Medical Grievance Decisions: • My Comments • Use of Physician Extenders • EMR is your friend / EMR is your enemy • Updated Testing • Document functional improvement / positive gain from treatment provided

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