Complex Claims

Helping Injured Workers Live Their Best Lives

Providers are developing new strategies for keeping up with advances in prosthetics and finding the best options for injured workers.
By: | May 2, 2017 • 7 min read

Experts are finding ways to mitigate the challenges of workers’ compensation claims involving the use of prosthetics, given the rising costs of ever-more complex devices — and the potential for psychosocial impacts and comorbidities.

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One Call Care Management this month announced the launch of its prosthetics clinical review program, in which a prosthetist certified by the American Board for Certification will assist claims adjusters in understanding the complexities of prosthetics and in making the most informed decisions about them.

Referrals meeting one or more of the following criteria will typically trigger such reviews:

  • myoelectric upper extremity systems
  • system upgrades and/or excessive replacements
  • microprocessor-controlled knee and ankle prosthetics; and
  • excessive socket changes

Recent case studies have shown savings of up to 52 percent when clinical reviews are added to the claims approval process, according to One Call.

Jennifer McCarthy, a One Call clinical specialist based in Boston who will lead the new team, said that clinical reviews are needed because claims costs continue to rise as advances in prosthetics happen so rapidly that carriers can’t keep track of the changing technology.

“Historically in times of war or conflict that involves our military, the U.S. government awards grants to researchers to develop prosthetic technology, so we have seen a recent influx of advanced prosthetic devices,” McCarthy said.

“Because the devices often can involve robotics, they are expensive to manufacture at such a small quantity. The manufacturers then to transfer the costs of research, development and manufacturing onto the provider and payer.”

Jennifer McCarthy, clinical specialist, One Call Care Management

Moreover, since some of the devices are so new, there is no set fee schedule from Medicare, she said. The manufacturers can suggest a retail price for the providers to bill or the providers will charge an amount above their invoice costs.

“They attempt to make this pricing somewhat standardized, but there can often be a significant variance in the pricing between providers for the same device,” McCarthy said.

One Call’s prosthetics clinical review program is different than a utilization review, which verifies the medical necessity of the device being recommended from a nurse’s perspective.

“Our new program is more of a clinical oversight from a prosthetist’s perspective to make sure the recommendation is truly appropriate and there are no other types of prostheses that would allow for a better outcome,” she said.

“Our goal is to ensure that the device the prosthetist is recommending is appropriate for the patient’s functional level and will allow the individual to reach his vocational and avocational goals.”

Outreach to the prosthetist involved in the claim is often necessary to determine what other types of prostheses were considered and why they would not be appropriate, McCarthy said.

“If local expertise and resources are not available, it is sometimes more advantageous to send the patient to a center with expertise to minimize the risk and costs associated with ‘trial-and-error’ approach to prosthesis management.” — Julie Fawson, director of clinical services, Paradigm Outcomes

Sometimes the team will come to the conclusion that an alternate device may be more appropriate or there might be coding changes that more accurately represent the device recommendations, which can reduce costs.

In determining the most appropriate device, One Call’s team will also consider the health history of the injured worker, what their experiences have been with any previous prostheses and the environmental history — which includes the worker’s support system, home and social environments.

“This gives us a more holistic approach to determining whether this particular prosthesis would allow them to reach their highest functional level,” McCarthy said.

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Upon request from claims adjusters, One Call will create a prosthetics cost projection document covering the costs of maintenance, servicing and replacement for the particular device.

The company already has a clinical review program for physical therapy and dental, so prosthetics is “the next natural progression of providing clinical oversight to our customers,” she said.

Julie Fawson, RN, director of clinical services at Paradigm Outcomes in Walnut Creek, Calif., said that workers’ comp carriers face many challenges when planning for an injured worker’s prosthesis needs, especially in the current environment of rapidly advancing technology and cost of prosthetics.

“Our team defines broad achievements, such as returning to work, and detailed goals that focus on specific areas of function,” she said.

When reviewing claims involving prosthetics, Paradigm Outcomes considers the complexity of the amputation; impact of comorbidities and conditions; the expertise and resources of the treatment team; and the management of the patient’s needs and expectations.

“In general, the more proximal the amputation, the more complex and costly it can be,” she said.

“For example, an above-elbow amputation is more complex than a below-elbow amputation. While in both scenarios the amputee may be a candidate for body-powered and myoelectric prosthesis options, fabricating a prosthesis that incorporates elbow function is much more significant in terms of cost, therapy/training, maintenance and functional recovery expectations.”

It is also important to consider comorbidities or conditions that may add to the complexity of amputation and prosthesis management, Fawson said. For instance, a patient with extensive muscle or nerve tissue damage at the amputation site, or with a very short residual limb, will be more complex in terms of fabrication, fit and function of the prosthesis.

A patient could also require reconstructive surgeries of the residual limb over time, which will change the composition of the residual limb, thereby increasing the frequency of costly socket revisions in the first couple of years.

Complexity on Many Levels

In all prosthestics claims, expertise of the treatment team — the physician, therapist and prosthetist — and the resources they provide, are vital to the success of managing complex amputees, especially given the high technology, high cost prosthesis options available today, she said.

“If local expertise and resources are not available, it is sometimes more advantageous to send the patient to a center with expertise to minimize the risk and costs associated with ‘trial-and-error’ approach to prosthesis management,” Fawson said.

It is also important to understand the patient’s occupational goals, lifestyle and avocational interests, to guide the treatment team and patient to make the most appropriate prosthesis choice that will optimize the patient’s functional and psychological outcome, she said.

Julie Fawson, director of clinical services, Paradigm Outcomes

To alleviate the challenges of locating qualified providers of prosthetics, Memphis-based Sedgwick Claims Management Services Inc. developed a provider benchmarking tool to help identify providers who are known for consistently delivering high quality care and desired outcomes, said Kimberly Talton, a Sedgwick complex claims advisor based in Dallas.

“Another challenge is determining what to expect when it comes to amputees’ ongoing needs and care,” Talton said.

“Within the complex claims unit, we work with the team to provide education about critical care pathways to identify what to expect with these types of injuries, ongoing needs and costs of these types of claims.”

One of the challenges is determining the appropriate type of prosthetic for a particular person, as every individual and amputation is unique, said Riverside, Calif.-based Edward Canavan, vice president of Sedgwick’s workers’ compensation practice and compliance.

“Some individuals with amputation could end up being diabetic, and so they’ll have different needs than other amputees,” Canavan said.

“We want to get individuals to the right doctor who can give them the right recommendation to fulfill those needs, and then we can partner with the individuals to get them the right prosthetics.”

Other challenges are centered around the fast-paced evolution of technology for prosthetics, and determining whether the medical and peer review guidelines allow the use of particular devices that have recently been developed, he said.

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“There is so much research going on in every sort of prosthetic to help the injured worker, including the development of devices to feel what they are touching, exoskeleton research to help the person walk again, and stem cell therapy,” Canavan said.

“We need to balance that with determining what can help the injured person get the best possible outcomes. That’s where complex claims review comes into place. We can also leverage the right resources such as a prosthetics clinical review program.”

Prosthetics claims can be impacted if the affected amputation area hasn’t healed properly and completely before being fitted, said Rachael Ruther, a Sedgwick complex claims advisor based in Brea, Calif.

“Prosthetics are so specialized,” Ruther said.

“You want to be sure there is a proper fit; otherwise, the prosthetic may not be functional and may go unused.”

The key to providing the best care possible is to get patients as close to a normal level of functionality as possible, Talton said.

“Hopefully we can reduce some of the mental issues that come with these types of injuries such as depression and anxiety,” she said. &

Katie Kuehner-Hebert is a freelance writer based in California. She has more than two decades of journalism experience and expertise in financial writing. She can be reached at [email protected]

More from Risk & Insurance

More from Risk & Insurance

4 Companies That Rocked It by Treating Injured Workers as Equals; Not Adversaries

The 2018 Teddy Award winners built their programs around people, not claims, and offer proof that a worker-centric approach is a smarter way to operate.
By: | October 30, 2018 • 3 min read

Across the workers’ compensation industry, the concept of a worker advocacy model has been around for a while, but has only seen notable adoption in recent years.

Even among those not adopting a formal advocacy approach, mindsets are shifting. Formerly claims-centric programs are becoming worker-centric and it’s a win all around: better outcomes; greater productivity; safer, healthier employees and a stronger bottom line.

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That’s what you’ll see in this month’s issue of Risk & Insurance® when you read the profiles of the four recipients of the 2018 Theodore Roosevelt Workers’ Compensation and Disability Management Award, sponsored by PMA Companies. These four programs put workers front and center in everything they do.

“We were focused on building up a program with an eye on our partner experience. Cost was at the bottom of the list. Doing a better job by our partners was at the top,” said Steve Legg, director of risk management for Starbucks.

Starbucks put claims reporting in the hands of its partners, an exemplary act of trust. The coffee company also put itself in workers’ shoes to identify and remove points of friction.

That led to a call center run by Starbucks’ TPA and a dedicated telephonic case management team so that partners can speak to a live person without the frustration of ‘phone tag’ and unanswered questions.

“We were focused on building up a program with an eye on our partner experience. Cost was at the bottom of the list. Doing a better job by our partners was at the top.” — Steve Legg, director of risk management, Starbucks

Starbucks also implemented direct deposit for lost-time pay, eliminating stressful wait times for injured partners, and allowing them to focus on healing.

For Starbucks, as for all of the 2018 Teddy Award winners, the approach is netting measurable results. With higher partner satisfaction, it has seen a 50 percent decrease in litigation.

Teddy winner Main Line Health (MLH) adopted worker advocacy in a way that goes far beyond claims.

Employees who identify and report safety hazards can take credit for their actions by sending out a formal “Employee Safety Message” to nearly 11,000 mailboxes across the organization.

“The recognition is pretty cool,” said Steve Besack, system director, claims management and workers’ compensation for the health system.

MLH also takes a non-adversarial approach to workers with repeat injuries, seeing them as a resource for identifying areas of improvement.

“When you look at ‘repeat offenders’ in an unconventional way, they’re a great asset to the program, not a liability,” said Mike Miller, manager, workers’ compensation and employee safety for MLH.

Teddy winner Monmouth County, N.J. utilizes high-tech motion capture technology to reduce the chance of placing new hires in jobs that are likely to hurt them.

Monmouth County also adopted numerous wellness initiatives that help workers manage their weight and improve their wellbeing overall.

“You should see the looks on their faces when their cholesterol is down, they’ve lost weight and their blood sugar is better. We’ve had people lose 30 and 40 pounds,” said William McGuane, the county’s manager of benefits and workers’ compensation.

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Do these sound like minor program elements? The math says otherwise: Claims severity has plunged from $5.5 million in 2009 to $1.3 million in 2017.

At the University of Pennsylvania, putting workers first means getting out from behind the desk and finding out what each one of them is tasked with, day in, day out — and looking for ways to make each of those tasks safer.

Regular observations across the sprawling campus have resulted in a phenomenal number of process and equipment changes that seem simple on their own, but in combination have created a substantially safer, healthier campus and improved employee morale.

UPenn’s workers’ comp costs, in the seven-digit figures in 2009, have been virtually cut in half.

Risk & Insurance® is proud to honor the work of these four organizations. We hope their stories inspire other organizations to be true partners with the employees they depend on. &

Michelle Kerr is associate editor of Risk & Insurance. She can be reached at [email protected]