What You Should Know About Handling Workers’ Compensation Claims

Becoming a qualified medical evaluator in workers’ compensation cases may be a significant referral generator for your practice. Accordingly, this author offers a closer look at his experience with these cases, reviews pertinent points in the evaluation of these patients and key steps you can take if you wish to start seeing these patients in your practice.

   Over the years, I have found that assessing and treating patients in workers’ compensation cases allow you to see some pathology you may not normally encounter in the normal day-to-day caseload of a podiatry practice. I have also found that being involved in these cases provides a good source of patient referrals and enables you to forge relationships with other physicians who are involved in the treatment of injured workers.

   I started assessing injured workers for workers’ compensation cases approximately 20 years ago. At first, I treated a few injured workers. Then I was asked to become an independent medical examiner (IME) and was sent patients to evaluate for disability. I eventually became a qualified medical evaluator (QME).

   The state of California decided it wanted to have a pool of QMEs to evaluate for disability as well as other issues in the treatment of injured workers. It therefore created a QME system approximately 15 years ago. In order to become a QME, you had to take a test and be qualified by California’s Department of Workers’ Compensation.

   Some QMEs become agreed medical evaluators, who represent the insurance company, employer and the injured worker. They are expected to follow the worker’s compensation laws of the state of California. Agreed medical evaluators have more responsibility and they also get paid 25 percent more for their medical-legal evaluations.

   When I began treating workers’ compensation patients, referrals came from occupational medicine centers as well as attorneys representing injured workers and attorneys representing insurance companies and the employer (see the sidebar “A Glossary Of Relevant Terms For Workers’ Compensation Cases”).

Understanding The AMA Guide To Workers’ Compensation

   California’s disability evaluation guidelines previously evaluated injured workers. Currently, the state uses the American Medical Association (AMA)’s Guide to the Evaluation of Permanent Impairment, Sixth Edition.

   There is a section in the AMA Guides on the lower extremity. Chapters 1 and 2, which are considered to be the most important chapters, instruct the evaluating physician on how to go about his or her duties. Essentially, the key with this system is determining the level of impairment as opposed to disability.

   Previously, physicians used the term “disability” as per the Guidelines for Work Capacity in order to evaluate patients’ ability to compete on the open job market. The AMA guides use “impairment” to determine whether there is permanent impairment.

   The AMA wrote the guide to permanent impairment. There is no podiatry input. There is input from the American Orthopedic Association but no specific input from the American Orthopedic Foot and Ankle Society.

   Regarding the American College of Occupational and Environmental Medicine (ACOEM) Second Edition Guidelines for Occupational Medicine, membership in ACOEM is primarily for occupational medicine doctors and physical medicine doctors. There is no membership category for podiatrists. Therefore, there has been no podiatry input on the foot and ankle section.

   Needless to say, the lack of podiatry input in both of these books that are the standards for treating and evaluating injured workers in California is a source of frustration for the podiatrist who does this type of work.

What Are The Responsibilities Of The Treating Physician?

   There are two types of treating physicians. The first is the primary treating physician who has medical control of the patient. This may be a physician at an occupational medicine center such as Kaiser Occupational Medicine, United Healthcare Workers’ Compensation Clinics or Concentra. Different states have different occupational medicine clinics. There may be a private practice primary treating physician who could be the injured worker’s family physician or some other specialist.

   A podiatrist can function as a primary treating physician or a secondary physician. If an occupational medicine clinic refers the injured worker to a podiatrist, the podiatrist will function as a secondary physician who reports to the primary treating physician, who is the occupational medicine doctor. The primary treating physician is responsible for reporting to the claim examiner and the attorneys involved with the case if any are involved.

   The primary treating physician fills out a PR-2 form each time the patient receives treatment. This form reports the status of the patient to all parties. Of importance are the modified work restrictions. Is the patient able to return to work with modified restrictions or are they totally disabled? The primary treating physician is responsible for:

   • obtaining authorization for treatment through utilization review for procedures that require this;

   • informing all parties of the worker’s ability to return to work full duty or with modified duties;

   • defining what modified work restrictions are needed on an actual or prophylactic basis;

   • determining whether consultations with other specialists are needed; and

   • determining whether treatment with another specialist is needed.

   The primary treating physician is supposed to determine when the patient has reached maximal medical improvement and fill out what is called a PR-4 form or do a final ratable report.

   However, if the primary treating physician does not feel qualified to do a final ratable report, he or she can request that the patient be evaluated by a panel QME or an Agreed Medical Evaluation (AME) for a final ratable report. They can even refer the patient to a colleague who is known to do QME quality permanent and stationary maximal medical improvement (MMI) ratable reports.

Weighing The Pros And Cons Of Treating Injured Workers

   Why would a podiatrist wish to become involved in treating injured workers? I became involved because the injured workers had such interesting pathology. I was interested in treating trauma and especially mature trauma. An example of this is an injured worker who falls off a building and is taken to the emergency room. In our community, the orthopedic trauma surgeon repairs the fractures. Then the patient gets a referral to be treated until he or she reaches a maximal medical improvement status.

   I enjoy treating these patients. Often it would mean removing hardware and performing subtalar joint fusions. At times, patients could have ankle fractures that were reduced appropriately but the hardware needed to be removed and the patients needed to have additional procedures in order to facilitate maximum medical improvement.

   In addition, the injured workers often present with more complex injuries that require more complicated surgery. Referrals from occupational medicine centers and other sources were a welcome source of business to my practice.

   I became more interested in doing QMEs and AMEs as I became older. I found that many of my orthopedic colleagues, as they became older, retired from surgery and finally retired from practice. Yet they enjoyed doing medical-legal evaluations. This was an extra source of income for them as they cut back from surgery and practice and finally retired. At one time, 85 percent of my practice was treating workers’ compensation patients. Now it is about 60 percent.

   The downside of treating workers’ compensation patients is that there is a great deal of paperwork involved and you do have to have some elementary knowledge in the workers’ compensation system. In addition, the utilization review process is frustrating and often the treating physician has to appeal the decision of the utilization review physician in order to have treatment authorized.

   In addition, I have students from the California School of Podiatric Medicine at Samuel Merritt University rotate through my office for one month. These are usually third-year students. They see me involved in the workers’ compensation system and become interested in treating injured workers since they see it as a fulfilling part of my practice although it is difficult at times. The students rotate through many offices and various facilities. They always tell me that they see pathology at my office that they have not seen elsewhere. This is because of the workers’ compensation patients I see.

How You Can Get Involved In Treating Patients In Workers’ Compensation Cases

   If you are interested in treating workers’ compensation patients, I assure you it will be a rewarding part of your practice and it can be profitable. It helps you form good relationships with the occupational medicine clinics and their doctors, the orthopedic colleagues and other specialists who treat injured workers. Other specialists may include pain management specialists, psychiatrists and other clinicians involved in the treatment of the injured worker.

   If you are interested in getting involved in treating injured workers, you should contact your state’s Department of Industrial Relations and the Department of Workers’ Compensation. Find out what type of system your state has and what it takes for you as a podiatrist to treat injured workers. Every state is different.

   If you wish to become a qualified medical evaluator, you will have to take courses and pass a test. If you wish to become an independent medical examiner, evaluating federal workers who have disability or federal employees such as postal workers, you will have to take a course on how to use the aforementioned AMA Sixth Edition Guide. You may wish to join the American Association of Independent Medical Examiners and take its course, which I did.

   Finally, the state of California is fortunate in having the California Society of Industrial Medicine and Surgery. We encourage podiatrists to join. Our association has yearly educational meetings and regional meetings throughout the year. We have a Web site informing our members of recent changes in case law and how to go about navigating the workers’ compensation system. In addition, most states have a Workers’ Compensation Division and they welcome podiatrists to come to their meetings to learn what they are doing and introduce themselves.

Dr. Subotnick is in private practice in San Leandro, Calif. He is a Past Professor of Biomechanics and Surgery at the California College of Podiatric Medicine and a board member of the California Society of Industrial Medicine and Surgery. Dr. Subotnick is the Past President of the American Academy of Podiatric Sports Medicine and a Fellow of the American College of Sports Medicine. He is a Fellow of the American College of Foot and Ankle Surgeons and Fellow of the American College of Podiatric Orthopedics and Primary Care.

For further questions, e-mail the author at stevensubotnick@yahoo.com. His Web site is www.drsubotnick.com.

References:

1. Occupational Medicine Practice Guidelines, Second Edition, The American College of Occupational and Environmental Medicine (ACOEM), OEM Press, Beverly Farms, Massachusetts. 2. AMA Guide to Evaluation and Permanent Impairment, Sixth Edition. Published by AMA Press. 3. California Society of Industrial Medicine & Surgery, Sacramento, Calif.