When orthopedic surgeons and other physicians take on workers' compensation cases, they are routinely asked several questions that can be hard to answer and even off-putting, says John DiPaola, MD, an orthopedic surgeon in Tualatin, Ore. To be successful with workers' comp, practices should anticipate the following six questions and know how to answer them. "You have to be organized and give everybody the information they want," says Dr. DiPaola, whose practice, Occupational Orthopedics, is 100 percent workers' comp. "It mitigates the administrative burden."
1. Was the patient's injury work-related? To qualify for workers' comp, the injury had to happen at work. The physician has to play detective, using his medical skills. For example, a warehouse worker says he hurt his shoulder. An MRI scan shows a rotator cuff tear and the patient says he was lifting a 100-pound weight when it slipped and he tried to catch it. This has the markings of a work-related injury. On the other hand, a truck driver says his shoulder is killing him. An MRI scan also shows a rotator cuff tear, but turning a steering wheel is insufficient to tear a rotator cuff.
2. What percentage of the injury was related to work? An injury can result from a combination of circumstances, such as arthritis combined with a slip and fall at work. Some workers' comp programs, such as in Kansas or the federal longshoremen's program, recognize a claim even if only a small part of it can be attributed to work. But in many states, including Oregon, the cause of the condition needs to be at least 51 percent work-related. In these cases, the physician has to apportion the injury, naming an exact percentage attributed to work.
3. What restrictions is the patient under? Even if the patient can't do his regular job, the company wants to get him back to work as soon as possible. Wal-Mart, for example, uses its injured workers as greeters. "The physician should not be issuing blanket orders against any work, except for the recovery period right after surgery," Dr. DiPaola says. Instead, the physician must specify parts of the body that should not be used, such as the right arm. "The employer needs the information to determine the kind of work that patient can do before full recovery," he says.
4. When is the patient's next appointment? The employer and claims adjuster always want to know this information. The physician's office must enter it into the work release that is sent out. Those that forget to include this information may experience payment delays. "Offices that anticipate the information the employer needs will be more successful with workers' comp cases," Dr. DiPaola says.
5. Will the patient recover fully? The employer needs to know this in order to plan the worker's future employment status. The company may have to find him a new assignment and may be responsible for vocational rehabilitation so that he can start a different job.
6. When will recovery be complete? This is important because the company is required by law to set aside money for the employee's medical care until the injury is healed. "The company can only release the money when the patient has recovered," Dr. DiPaola says. This requirement annoys many physicians. "They'll say, 'I am not going to predict,' because they believe that if they are wrong, they'll be sued," he says. In fact, if the prediction is off, the company simply asks the physician to revise it. The physician may base his prediction on benchmark data, such as that 85 percent of people with rotator cuff tears recover in 5-6 months and 95 percent of patients with meniscus tears recover in 3-4 months.
Learn more about Occupational Orthopedics.
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