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November 3, 2011

Shorten The Claim Life Cycle With Functional Restoration – A Case Study

Summary:

The Medical Treatment Utilization Schedule defines functional restoration as a process by which the individual acquires the skill, knowledge and behavioral change necessary to avoid preventable complications and assumes or re-assume primary responsibility ("locus of control") for his/her own physical and emotional well-being post-injury.

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Receiving the call from the claims adjuster was not what I wanted to hear. After an accepted mild back strain, I, the permissibly self-insured employer am informed of continued physical therapy two times/week for 6 weeks as well a prescription for opioids to treat the chronic, yet unresolved pain. This injured worker has been off work for more than 6 months, with work restrictions that cannot be accommodated due to the collective bargaining agreement, and escalating claim costs. Frustrated, I ask the claims adjuster what the options are for claim resolution. Sadly, it appears to be business as usual until the doctor determines a stay in maximum medical improvement. We have been down this road before. An injured worker, an open claim, more medical treatment and I feel as if I have lost the key to open the lock to break the chain that binds. We conclude the call with a diary to discuss next week after the physical therapy is underway.

Business Insurance Associate Editor Matt Dunning in its 9/25/11 Business Insurance magazine stated the opioid problem began with about 20 states relaxing laws that had discouraged doctors from treating “chronic, non-cancer pain” with opioid prescription pain medications, an occupational medicine expert said.

The trend, which began in the late 1990s, allowed “extreme permissiveness” in increasing opioid doses prescribed to injured workers, said Dr. Gary M. Franklin, medical director for the Washington State Department of Labor and Industries and a research professor in the departments of Environmental and Occupational Health Sciences and Medicine at the University of Washington in Seattle.

Consequently, the increased use of opioids to treat workers’ compensation injury claims is creating challenges for employers in resolving claims with injured workers with chronic pain. Medical, indemnity and prescription costs continue to rise and employers are looking at ways to limit liability, close claims and get the injured worker back to work.

One of the opportunities for California employers is the use and understanding of Medical Treatment Utilization Schedule (MTUS) and American Medical Association guidelines in the treatment and utilization of medical procedures in the claims handling process. Utilization review is also a venue to help employers have appropriate medical treatment given for the injured worker.

During the course of my tenure managing a private self-insured employer’s workers’ compensation program, we had many individuals suffering from soft tissue injuries, musculoskeletal disorders and chronic pain syndrome. The use of prescription drugs and opioids were on the rise and a key, something, had to be introduced to unlock the lock and address the injured worker in lieu of treating a symptom or site-specific injury. After the appropriate medical treatment and physical therapy given, with some injured workers there remained a gap and something else needed to be introduced to close it.

The Medical Treatment Utilization Schedule defines functional restoration as a process by which the individual acquires the skill, knowledge and behavioral change necessary to avoid preventable complications and assumes or re-assume primary responsibility (“locus of control”) for his/her own physical and emotional well-being post-injury. The individual therefore maximizes functional independence and pursuit of vocational goals as measured by functional improvements. Functional restoration, with a quality vendor and pre-approved as part of the utilization review (UR) process can be an effective solution in improving and restoring the health of injured workers. It is also a proven cost savings and reduction for the workers’ compensation claim. An effective functional restoration program decreases resource utilization required for treatment, decreases dependency on opioids and increased pharmaceutical costs and improves the quality of life for the injured worker.

My previous employer utilized the services of Savvy Fitness, headquartered in Folsom, California. The founder and owner, Paul Wright has created an approved Medical Treatment Utilization Schedule and American Medical Association functional restoration program that addresses the overall physical conditioning, postural responsiveness to activities of daily living and a motivational element that embeds the components of the program into sustainable lifestyle changes. It is a proven cost savings and reduction in the life cycle of a workers’ compensation claim.

A key player in the workers’ compensation claim resolution, who works with and on behalf of the employer, is this Savvy F.I.T. Academy (Functional Intervention Training) program. This employer-oriented company co-creates with the employer a unique experience which inspires personal health and well-being and the discovery of the full human potential. Over 156 participants, pre- and post-injury, have participated in this program. Overall Workers’ Compensation claims costs decreased by 69% as well as the length of the open claims reduced by 65%.

By the way, the story about the injured worker at the beginning? He was a graduate of the Savvy Fitness program and was so appreciative of gaining control of his life, he had his wife participate in the program out of his own paycheck. Innovative, caring, cost-effective approach to claims management and treating the injured worker with respect, dignity and hope. Check it out at www.savvyfitness.com. It could be the key that unlocks the “chains that bind” in with your workers’ compensation claims.

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