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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
OWCAMedical Treatment Guidelines

Christopher J. Rich, MD, MBA

Medical Director

Office of Workers' Compensation

owca medical treatment guidelines1
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
owca medical treatment guidelines2
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,………
owca medical treatment guidelines3
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.
owca medical treatment guidelines4
OWCAMedical Treatment Guidelines

Best

Evidence

Available

Clinical

Experience

Patient

Values

owca medical treatment guidelines5
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
owca medical treatment guidelines6
OWCAMedical Treatment Guidelines
  • The Medical Treatment Guidelines
    • Chapter 20

Spine MTG

      • Cervical
      • Low Back
    • Chapter21

Pain MTG

      • Chronic Pain
      • CRPS
owca medical treatment guidelines7
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
owca medical treatment guidelines8
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.
owca medical treatment guidelines9
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
owca medical treatment guidelines10
OWCAMedical Treatment Guidelines
  • Review Process
    • Chapter 20 - Spine Public Hearing
    • From 2013 Session In Process
      • E/M Codes
      • PT Visits
    • General Principles Public Hearing
owca medical treatment guidelines11
OWCAMedical Treatment Guidelines
  • Review Process
    • Bibliography Review Ongoing
    • Pharmacy / Medication WCAC
    • Elbow / Hand Disorders 2014
    • Closed Head Injury 2014
owca medical treatment guidelines12
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
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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
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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.
owca medical treatment guidelines15
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
owca medical treatment guidelines16
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
owca medical treatment guidelines17
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
owca medical treatment guidelines18
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
owca medical treatment guidelines19
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%
owca medical treatment guidelines20
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%
owca medical treatment guidelines21
OWCAMedical Treatment Guidelines
  • Medical Grievance Decisions:
    • Data from Inception
      • MGD Filed3050
      • No Decision 204 6.7%
      • Approved 954 31.3%
      • Denied 1892 62.0%
owca medical treatment guidelines22
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%
owca medical treatment guidelines23
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%
owca medical treatment guidelines24
OWCAMedical Treatment Guidelines
  • Medical Grievance Decisions:
    • Data from Top 10 - 1009 filers
      • Total MGD 1119
      • Approved 19.31%
      • Denied 80.69%
owca medical treatment guidelines25
OWCAMedical Treatment Guidelines
  • Medical Grievance Decisions:
    • Data from The #1 - 1009 filer
      • % MGD Denied 93.4%
      • % of Total Denials 9.6%
owca medical treatment guidelines26
OWCAMedical Treatment Guidelines
  • Medical Grievance Decisions:
    • Medical Treatment Guideline
      • Low Back 56%
      • Chronic Pain 22%
      • Cervical 11%
      • Upper Extremity 08%
      • Lower Extremity 03%
owca medical treatment guidelines27
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
owca medical treatment guidelines28
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
owca medical treatment guidelines29
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
owca medical treatment guidelines30
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
owca medical treatment guidelines31
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.
owca medical treatment guidelines32
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.
owca medical treatment guidelines33
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.
owca medical treatment guidelines34
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
owca medical treatment guidelines35
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
owca medical treatment guidelines36
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.
owca medical treatment guidelines37
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.
owca medical treatment guidelines38
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
owca medical treatment guidelines39
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.
owca medical treatment guidelines40
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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