Treatment guidelines promise positive change

An important change is about to happen in the New Mexico workers’ compensation system.  Potentially, it could make the system both more cost-effective and more compassionate to the injured workers who receive medical care under this system.

It’s likely to be quite messy for a while, as medical people and insurers figure out how to work with it.  That became clear in vigorous discussions recently at the annual conference of the New Mexico Workers’ Compensation Association.

The concept is called treatment guidelines.  The use of such guidelines is not unique to workers’ comp, but the introduction of a particular set of guidelines as a recognized standard is.  Here’s what it means.

Treatment guidelines are protocols for doctors, advising them how to treat every kind of injury using “evidence-based medicine” — what has been found to work best in the majority of similar cases.  The guideline for a particular injury might recommend an MRI, 12 sessions of physical therapy, restrictions on movement and activity for a specified period, a specific medication, and so on.

You may be incensed at this idea of cookbook medicine, but hang on.  There are several pieces to this concept.

The workers’ compensation law requires the insurer to pay only for treatment that is related to the injury and that is deemed reasonable and necessary by medical standards.  The job of claims adjusters has been to review and approve treatment in advance, to make sure the doctor, the physical therapy clinic, the pharmacy and the MRI clinic will be paid.  This is usually done the old-fashioned way, by phone calls and faxes – which can cause serious delays.  I have been hearing for years about unreturned phone calls, frustrated doctors, litigation, and probably, though we don’t have documentation to prove it, real hardship for injured workers.

A new rule issued by the Workers’ Compensation Administration (Rule F NMAC) says that starting July 1, all medical treatment that is recommended in a reference work called the ODG (Official Disability Guidelines) is presumed reasonable and necessary.

That means if the proposed service fits the guidelines, the insurer is required to pay for it.  The claims adjuster doesn’t have to review it; the doctor can go ahead and prescribe it or order it.

It’s estimated that the guidelines will work for 80 to 95 percent of cases but not all.  If a case doesn’t fit, for whatever reason, the doctor is supposed to go back to the old-fashioned method and provide documentation to justify the recommended treatment. Those cases will probably proceed more slowly, but that’s the price of human variability.

It’s going to take a while for this process to shake out.  A physical therapist told me some insurers are already refusing to pay for any treatment outside the guidelines.  This is incorrect, and fixing it will be part of the learning curve.  A doctor said in emergency cases he will take action even if the clinical symptoms don’t fit the guidelines.  A claims manager said he’s worried that doctors will go ahead and treat without contacting the insurer to make sure the claim itself is authorized.  What if the employer changed insurance companies, or the insurer decided the injury wasn’t work-related and therefore not covered?

We’re sure to hear controversy about the guidelines themselves, as busy doctors try to figure out how to use them and make judgments about how user-friendly they are and even whether they are accurate.  That will no doubt be a hot topic at next year’s conference.

But if you’re the injured worker, and you can’t move your arm until the doctor does something, and he can’t do anything until you get the MRI and you’ve been waiting two weeks for the authorization, this change looks very promising indeed.

This entry was posted in Articles, Workers' Comp. Bookmark the permalink.

Leave a Reply

Your email address will not be published. Required fields are marked *