Managing Absenteeism Claims The Value of Peer Revie · 2017. 11. 7. · Overview of Peer Review...

Managing Absenteeism Claims The Value of Peer Review

Seminar Outline

1) Meet the Presenters

2) Overview of Peer Review

I. What is it?

II. Review of Various Services

III. The Peer Review Method

IV. Key Statistics and Figures

3) Overview of Second Opinion

4) The Interaction between Peer Review and Absenteeism Claims

5) Red Flag Indicators Prompting the Need for Peer Review

6) Case Study – Absenteeism Claims

7) The Impact of Peer Review on the Effective Management of Absenteeism Claims

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Meet the Presenters

Jacob Lazarovic, MD, FAAFP SVP/Chief Medical Officer Medical Department, Broadspire email: [email protected] web: www.choosebroadspire.com

Dr. Lazarovic is Senior Vice President and Chief Medical Officer for Broadspire, a Crawford Company. Dr. Lazarovic is a board-certified family physician, and experienced medical administrator. He completed his medical training and residency at McGill University and subsequently practiced family, emergency, and geriatric medicine while teaching in a residency program. At Broadspire, Dr. Lazarovic directs the Medical Department which produces clinical guidelines and criteria that support sound medical claim and case management practices; participates in analysis, reporting and benchmarking of outcomes, and quality improvement initiatives; develops educational and training programs that update adjusters’ and nurses’ clinical knowledge and skills; and provides expertise which enhances the medical bill review process. Additionally, the Medical Department operates a comprehensive in-house physician review (peer review) unit that contributes to effective utilization and case management decisions, promotes the appropriate use of medical services, and facilitates timely return to work through communication with treating physicians. The Medical Department also carries out and publishes original research and development on issues relevant to workers’ compensation and disability.

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Meet the Presenters

Dan Ogale Client Service Manager, NCMC Crawford & Company (Canada) Inc. Email: [email protected] Website: crawfordandcompany.com

Dan Ogale, Client Service Manager at Crawford & Company (Canada) Inc., is a seasoned insurance and risk management professional with over 30 years of experience working in Canada and the US. He started his career in 1984 in Windsor, ON as a claims adjuster. Having spent 19 years of his career working for Crawford in Canada and the US, he has taken on various roles of increased responsibility. Most recently, he was a consultant overseeing the management and implementation of workers’ compensation and third party administration programs. As an insurance professional he has held executive and management positions in claims and risk management for private organizations in the global transportation and storage industry, as well as with insurance carriers.

Overview of Peer Review What is it?

• Also known as physician review (not an independent medical examination – IME)

• Peer reviews are conducted by a board certified specialist physician

– These fully-accredited physicians advise on the clinical management of a claim

– The physician(s) conducting the peer review is/are assigned according to their speciality as it pertains to the particular case in question

• Peer reviews often include a discussion between the reviewing and treating physicians, known as a peer-to-peer (p2p) teleconference

• Peer review is faster and more cost effective than obtaining an IME

Overview of Peer Review Peer Review Services for Workers’ Compensation and Liability Claims Include:

• Utilization Review: Determining the medical necessity and appropriateness of care through prospective, concurrent or retrospective review

• Causality: Examining whether diagnoses and therapies are tied to the compensable injury

• Return to work issues: Evaluating the employee’s capabilities, and pertinent work restrictions and accommodations

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Overview of Peer Review Peer Review Services for Workers’ Compensation and Liability Claims Include:

• Impairment: Assessing assigned impairment ratings for accuracy

• Comprehensive pain program: Advising on the optimal strategies to prevent or mitigate chronic pain

• Radiology reviews: Confirmation of radiology interpretation along with aging of the studies done

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Overview of Peer Review Peer Review Services can Reinforce Short and Long-term Disability Administration

• Disability status: Clinical rationale for work absences

• Functional assessment: Determine whether there are objective medical data to support an impairment determination

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Overview of Peer Review Peer Review Services a Valuable Tool to Use on Auto Liability Claims

• Causality: Evaluating if the diagnosis is related to the accident of record

• Medical necessity: Determining if the requested treatment is appropriate for the current diagnosis

• Return to work: Evaluating the employee’s or claimant’s capabilities, and pertinent work restrictions and accommodations

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Overview of Peer Review Peer Review Method • Referral for peer review is entered into a secure system – the

physician review services (PRS) system – and all medical documentation related to the case is attached

• Referral generator selects questions and decisions to be addressed by the reviewing physician

• Peer reviewer accesses the system to view the referral and records, and conducts a p2p teleconference in most cases

• Reviewer's determinations and rationale are entered into the system by the physician by direct entry or transcription

• Quality assurance review takes place to ensure that the report is comprehensive and sound

• Requestor is notified by email that a completed report is available in the system

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Overview of Peer Review Peer Review Method - Evidence-based Medicine Guidelines

Using evidence-based medicine (EBM) guidelines and an extensive database:

– American College of Occupational and Environmental Medicine (ACOEM)

– Clinical Evidence (British Medical Journal)

– MD Guidelines (Medical Disability Advisor)

– Official Disability Guidelines (ODG/WLDI)

– Proprietary Clinical Content

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Overview of Peer Review URAC Accredited

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Organizations that perform this service are free from conflicts of interest, establish qualifications for physician reviewers, address

medical necessity and experimental treatment issues, have reasonable time periods for standard and expedited reviews, and appeals processes.

Overview of Peer Review Peer Review Method – Clinical Content (Proprietary)

Medical Advisories Position papers on controversial/questionable services which in most cases are not recommended for certification.

Physician Advisory Criteria

Utilization review criteria used by our UR nurses for services which are potentially certifiable.

Disability Criteria

Functional impairment guidelines for common conditions arising in disability reviews (short/long term disability plans).

Pharmacy Guidelines Guidelines for the use of pain management medications; non-formulary drug list (medications not typically appropriate for workers’ compensation, with exception criteria).

Physical Medicine Criteria Utilization review criteria for a broad range of conditions/body regions for which physical modalities can be considered.

Mental Health Criteria

Utilization review criteria for psychiatric/psychological conditions/services.

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• Alcohol Induced Disorders • Anxiety Disorders • Asthma • Bariatric Surgery • Cancer • Cardiac Conditions • Complex Regional Pain Syndrome/Reflex

Sympathetic Dystrophy • COPD • Depression • Diabetes Mellitus • Fibromyalgia (Chronic Fatigue Syndrome,

Irritable Bowel Syndrome, Multiple Chemical Sensitivities)

• Gallbladder Conditions • Gastroesophageal Reflux Disease • GYN Conditions • Headaches-Migraines • Hepatitis/Cirrhosis • Herpes Zoster • HIV-AIDS

• Hypertension • Inflammatory Bowel Disease • Knee Disorders • Multiple Sclerosis • Muscle Strength Testing • Pancreatitis • Peptic Ulcer Disease • Pneumonia/Bronchitis • Pre-Syncope, Syncope • Pregnancy • Renal Insufficiency/Failure • Rheumatological Disorders • Sarcoidosis • Seizure Disorder – Epilepsy • Shoulder • Sleep Disorders • Thyroid Conditions • Upper Respiratory Infection • Vertigo/Dizziness/Giddiness • Visual Impairment

Overview of Peer Review Peer Review Method – Disability Criteria

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Disability Determinations: Diabetes Mellitus ICD-9 Code: 250 - 250.9

Conditions (Click on Topic)

Reference Code: 50009

Reference: Broadspire Disability Criteria: Diabetes Mellitus

¨ Hyperglycemia (Elevated Blood Sugar)

¨ Hypoglycemia (Low Blood Sugar)

¨ Neuropathy

¨ Peripheral Vascular Disease

¨ Nephropathy

¨ Eye Involvement

¨ Definitions

¨ References

Effective Date: 9/5/01

Reviewed/Revised Dates: 6/30/05, 6/1/07, 10/17/08, 7/15/09, 6/23/10, 10/12/11, 11/19/12

Version: 1.5

C:/Users/vmmelt/AppData/Local/Microsoft/Windows/Temporary Internet Files/Content.MSO/Eye Involv


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Over 240 board-certified specialists, from the disciplines listed below, who are fully credentialed, trained and monitored via ongoing QA program.

Overview of Peer Review Physician Review Services Panel

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• Acupuncture

• Aerospace Medicine

• Allergy/Immunology

• Anesthesiology/Pain Management

• Cardiology

• Chiropractic

• Dentistry

• Dermatology

• Emergency Medicine

• Endocrinology

• ENT (Otolaryngology)

• Family Practice

• Gastroenterology

• General Surgery

• Hand Surgery

• Hematology/Oncology

• Infectious Disease

• Internal Medicine

• Nephrology

• Neurology

• Neuropsychology

• Neurosurgery

• Obstetrics/Gynecology

• Occupational Medicine

• Ophthalmology

• Orthopedic Surgery

• Physiatry

• Physical Therapy

• Plastic Surgery

• Podiatry

• Psychiatry

• Psychology

• Pulmonology/Critical Care

• Radiology

• Rheumatology

• Trauma Surgery

• Vascular Surgery

• Urology

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Key Statistics: Peer Review Outcomes

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55% of reviews for medical necessity/appropriateness determined those services unnecessary or inappropriate

67% of reviews for optimal treatment plans found the plans not optimal

63% of reviews for causality found conditions to be unrelated to compensable injury/illness

70% of reviews of functional impairment found the claimant not functionally impaired

79% of reviews for medications found that the prescribed medications are not optimal

Peer Review Outcomes

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Second Opinion

What is a Second Opinion Program (SOP)?

• Not a peer review

• Not a component of a claim (e.g., workers’ compensation, STD/LTD, liability)

• A product increasingly offered by companies as an employee benefit

• An expert, remote, confidential consultation to provide an employee with an opinion on their medical condition/treatment to ensure that their current treating physician(s) have arrived at the most accurate diagnosis, and the optimal plan of therapy

• Such programs typically utilize the resources of prestigious academic medical centres

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Why is a SOP valuable?

• Ensures employees receive the best medical care – eliminating unnecessary care, and promoting the optimal diagnostic and therapeutic measures.

• Reduces costs of misdiagnosis and delayed or incorrect treatment

• Improves workplace satisfaction and productivity • Provides employees with peace of mind and reassurance, and/or

specific recommendations for alternative intervention • Second opinion reports can be shared with employee’s treating

physician(s) for discussion and implementation, as needed. • Allows patients to make informed decisions about future care • It is reported that SOPs modify or replace existing diagnoses 37%

of the time, and result in treatment plan changes in 78% of cases

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The SOP Process

• An employee exercises the option to use the benefit, in order to satisfy him/herself that the medical care being delivered is sound and state-of-the-art

• The employee contacts the provider and arranges for transmission of all pertinent medical records, including physician records, lab tests, imaging studies, pathology reports, etc.

• The service provider’s nursing staff ensure that all necessary records are available, and clarify all of the employee’s questions and concerns

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The SOP Process

• Using a secure web portal, the consultation request and data is forwarded and assigned to the most knowledgeable specialist for the case under review

• Within 10 days, a comprehensive consultation report with conclusions and recommendations is provided to the employee

• The employee, facilitated by the service provider, has the opportunity to submit further questions concerning the report’s contents over the next 30 days

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The Interaction between Peer Review and Absenteeism Claims

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Red Flag Indicators Prompting the Need for Peer Review When Should They Be Used?

• Utilized by employers dealing with short and long-term disability and workers’ compensation claims

• Considered when an employee’s recovery has exceeded standard MMI guidelines

• If an employee has an occupational injury and also has other non-occupational medical issues, a peer review could be used to determine what is and is not compensable

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Case Study #1: WSIB claim where employer is considering an appeal Scenario

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Sally has been employed as clerk in a local police department since October 2014. On January 15th, 2015 she injured her lower back while attempting to pick up a box of files. She was diagnosed with a back strain and was advised to rest for one week and then return to work with the restriction of lifting no more than 10 lbs. (or greater) and no excessive bending. The employer was willing to accommodate these restrictions.

Sally has now been off work for ten weeks and claims total disability. The WSIB has accepted the claim and continues to pay medical and wage loss to Sally. Her treating doctor has indicated an indefinite return to work date. Sally has a history of back problems.

As the employer, you are considering an appeal of the continuing benefits as you feel her current issues are not work-related.

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Case Study #1 Application of Peer Review

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• Prior to deciding whether or not to proceed with an appeal, a peer review will be helpful.

• The peer review will help support the employer’s decision to appeal and increase the chances of a favorable decision. By doing so, the employer will be able to make an informed decision about filing an appeal.

• The results of the peer review could be useful in determining whether to ask for a complete or partial denial of benefits.

• Return on investment.

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Purpose:

• The purpose of this policy is to outline the employer's right to request a worker to undergo a health examination, the worker's right to object, and the WSIB's responsibility to provide direction.

For accidents on or after January 1, 1998, the following guidelines apply:

• The worker may object to undergoing the examination, or to its nature and extent. If the worker objects, the employer has up to 14 calendar days to ask for direction from the WSIB.

• Criteria for WSIB involvement

• The WSIB does not get involved unless:

– The worker has made a claim for, or is receiving, benefits

– The worker refuses the examination or objects to its nature and extent

WSIB Legislation: Section 17-04-02

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For accidents on or after January 1, 1998, the following guidelines apply:

• The employer has asked, in writing, for WSIB involvement. The WSIB must receive the letter within 14 calendar days of the employer learning of the worker's objection.

• Once these criteria for WSIB involvement are met, the WSIB gathers information from the worker and the employer and then determines:

– Whether the worker must undergo the examination, and

– The nature and extent of the examination.

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Need for Examinations:

• The WSIB determines that an examination is needed if it will help:

– In the worker's work reintegration activities,

– Provide significant new information not already available to the employer through claim file access,

– Clarify discrepancies in opinions between health professionals, or

– Clarify the nature of the injury, work-relatedness, the level of impairment/disability, or the worker's physical precautions.

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Need for Examinations:

• Based on the WSIB legislation the employer is within their rights to request a peer review. While the employee does not directly participate in the review the legislation would suggest that they have to be informed and must agree to the peer review process.

• The reasons why a peer review or request for a medical examination is justified is spelled out clearly within section 17-04-02 of the WSIB legislation.

• Does a peer review meet the strict definition of “health examination”?


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Case Study #2: Long term disability claim Scenario

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John has worked for an employer for 18 years as a mechanic. He is a valued employee who has been recently diagnosed with Multiple Sclerosis.

John finds it increasingly difficult to perform his duties and is off work on short-term disability. The employer is self-insured for its short-term and long-term disability programs.

It is expected that John will not be able to return to work as a mechanic.

Case Study #2 Application of Peer Review Services

• Use of a peer review or second opinion will be helpful at an early stage to determine if the current treatment plan is appropriate.

• Offering a second opinion review of John’s case may offer him some hope on alternate treatment plans that may be better suited to his needs.

• A peer review or second opinion might help the employer and employee come up with a plan that is in the best interests of all involved. Since the employer is self-insured for long-term and short-term disability, the peer review or second opinion review may help the employer save money in the long run and help the employee to return to modified duty.

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Legal Implications Under WSIB Legislation

• Under WSIB legislation the process for peer review is not clearly addressed; there is some grey area as to whether a peer review meets the definition of “health examination” under the WSIB legislation.

• Since the employee is not actively participating in the examination, an argument could be made that the peer review falls outside of the scope of the legislation.

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Using Peer Reviews to Manage Short-Term Disability (STD) or Long-Term Disability (LTD) Claims

• Peer reviews are used more frequently in STD/LTD claim management than i workers’ compensation claims.

• In STD/LTD cases, particularly when an employer is self-insured, the use of peer review can be useful in helping the employer determine ongoing disability.

• It serves to provide a secondary, objective medical opinion and might be useful in developing a more robust treatment plan to aid in recovery.

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Managing Absenteeism Claims The Value of Peer Revie · 2017. 11. 7. · Overview of Peer Review...

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