Workers' Compensation Referrals

[Medman2737]

Quick question for the more seasoned veterans in private practice:

About how much of your referrals (ballpark %) come from workers' compensation.

Reason for asking: Do you think it would be sustainable to have a private practice purely from workers compensation referrals/IME's/etc.?

Thanks for any input!!

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[Jcm800]

wow, i would hate that practice...

mine is low, and i like it. maybe 3-5%. My partner does most of it. the money can be good, but almost always a hassle.

 

[Tenesma]

i would rather gouge my eye out with a tuohy needle than do 100% work comp...

it would also be hard to sustain because over time you'd become known as being in the pocket of the work comp carriers and you will cease to be useful to them.

now you could ask the work comp carrier to hire you - which is like just being an occupational med doctor where they expect you to minimize findings and only recommend the cheapest therapies (naproxen, flexeril, 2 weeks of PT and back to work)....

work comp will not be interested in using you frequently if you a) request imaging b) offer injections...

 

[Mister Mxyzptlk]

I don't do any WC at all. For others, it has its ups and downs:

As an example, the doctors cite the case of Dr. Aaron Calodney, a Tyler pain management specialist, a contributor to various candidates since 2006 and a gubernatorial appointee at the time he was under investigation by the MQRP. State Rep. Leo Berman, R-Tyler, told the Tribune he intervened on Calodny’s behalf after learning the doctor was under review. Berman said he reached out to Commissioner Bordelon, who then decided “there was no need to evaluate” what Caldoney was doing. Division records show Caldoney billed insurers $1.9 million for workers’ compensation claims over two years.

http://www.txbiz.org/news_articles/55

I don't know what to make of this. We have been friends for years and everyone I know holds him in high esteem.

He is also the only pain doc in his county who accepts WC. Maybe now nobody will. Then they will run newspaper articles about how injured workers can't find a pain doctor in Smith County.

 

[Tenesma]

it looks like they paid at 25% of his billed charges - so that means that they paid out 500k over 2 years --- which is 250k/year in work comp income --- if he is the only one doing work comp cases - then that sounds not unreasonable

what is the big deal then?

 

[lobelsteve]

it looks like they paid at 25% of his billed charges - so that means that they paid out 500k over 2 years --- which is 250k/year in work comp income --- if he is the only one doing work comp cases - then that sounds not unreasonable

what is the big deal then?

He only saw 10 patients.


Just kidding, no idea. Met him at NANS, nice guy at the meeting.

 

[Finally M3]

I do a workers comp clinic 2 half days a month.

I get 1-3 EMGs a half day. The rest is E&M. Have gotten a few injections out of it.

The E&M, about 25% want to get better. The rest want to go on disability (short v. long).

A lot have real pathology (big disc herniations, radiculopathy, etc).

Doing it full time, I would kill myself. At most, I could see myself doing it 1 half day a week.

 

[Dr. Ice]

if I never see another WC patient again I would be happy!

 

[Tenesma]

i have already severely restricted my work comp population...

and i have stopped playing nice and believing everybody.... when i tell a patient that i don't see any indication for them to stay out of work, they usually don't come back.

 

[Jcm800]

i have already severely restricted my work comp population...

and i have stopped playing nice and believing everybody.... when i tell a patient that i don't see any indication for them to stay out of work, they usually don't come back.

this is how i handle it also...

initially we looked for this business for the obvious reasons, only to find out it was more work then worth it, and not rewarding work. someone was obstructive, whether it was patient, the case worker, the employer , or the payor. someone was typically not too honest. Then despite approvals, denials would happen. Even things that got approved, didnt get paid for many, many months...

and dealing with those s***** case workers...indiana is the type of states where work comp is a complete racket...

i dont refuse it... but i dont chase it, i dont play nice, and there are plenty of guys around here that salivate at the opportunity. they can have it.

 

[Disciple]

Interesting...

In my area work comp is highly coveted amongst Ortho, Physiatrists, Pain Specialists and some Neurologists (even with current unfavorable state legislation),

because the alternative is heavy HMO/Medicare.


Alot of the non-hospital owned surgery centers around here would go under without it.

 

[Tenesma]

i will take three medicare patients over one w/c patient any time - at least the medicare patients get better.

 

[PMR 4 MSK]

The problem is WC is not set up to accommodate pain management. It is set up on the premise a worker gets injured, has clear pathology, has objective findings and has standard restrictions with a clear-cut time limit to MMI. That works well with fractures, lacerations, bumps and bruises, but is completely incompatible with chronic pain management.

How many of you patients have truely objective findings? Very few. Most are "OWWWWW THAT HURT!!!!!" when you examine them. They have questionable weakness, suspicious sensory loss and paraesthesias, loads of Waddell's signs, and a lot of psychosocial baggage that they want WC to pay for.

I'm about 10% WC and they account for about 40% of my PITAs.

 

[Tenesma]

AMAZING:

just saw a patient over the weekend ... this patient apparently works as a volunteer EMT and was seen lifting, pushing and pulling like there was no problem what soever.

this same patient is seeing me for a neck/arm injury for MVA that is "disabling" ...
and is seeing a colleague for a back injury for w/c that is "disabling" ...

i am going to add a note in the chart that i saw the pt doing just fine...

pisses me off..

 

[Finally M3]

AMAZING:

just saw a patient over the weekend ... this patient apparently works as a volunteer EMT and was seen lifting, pushing and pulling like there was no problem what soever.

this same patient is seeing me for a neck/arm injury for MVA that is "disabling" ...
and is seeing a colleague for a back injury for w/c that is "disabling" ...

i am going to add a note in the chart that i saw the pt doing just fine...

pisses me off..

Video surveilance...recommend it

 

[Mister Mxyzptlk]

AMAZING:

just saw a patient over the weekend ... this patient apparently works as a volunteer EMT and was seen lifting, pushing and pulling like there was no problem what soever.

this same patient is seeing me for a neck/arm injury for MVA that is "disabling" ...
and is seeing a colleague for a back injury for w/c that is "disabling" ...

i am going to add a note in the chart that i saw the pt doing just fine...

pisses me off..

When I took the pain boards last time there was actually a question like this - seeing a patient who supposedly has terrible pain playing sports in the park. I have no idea what the right answer to the question was. The politically correct answer was probably "talk about it at the next visit", whereas my reaction was "fire his ass".

 

[DigableCat]

Secret video disputes disability of ex-Seattle firefighter

 

[Jitter Bug]

I see about 15% W/C in my practice. It pays well but it does take extra time for documentation and QRC visits (which can be billed separately).

It's a mixed bag, a patient who likes their job is highly motivated to return to work and fun to treat. A patient who feels entitled to "something" for their injury never seems to get better, and is almost disappointed when I reassure them I expect a full recovery.

 

[Tenesma]

it is absolutely amazing: the look on a work comp patient when you tell them that within a few months this will likely all be resolved.... it is the same look i get when i tell them that their condition does not preclude a return to work...

to describe the look: imagine somebody squinting at you and wishing they had never come to see you..

 

[PMR 4 MSK]

Just had a Work comp pt referred back to me. I declared him @MMI in Jan this year. Back pain that started while doing PT after a fibular fx. He milked it for 6 months, as we did meds and PT, then MRI, then ESI, then facets, the SIJI, plus a EMG for good measure. The only thing that helped was the SIJI, but only for 2 days. Sent him out to a local guy who does RFA of the SIJ. He did it and the moderate pain relief lasted less than 30 days.

Basically, I think the guy was bored from delivering bread for 20 years, and saw his ticket out. I eventually got FCE, we he sandbagged, so I released him at full duty. His lawyer went ape****, demanding I change my statements as inflammatory ("The patient did not give full voluntary effort as reported by the therapist. Therefore, the FCE is invalid and no permanent restrictions can be placed on the patient based on this FCE."), demanding a repeat FCE at a facility of his choosing and demanding I recind my opinion that the patient is at MMI. Never before have a seen balls like this. I ignored him.

When I got the referral today to re-evaluate the pt for exacerbation of previous injury, my reply - "I have nothing to offer this patient." Buh-bye.

 

[Jitter Bug]

it is absolutely amazing: the look on a work comp patient when you tell them that within a few months this will likely all be resolved.... it is the same look i get when i tell them that their condition does not preclude a return to work...

to describe the look: imagine somebody squinting at you and wishing they had never come to see you..

Ha Ha. That's the look exactly. I can see them mentally wondering "if I grab the chart and all the notes and run, can it be like I never came here?"

 

[Mister Mxyzptlk]

Follow-up on the Calodney story. Apparently over the years he has hired several docs and PAs but everything is billed under under Aaron Calodney, P.A.

So the data miners see that Aaron Calodney, P.A. the corporation is billing this huge amount and they go after Aaron Calodney, M.D. the individual.

Where do you go to get your reputation back? Is the newspaper that ran this going to run another story- "We Made a Stupid Mistake - Doctor Is Ok"?

 

[ctts]

I have such mixed feelings when I get a denial from workers comp... Say a patient comes in with radicular symptoms and MRI findings that can be related to the pain. On physical exam, they have no objective findings of radic, with 5/5 strength, normal sensation and reflexes (I believe workers comp doesn't care as much about SLR test). If I document it this way, and request ESI, then it will get denied. Workers comp does not understand that you can have painful radiculopathy without objective neurological findings. If the patient was malingering anyway, then that is fine, but how does one ever know for sure? If the patient was really in pain, then they are getting denied treatment that could help their pain. If convince myself that maybe that muscle was 4+/5 and not 5/5 and document it that way, then it meets their criteria and gets approved... We can also have a similar discussion about splitting hairs between documenting 50% relief with a procedure versus 70 or 80% relief... What is one to do? Perhaps as PMR4MSK posted above, I should use the line, "I have nothing to offer this patient". My problem is I just don't see the world as black and white, and hence I am always feeling like I am caught in the middle.

Sorry to drag this out, but along that lines, when a patient says they can't go back to work, and you don't see any objective reason why they couldn't...how does one move forward? I don't see how it is helpful to tell that patient they can go to work when they firmly believe/claim that they can't. It is similar to a patient coming in with what seems like non-organic pain, and you don't see why they should have pain...it is not helpful to tell them that they don't have pain because it is a subjective experience.

I guess I am not really asking any specific questions, but just soliciting thoughts and comments from others, as I think it would help me to shape my own mental framework as far as how to work with these patients.

 

[emd123]

I have such mixed feelings when I get a denial from workers comp... Say a patient comes in with radicular symptoms and MRI findings that can be related to the pain. On physical exam, they have no objective findings of radic, with 5/5 strength, normal sensation and reflexes (I believe workers comp doesn't care as much about SLR test). If I document it this way, and request ESI, then it will get denied. Workers comp does not understand that you can have painful radiculopathy without objective neurological findings. If the patient was malingering anyway, then that is fine, but how does one ever know for sure? If the patient was really in pain, then they are getting denied treatment that could help their pain. If convince myself that maybe that muscle was 4+/5 and not 5/5 and document it that way, then it meets their criteria and gets approved... We can also have a similar discussion about splitting hairs between documenting 50% relief with a procedure versus 70 or 80% relief... What is one to do? Perhaps as PMR4MSK posted above, I should use the line, "I have nothing to offer this patient". My problem is I just don't see the world as black and white, and hence I am always feeling like I am caught in the middle.

Sorry to drag this out, but along that lines, when a patient says they can't go back to work, and you don't see any objective reason why they couldn't...how does one move forward? I don't see how it is helpful to tell that patient they can go to work when they firmly believe/claim that they can't. It is similar to a patient coming in with what seems like non-organic pain, and you don't see why they should have pain...it is not helpful to tell them that they don't have pain because it is a subjective experience.

I guess I am not really asking any specific questions, but just soliciting thoughts and comments from others, as I think it would help me to shape my own mental framework as far as how to work with these patients.

I agree. Work comp is a tangled web of conflicts of interest. On one hand we're supposed to be patient "advocates" and patient "satisfaction" is King, but on the other hand a patient may want to crucify you for suggesting they can work. Work comp wants to crucify you for suggesting they can't. You can't win.

 

[Ligament]

Yes it is possible. I know of a physiatry/pain practice here in Seattle that is largely workers comp. They do very well and are great docs. That said, I'd rather die.