Clinical peer reviewer for workers comp

[painfre]

I got an offer to do a part time offer as a clinical peer reviewer job for workers comp. I know some of Physicians here has experience in this. I do not have prior experience in doing these but I can get trained online. I am currently working as Pain physician for 4 days a week at VA hosp in Texas. I am thinking of working as a reviewer for about 8-10 hrs a week. In the state of Texas, since there is no direct doctor-patient relationship , no malpractice can occur. Am I correct? Do I need to get any coverage from Insurance company. Currently, I do not carry any liability insurance coverage. Thanks

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[RUOkie]

Do you have any experience with the workers comp system? Especially in Texas. Their "peer review" process in usually intended as a means to deny or delay service. Also, if you have never worked with the workers compensation system, what actually qualifies you to be a "peer reviewer"? I am not saying this to be nasty. If you are called to deposition or testify, would YOU be comfortable defending your positions?

And if the answer is yes, the company employing you should provide liability insurance for you. It is fairly cheap for them. Because you CAN be sued, not for malpractice, but for delaying appropriate care.

 

[painfre]

Thank you for your response. I donot have any prior workers comp experience. Actually, it is part time offer as a clinical peer reviewer job involving workers comp cases. It is done online for utilization review company and I was told that I will be trained online for this. Is there any better way of getting training?

 

[axm397]

in texas - there are courses you can take to become certified as a designated doctor to do DD exams (take course, then test at end of course). Peer reviews don't require that certification - but you will need to be familiar with ODG guidelines. A lot of peer review companies have PAs and nurses doing the initial chart review write up but need an MD/DO signature to make the report valid. The money is not that great - usually about 20 bucks a call and 50-75 bucks a report that you sign off on. texas has a fee schedule for work comp and most of the companies that do peer reviews take 60-70% of the fee leaving you with about 30-40% - that is the price you pay for them getting the cases, doing the chart organization, etc. Most of the time, you will be denying services. ODG guidelines are basically written by a bunch of occ med docs and gives you "evidence based" reasons not to pay for something. You may also be denying admission of a diagnosis as it relates to the work injury. in terms of spine - most of the time they will admit to sprain/strain but not radiculopathy or HNP. If there's any mention of spondylosis on report, they will jump on that and use that to deny services. I have been on both sides - both peer reviewer and treating physician. sucks either way but may make sense for you to make some spending money on the side.

 

[RUOkie]

OP, if you feel ok with effectively being a ***** for the insurance companies just denying care based upon the ODG guidelines, then go for it. I do a lot of IMEs for the TX state division of Workers compensation and I read these peer review chart reviews all the time. I don't remember the last time I saw any critical thinking in them.

IMO the best way to be trained to understand the workers compensation system is to actually be a treating doctor for a few years. And then to take a SEAK or AADEP course.

 

[eljefe]

I currently do a similar gig part time. No training needed--just have to get familiar with the ODG which is a pain at first then becomes really easy. Regardless of what the other folks say, I feel you can do these reviews and not be an insurance *****. It's pretty easy to see who is trying to do the right thing and who is abusing the system. For those trying to do the right thing, it usually turns out to be just an issue of documentation and them not being familiar with the ODG. I then call them for the peer to peer and coach them through it on how to get it approved. The outliers get denied and you get a little satisfaction to shut down a huckster that gives us a bad name.

Apart from some extra cash, you also learn quite a bit seeing how everyone else practices and you will have minimal problems with your own WC patients once you become familiar with the ODG (unless you're at the VA). You will also become more familiar with the literature which helps your personal practice. The ODG is not perfect but seems to be pretty in line with evidence based medicine overall. The ODG is after all just recommendations and if you feel it is not correct, you just support your recommendation with applicable medical literature. In addition to the ODG, there is a lot of WC peer review work out of California which uses the MTUS (based on the ODG guidelines).

I've been doing it about 2-3 years and made around $100K last year on peer review (most are TX WC cases, but some non WC stuff too). I spend 2-3 hours a day doing these (lunch break and a couple hours after the kids go to sleep) and most cases are straight forward. Number of PT sessions, whether an ESI is appropriate, etc. I see very few cases regarding causality and for those few cases use the "within a reasonable degree of medical certainty" line a lot (>51% chance). In other words, if it is in the ballpark it is workplace related.

You definitely take a tax hit with the 1099 income but the checks are nice until 4/15. With that being said, I am out of the peer review business as soon as I get out of debt 🙂

 

[imagoodmanyea]

How does someone get into this line of work? Do you contact the work comp insurances directly? Or are there companies that manage the peer-review process for work comp?

 

[Jitter Bug]

They usually want board certified docs with at least 5 years of clinical experience. Once you hit year 5, they will probably find you.

 

[Xardas]

I got an offer to do a part time offer as a clinical peer reviewer job for workers comp. I know some of Physicians here has experience in this. I do not have prior experience in doing these but I can get trained online. I am currently working as Pain physician for 4 days a week at VA hosp in Texas. I am thinking of working as a reviewer for about 8-10 hrs a week. In the state of Texas, since there is no direct doctor-patient relationship , no malpractice can occur. Am I correct? Do I need to get any coverage from Insurance company. Currently, I do not carry any liability insurance coverage. Thanks

Go to an AADEP course as RUOkie (seasoned contributor) says. You will learn a lot. There are types of language you need to put in reviews. First of all you never refer to the person as a 'patient.'

I disagree you are whoring for one side or the other. I look at it as providing a service. i get paid to provide my opinion. I usually try to give my opinion based on what the person asking me questions has, but I do not let that sway my opinion.

Sometimes I agree, and sometimes not. Just because I say yes or no (based on my opinion), has not meant that certain referral sources stop or only use me.

I sometimes see awful or redundant or just plain wasteful care being provided so its not as if just because the physician doign the reviewer is being an evil gatekeeper. And sometimes I see very appropriate care.

I've been doing this on and off a few years. Its ok. You get a little extra side income and its always interesting to read others' work. Its not exactly exciting as its just chart review. You kind of get paid less than the time it takes to read, dictate, correct reports.

You can always do some and decide if you like it or not.

 

[ampaphb]

Not sure how ODG works. In LA, we have guidelines. I helped write them. Most of the reviewers are unfamilar with them. Ours is a rule-driven process; there is zero room for clinical judgement. Either the request meets the Metical Treatment Guidelines, or it doesn't.

You do not need malpractice insurance to perform this task. I do get the sense that, a number of insurers will pressure you to rule against treating docs more than for them. In my state, we can then appeal to the medical director, who is also an MD/JD. I win about 90% of my appeals.

Your decision will never be called into court. This is a matter of whether the insurer is willing to pay or not, nothing more. At least in Louisiana, no WC case reviewer is EVER called upon do determine causation - that is an issue for the attorneys to hash out.

 

[Xardas]

Ampaph -- Disagree with you - you definitely WANT to get malpractice if you want to to these. Its rare but you can get sued. You will probably win but again, the cost is relatively low.

As for ODG its used in a lot of states. ONce you get used to the lay out of the web page its not bad.

I will say I've never ever felt pressured to rule one way or the other. I will say again the cases I've gotten, the insurers have had the right in asking for a review as again there are some questionble decisions out there.

 

[lobelsteve]

Ampaph -- Disagree with you - you definitely WANT to get malpractice if you want to to these. Its rare but you can get sued. You will probably win but again, the cost is relatively low.

As for ODG its used in a lot of states. ONce you get used to the lay out of the web page its not bad.

I will say I've never ever felt pressured to rule one way or the other. I will say again the cases I've gotten, the insurers have had the right in asking for a review as again there are some questionble decisions out there.

It is not malpractice insurance as there is no doctor-patient relationship. It is a liability insurance for errors of omission. The carriers or IRO's pay for it as part of your contract.

 

[Xardas]

Thanks for clarifying that Steve, as yes there is no doctor-patient relationship, and as such during the reports the physician does not refer to the reviewer as a patient but either by actual name, or use the term 'claimant.' This is a good thread.

 

[ampaphb]

There is no liability risk. You are not being asked to treat the patient. You are not being asked to render a medical opinion. You are being asked to assess whether the state specific guidelines allow for a particular procedure to be covered. Unless every idiot, high school educated clerk that the insurance companies hire to render such determinatons are at risk, you aren't either.