Section Menu

Understanding Your Biggest Challenges

June 2016

Corporate News

Several weeks ago, we asked you to respond to a survey to help Pinnacol assess the needs of the clinical provider and administrative community we value so highly.  Through this research, we have affirmed our positive working relationship with our provider community and gathered ideas for providing increased value.

The goal of this research was to inform strategies to expand communication, content, resources, tools and education for providers and understand the specific and unique needs of subsets of the provider community. 

Findings

Overall impressions of Pinnacol were very positive, and respondents appreciated that Pinnacol solicits providers’ feedback and focuses on continuous improvement. 

One provider said, “From a physician’s standpoint, they’re probably the easiest carrier I work with — especially their accessibility and willingness to talk to me. And aside from the financial side, they’re the easiest one as far as billing is concerned. But I think it’s the personal relationships that really make it unique for me as a physician.” 

Seventy-six percent of respondents said they valued interactions with their Pinnacol Provider Relations Specialists, and 75 percent said additional education and resources would further improve their satisfaction with Pinnacol. 

Top challenges

Respondents were asked to rate challenges they encountered when handling all workers’ compensation claims:  

  1. Understanding the DOWC rules, fee schedule and treatment guidelines
  2. Employer relations
  3. Navigating Pinnacol’s online provider portal
  4. Injured worker relations
  5. Billing and coding 

When working specifically with Pinnacol, respondents noted these tasks as challenging:  

  1. Managing claims denials
  2. Understanding the approval process
  3. Meeting credentialing requirements for accreditation
  4. Utilizing Pinnacol’s online provider portal 

Researchers also discovered that clinic administrators’ and clinicians’ needs were distinct. Administrative professionals said they value education and resources related to claims processing and communication, and clinicians value information about best practices for treating workers’ compensation patients and managing relationships with injured workers and employers. Administrators also said they prefer brief, more frequent email updates from Pinnacol, while clinical providers preferred less frequent and more specialty-specific content. 

Education topics were ranked by interest:

  1. How to bill and code effectively
  2. Understanding the DOWC rules, regulations and treatment guidelines
  3. Clinical best practices
  4. Advanced workers’ comp tutorials
  5. Basic workers’ comp tutorials
  6. How to network with other providers and build referrals 

Outcomes 

Pinnacol teams are hard at work identifying and enhancing the education, resources and tools most valued by the provider community.  

Pinnacol recently hired a full-time Network Educator, Laura Palmer, who brings experience in provider relations, education and medical practice administration. Her background includes 12 years in occupational medicine practice administration, 10 years of physician consulting with the Texas Medical Association and, most recently, as the Director of Professional Development for the Medical Group Management Association.  

Within the next several months, Pinnacol will be rolling out: 

  1. Enhanced interaction with Provider Relations Specialists. Focus group participants liked Pinnacol’s expanded approach to PRS, and providers will have access to more resources and customized information and education through their designated specialists. Staff will visit clinics more frequently, and the information they present will be customized to meet specific clinic needs, such as coding, documentation or billing.    
  2. Improved timeliness of communication and access to information  
  3. Expanded educational offerings and formats including in-person and online education
  4. More online resources, tools, information and content 

“With input from the provider community, we can provide new and ongoing training for billing, administrative and clinical staff to improve processes and understanding. Through enhanced relationships and closer communication, providers can expect targeted resources and education from Pinnacol. We would love to hear your suggestions for improvement,” said Palmer.  

Read More

Endoscopic Carpal Tunnel Release

June 2016

Endoscopic Carpal Tunnel Release

Submitted by Steven M. Topper, MD

The debate in the scientific literature between open and endoscopic carpal tunnel release (ECTR) through the 1990s and into the early part of the 21st century was voluminous. In the end, we were left with no definitive scientific proof favoring one procedure over the other. Consequently, both are still done today. While the controversy has died down, questions still remain. The Academy of Orthopedic Surgeons Work Group, which created clinical and diagnosis guidelines for carpal tunnel release, expressed in their 179-page report what is generally accepted as the conventional wisdom. They concluded that ECTR was favored for outcome measures of less pain, greater pinch strength and fewer wound complications at 12 weeks. Open carpal tunnel release was favored for fewer reversible nerve issues (neuropraxia is slightly less likely with open carpal tunnel release). There were no differences for functional status and symptom severity at one year, including complications or infections.1 In other words, both procedures are equally safe and effective, and there is a quicker recovery with the endoscopic approach in the first three months which has obvious implications in the workers’ comp setting. Perhaps societal issues such as cost-effectiveness and quality of life will drive us to seek more definitive answers, such as happened with laparoscopic cholecystectomy. Until that time, we are left with randomized controlled trials and meta-analyses that generally have insufficient power and inconsistent outcome measures, making it hard to draw conclusions. 

Fortunately, division of the transverse carpal ligament is an effective way to treat carpal tunnel syndrome. The application of minimally invasive (endoscopic) techniques to the most commonly performed orthopaedic procedure, back in the 1980’s, made sense. The hope was that it would decrease the morbidity of the procedure and yield a quicker recovery. In so doing it may also create a societal cost savings, in light of the number of working “young” people that have carpal tunnel surgery. Though there is no definitive scientific proof that this has been accomplished, there is also no proof that it hasn’t. Early on, there were concerns about the safety of ECTR because the technical aspects of the procedure required a relatively new skill set called triangulation. Triangulation is used in all arthroscopic and endoscopic procedures today and is a universal skill set among orthopedic, plastic and general surgeons. 

From a practical point of view, in the work comp setting, recovery time matters. The three primary factors in determining return to work recommendations include risk, capacity, and tolerance. Risk involves the likelihood of exacerbation, recurrence, or re-injury. Capacity is an individual’s actual functional ability to perform required tasks, and tolerance is the individual’s perceived ability based on pain behavior and willingness to perform duties. We advise our patients who have had an ECTR to continue with activities as tolerated without requiring medically necessary activity restrictions. Given that there is relatively little tissue damage as result of the ECTR technique, the risk of re-injury or exacerbation of problems is small. Capacity to perform activities is limited only secondary to postsurgical pain at the incision site and any preexisting deficits such as weakness, numbness and tingling, or pain that take time to resolve after the carpal tunnel has been decompressed.2

As there is little risk of re-injury following the minimally invasive ECTR technique, sedentary type workers are advised to return to work on postoperative day one or two and manual laborers on postoperative day 5-7. Official Disability Guidelines recommend 21 days as the optimum return-to-work best practice for people who perform medium level work (exerting up to 50 pounds of force occasionally, and/or up to 25 pounds of force frequently, and/or up to 10 pounds of forces constantly to move objects.) The recommended optimum ranges vary from 7 days for sedentary work to 48 days for very heavy work.3

In the first quarter of 2016, The U.S. Department of Labor’s Bureau of Labor Statistics has estimated the cost of lost productivity at $830 per week based on the median weekly earnings (not seasonally adjusted) of full-time wage and salary workers.4 The difference in lost work productivity due to differences in return to work between ECTR and open surgical treatment for carpal tunnel syndrome is estimated to be $2,656 per patient.   (Estimated as 21 days – 5 days = 16 days x $166/day = $2,665 using medians and averages). While this is a rough estimate based on accepted guidelines, it does bring into focus a concept that is particularly relevant in the workers’ comp setting.

Steven M. Topper, MD, President

Colorado Hand Center

2925 Professional Place 

Colorado Springs, CO 80904

References

1. CTS Guideline 2016 - Work Group Members. "CTS Treatment Guideline." AAOS. American Academy of Orthopaedic Surgeons. 18 Apr. 2013.  http://www.aaos.org/Research/guidelines/CTStreatmentguide.asp. (Requires member login), Accessed 6/16/16

2. http://www.mdguidelines.com/carpal-tunnel-syndrome  Accessed 6/16/16

3. http://www.mdguidelines.com/search/medical-disability-advisor Accessed 6/16/16

4. http://www.bls.gov/news.release/wkyeng.nr0.htm  Released April 19, 2016, Accessed 6/16/16

Read More

Pinnacol Healthcare Conference Expands Agenda, Broadens Participation

June 2016

Featured Story

The 2016 Pinnacol Healthcare Conference offers tracks for clinicians and practice staff and welcomes out-of-network providers.

With a new name, a new format and new content, our annual provider event — renamed the Pinnacol Healthcare Conference — this year will offer new and greatly expanded continuing education not just in Denver, but in Grand Junction as well, and promises to attract a record number of attendees.

The Denver event on Sept. 29 will welcome as many as 250 providers; the Grand Junction conference expects about 100 attendees. 

Broadened participation, distinct tracks for clinicians and practice staffs

This year Pinnacol is inviting out-of-network providers to the accredited conference events. In past years, attendance was limited to Pinnacol’s proprietary SelectNet network.

“Out-of-network physicians and facilities treat our policyholders’ injured workers too,” noted Network Educator Laura Palmer, who plans and executes the Pinnacol Healthcare Conference and other educational programs for our healthcare stakeholders. “Pinnacol is making educational opportunities available to SelectNet and non-SelectNet providers to enable the most coordinated, highest-quality care and best outcomes for injured workers.”

The excitement this year is also due to the offering of billing and administrative topics as a separate, distinct track. This will allow practice management staffs — perhaps 40 percent of attendees — to attend sessions most helpful to them, while clinicians benefit from sessions focused on patient treatment.

As in previous years, the 2016 conference will offer insightful panels on the latest clinical developments. But there will also be sessions on communications and relationship-building. “How to Coach Your Patient to Show Up in the Healing Process” will be one keynote address. Another is titled “Managing Relationships — Dealing With Difficult People.”

Provider feedback, input drive accredited conference content

“Surveys and focus groups told us that providers can get continuing education events elsewhere that offer strictly clinical information,” Palmer said. “What providers want is guidance on how to manage varying personalities and challenging interactions. They want continuing education on how to involve patients in shared decision-making, as well as how to optimize relationships with employers, attorneys and practice staff. Uniquely, Pinnacol will provide accredited guidance on these critically important soft skills.”

“Kudos to Laura for digging into feedback from prior-year events,” said Director of Provider Network Management Bonnie-Lyn Cahoon, Palmer’s manager. “The buzz about the Pinnacol Healthcare Conference is due in large part to Laura’s efforts.” 

Cahoon said Palmer has pored over evaluations, involved co-workers, consulted with SelectNet clinicians and administrators, and coordinated closely with the Colorado Medical Society. Palmer has used this collective input from the provider community to determine the agenda of the 2016 Pinnacol Healthcare Conference. 

“Hired earlier this year, Laura brings 12 years of occupational medicine experience, as well as 14 years of physician education and practice management experience,” Cahoon added. “I’m confident this will be reflected in the quality of this fall’s Denver and Grand Junction events.” 

Register now for the conference or contact your provider relations specialist for details.

Read More

Amendment 69 Would Demolish Colorado’s Stable Workers’ Comp System

June 2016

Workers' Comp Coordination

Colorado’s workers’ compensation system is one of the best in the nation, effectively balancing the needs of labor and business. The stability and financial security of the system is a boon to the state’s economy, helping retain business and lure new employers. But that will change if Amendment 69, or ColoradoCare, is approved by voters in November. Read the full story

Read More

Colorado Supreme Court Clarifies Standard for Firefighter Cancer Claims

June 2016

Workers' Comp Coordination

By Harvey Flewelling, Associate General Counsel, Pinnacol Assurance

Policyholders expect us to understand what’s happening in their businesses and their industries. One way Pinnacol’s Public Entity Sector Center of Excellence is working to meet this obligation is to find and share information that may impact the industries we work with. Recently, Colorado’s Supreme Court issued decisions on three workers’ compensation cases involving firefighter cancer. Although these decisions won’t change the way Pinnacol handles claims, we want to ensure that you, as our provider partners, are informed. 

The Colorado Supreme Court recently issued decisions in three workers’ compensation cases involving firefighter cancer. These decisions clear up confusion around when cancers suffered by firefighters can be presumed to have been caused by their occupation. This article explores two of these decisions that best illustrate the issues being disputed and explains the implications of these decisions for Pinnacol’s policyholders and their injured workers. 

Background

In 2007, the Colorado General Assembly passed a law to make it easier for firefighters who have cancer to receive workers’ compensation benefits. That law creates a presumption that certain types of cancer result from a firefighter’s employment, as long as the injured worker has worked as a firefighter for at least five years and a pre-employment physical examination did not reveal such cancer. In other words, as long as these tests are met, it is legally presumed that workers’ compensation insurance will cover a firefighter’s cancer. However, the law also created an opportunity to overcome that presumption if the employer shows by a preponderance of the medical evidence that the cancer did not occur on the job.

Since the law was passed, it has been interpreted inconsistently by the courts. That’s created confusion about whether and to what extent the presumption can, in fact, be overcome. With its decisions in City of Littleton v. Industrial Claim Appeals Office, and in Industrial Claim Appeals Office v. Town of Castle Rock, the Colorado Supreme Court has now cleared up that confusion.

Overview of the issues

In City of Littleton, the injured firefighter was diagnosed with brain cancer. He met the test for the presumption that his cancer was compensable. However, the administrative law judge (ALJ) denied compensability after concluding that the employer had proven that his cancer was not related to his employment. The worker appealed, and a panel of the Court of Appeals reversed the ALJ’s decision on the grounds that the employer did not disprove the specific causation of the worker’s cancer.

The Supreme Court reversed the judgment of the Court of Appeals. The court held that an employer can meet its burden to overcome the presumption by establishing the absence of either general or specific causation — in other words, a fairly broad interpretation of the law.

The Town of Castle Rock case involved a worker who had worked as a firefighter, engineer and paramedic. During his off hours, he worked in construction — and sometimes outdoors — framing and building decks. He was diagnosed with malignant melanoma on his right outer calf. He underwent three surgeries to remove the growth and filed for workers’ comp coverage. The employer sought to deny the claim by presenting expert testimony that the worker’s various other exposures and risk factors placed him at far greater risk of developing melanoma than his activities as a firefighter. An ALJ disagreed, saying that the statute required proof that the injured worker’s cancer came from a specific cause not occurring on the job and requiring the employer to cover the claim. The employer appealed, and a different panel of the Court of Appeals sided with the employer, saying that an employer may overcome the presumption of compensability with specific evidence demonstrating that a particular firefighter’s cancer probably was caused by a source outside his firefighting work.

In this case, the Supreme Court affirmed the decision of the Court of Appeals, holding that the employer does not need to pay the claim if a preponderance of the medical evidence establishes that the firefighter’s particular risk factors make it more probable that the cancer arose from a source outside the workplace.

Implications

These decisions provide clearer guidelines for determining when it is appropriate to award workers’ compensation benefits in a firefighter cancer claim. While the presumption that a firefighter’s cancer is caused by on-the-job exposure remains in place, these decisions clarify the grounds on which an employer or insurance carrier can overcome that presumption and deny the claim. However, it’s important to understand that the presumption is not easy to overcome.

As we always do, Pinnacol will continue to investigate the merits of all claims individually. Based on the evidence obtained in our investigation and the applicable legal guidelines, we will then determine the position we will take on each claim on a case-by-case basis.

Read More

How Can Pinnacol’s Utilization Review Department Help Your Business?

March 2016

Billing/Administration

Pinnacol Assurance recently launched a new Utilization Review department to support clinical outcomes, ensure the appropriate utilization of medical resources and provide timely service to providers. 

What you need to know:

1. Our process has not changed. Prior authorization is still necessary when:

  • Required by the Division of Workers’ Compensation (DOWC) Medical Treatment Guidelines; 
  • The treatment exceeds established number of visits; or
  • The guidelines do not address the service being requested.

2. Prior authorization questions should be directed to the assigned claims representative handling the claim. Any requests for medical services should go to the assigned medical reviewer, viewable on the Pinnacol Provider Portal at Pinnacol.com. Requests for transportation and interpretation should be directed to the claims reviewer.

For more information on prior authorization requirements for payment, please refer to Rule 16 – Utilization Standards (7 CCR 1101-3, Section 16-9) on the DOWC website. Please share this information with your colleagues.

Read More

Cognitive Training for Traumatic Brain Injuries

March 2016

Featured Story

Contributed by Torsten Jess, M.S., CCC-SLP

How many times have you heard “Oh, he or she is fine because they have a hard head” when someone suffers a blow to the head? Truth be told, even if a person should have an unusually thick or tough skull, the inside of their brain is still moving. This is called a “coup” or “countercoup” injury and is described as the brain rocking back and forth forcibly against the inside of the skull. The result can leave the brain bruised and can injure the tissues by way of forcing them together or pulling them apart. This occurrence can cause physical, cognitive/thinking, communicative/language and emotional deficits that may very well impact an individual's ability to function as he or she once had. The extent of damage is often described as mild, moderate or severe, and is determined by the length of time of unconsciousness and/or by the force of impact. Such deficits can be temporary or permanent depending on the extent of damage. The causes of such are more often than not from motor vehicle accidents, assault, falls and sports-related injuries. 

As a cognitive (memory/problem solving) specialist and therapist for over 18 years, I can attest to the fact that each individual who walks through my door is unique. The initial focus is to determine where the individual sees his or her own deficits by way of a series of carefully delineated questions as well as their goals for treatment. Once obtained, a standardized test is pursued to assess the severity of deficits. From then on, a systematic approach is implemented that involves paper and pencil exercises, the manipulation of objects, computerized training as well as other various applications. In addition, specialty techniques are implemented so as to literally teach the individual to develop a photographic memory. Such techniques are considered to be invaluable and can be utilized in nearly every facet of an individual’s day-to-day routine. The potential to remember long lists of concrete items, abstract thoughts, numbers and names as well as many different lists of worthwhile information at the same time is often met with skepticism at first. Yet, there is rarely an individual that I come across who cannot benefit from this technique and/or master it within a mere five sessions, although 10 sessions are recommended. In fact, I relish the third session which is often when I ask the patient to devise their own list consisting of a combination of 30 or so objects, names, numbers, colors, etc., for me to remember. I then verbally repeat their list back to them in any order imaginable with the greatest of ease and can still do so when called upon throughout the entirety of our time together. By the end of that very session, the patient is also able to emulate exactly what it is I do … and that is only the beginning. 

If the case for cognitive training and the potential it offers wasn’t strong enough, studies also point to the fact that the more trauma a person’s brain undergoes throughout life, the greater the likelihood of developing dementia. Therefore, the need to undergo cognitive training is essential and the sooner the better. For more information, please refer to BrainFunctionOptimization.com or call Torsten Jess, M.S., CCC-SLP, at 303.658.9868. 

Read More

Causation of Upper Extremity Injuries

March 2016

Clinical Corner

Contributed by Jonathan L. Sollender, M.D., FACS

Causation of upper extremity injuries can sometimes be easily accomplished, or at times can be quite challenging for both treating providers and injured workers. When a singular injury occurs at the workplace, claims typically require a modest investigation before they're approved for coverage. However, in the case of a cumulative trauma condition, a more thorough investigation is frequently required, where the assistance of the employer and treating providers make the system work at its best. Fortunately, we have the assistance of the Medical Treatment Guideline known as Rule 17, Exhibit 5 (aka Cumulative Trauma Conditions) to lean against when making causation statements. This guideline only addresses issues from the elbow to fingertips and is not useful for shoulder conditions.

The first step is somewhat obvious and requires a diagnosis. Remember that pain is not a proper diagnosis but a symptom of some pathology, be it tendonitis, strain, fracture, laceration, etc. The second step is to clearly define the job duties of the worker. Here, one is asked to “not rely solely on the employer’s description of job duties. The worker’s description of how they actually perform the duties is extremely important. Jobsite evaluations are always appropriate, but are sometimes unnecessary when the physician can identify the job duty which appears to be causing the symptoms and provide a method for ergonomically correcting the activity.” This means the physician must ask, in detail, what the worker does, for how long per day, and the exact details of weight of objects lifted, the frequency per hour, and the postures assumed of the wrist and elbows. If the provider can’t quite image in their mind how the worker conducts his or her work, then lean on a vocational expert to go on-site for a Job Demands Analysis (JDA). Remember that the objective observations and record of a vocational expert is invaluable to confirm (or refute) the accuracy of what the injured worker tells you. They might think there work is repetitive for them, but without some numbers, to attach the allegation of repetitiveness or forcefulness or awkwardness, sometimes the determination of work relatedness can be challenging.

If a JDA is needed, ensure you understand the quality of information a JDA will give you rather than an ergonomic evaluation. An ergonomic evaluation will tell you if improper postures are present, but might not tell you how long the injured worker maintains such posture. A JDA will likely provide both awkward postures as well as the length of time such postures are present through a typical workday.

The third and fourth step requires comparing the worker’s duties with Primary and Secondary Risk Factor definitions on pages 21 and 22 of Rule 17, Exhibit 5. If, and only if, no Primary Risk Factor is present and a single Secondary Risk Factor is present, then one should look at the Diagnosis Based Risk Factor Table, not as a substitute for the steps 3 and 4. Looking at this table one sees various combinations of potential risk factors that must be present to confirm a work-related condition. There is also an easy-to-understand algorithm on page 19 of the guideline.

Remember, the goal of causation is to verify that a cumulative trauma condition could have arisen from the workplace. One also has to use logic to confirm a physiologic exposure to the factor that could cause certain conditions. Thus, if someone is seen for trigger finger on the left long finger, and a JDA shows a risk factor for mousing over four hours per workday, and they mouse with the right hand, it is not physiologically related to have a trigger finger of the left hand as an occupational condition if the only risk factor is right-handed mousing.

Causation analysis is time-consuming and challenging, especially in cases where the subjective information of an injured worker conveyed to the treating provider is vastly different from the information supplied by a vocational expert. Pinnacol has a multitude of consulting Physician Advisors who would be happy to assist you with these difficult issues. Feel free to reach out to your claims representative for assistance if you get into one of these situations. 

Read More

Pinnacol’s Physician Advisor Program

March 2016

From Pinnacol's Medical Director

Don’t you hate having someone looking over your shoulder and questioning your decisions?

So do I.

I don’t know of any physician who relishes the idea of having another doc reviewing your treatment choices and deciding what they feel is best for your patient. It’s just not something that most of us are ever going to enjoy.

But there are some bright spots on the horizon.

You already know that you don’t need our approval to provide treatments that are recommended by the DOWC’s Medical Treatment Guidelines, although we recognize that sometimes you ask us to give you a written authorization so that you can get other entities (like surgery centers) to book your cases, etc. To that end, we’re working to make it quicker and easier for you and your staff to get something in writing from us if you need it.

Then there’s the issue of getting approval for treatments not in the guidelines.

The Colorado statutes mandate that we have to have a process for this, but they don’t require that we make the process painful or slow.

We have a great group of your very dedicated colleagues that serve on our Physician Advisor panel. They’re doing all they can to provide timely, accurate and fair evaluations of your patient treatment requests. We hear that our system works pretty well (a lot better than any of our competitors), but we know it’s not perfect.

So we’re evaluating how to improve our Physician Advisor process, and we’re looking for ways to enhance our service to you. 

Here are some of the ideas we’re talking about:

1. Adding more physicians in several specialties so they can respond more quickly to your requests for approvals.

2. Assessing video conferencing solutions that:

  • Allow our Physician Advisors to do more work from their offices or homes as opposed to having to come to Pinnacol; and
  • Encourage more physicians who aren’t in Denver to become part of our Physician Advisor team.

3. Using our Physician Advisor team to help evaluate new treatments that hold promise for improving patient care.

4. Track the decisions the Physician Advisors are making and correlating how these decisions impact patient outcomes.

5. Providing options for high-performing providers to skip the Physician Advisor process completely (and get automatic approvals).

I’m sure you may have other ideas on how we can improve the service our Physician Advisors are providing to you, our most important partners. 

Finally, you may have heard that there is a proposal being discussed (likely at the March or April DOWC stakeholders meeting) asking the Division to consider bringing all authorization reviews for all Colorado providers into the Division. In other words, if you want to request a treatment that is not in the Colorado Guidelines, then you would not ask Pinnacol (or any other payer) for authorization. Instead, you would send your request to the DOWC and their panel of physicians who would review it and decide.

Please feel free to contact me and let me know your thoughts and ideas on how we’re doing and how we can improve our processes.

Sincerely,

Rick May, MD

Orthopedic Surgeon

Senior Medical Director

Pinnacol Assurance

Cell: 303.618.4366

rick.may@pinnacol.com

Read More