Pinnacol launches physical therapy and chiropractic utilization review program
By Tom Denberg, M.D., Senior Medical Director
Based on the Department of Workers’ Compensation (DOWC) Medical Treatment Guidelines and other DOWC rules, Pinnacol is phasing in a program to promote the appropriate use of physical therapy and chiropractic. This program was first introduced at the January 2019 provider conference in Denver.
For injury types in which physical therapy (PT) or chiropractic are reasonable treatment options, patients will be allowed six initial PT or chiropractic sessions. For both modalities, this corresponds to the initial time to produce effect (TPE) interval specified in the Medical Treatment Guidelines. Payment for a limited, additional number of sessions will be approved only if (1) the authorized treating provider (ATP) (who in rare instances might be a chiropractor) makes a formal request for additional sessions and (2) there is meaningful evidence that PT- or chiropractic-related functional gains have been realized during the sessions already provided. Specific actions include the following:
- Nurse advisors will notify physical therapists and chiropractors that copies of all their clinic notes must be submitted to Pinnacol and available for nurse review as soon as possible after TPE intervals have been reached. Nurse advisors will also notify ATPs when TPE intervals are approaching. They will ask ATPs to review the results of PT and chiropractic interventions and make formal requests if their patients need additional PT or chiropractic sessions. To facilitate communication and avoid interruptions in treatment, ATPs may be able to convey some requested information by phone and email.
- Nurse advisors will carefully review the PT and chiropractic documentation to confirm that meaningful, measurable and specific functional gains are being realized.
- If requested documentation is not provided or ATPs do not request additional PT or chiropractic, administrative denials of payment for additional sessions will be issued until documentation and requests are received.
- If there is insufficient evidence of functional gain by the end of a TPE interval, nurse advisors may obtain independent expert reviews that could result in denial of payment for additional sessions.
- If functional gains are demonstrated and ATPs have requested additional therapy or chiropractic, Pinnacol will approve additional sessions up to a subsequent TPE interval. Another ATP request for additional PT or chiropractic sessions, along with evidence of ongoing functional gains, will be required by the end of the new interval.
- The actions described above also apply to massage therapy because this form of treatment also requires formal assessments of functional gain.
This Pinnacol program is intended to improve quality of care and outcomes for our injured workers by promoting improved communication between therapists/chiropractors and ATPs, better medical record documentation, and more careful consideration of the DOWC Medical Treatment Guidelines. ATPs are urged to explain to their patients, as early and as clearly as possible, that while PT or other forms of treatment might be prescribed for an initial period, this treatment should be continued only if it produces genuine functional improvement. Providers should educate patients that pain by itself is an insufficient reason to continue with therapy when functional gains are not being realized. This will minimize patient frustration and confusion if treatment is discontinued, and will help patients establish realistic expectations for their care, which should aid in their recovery.
If you have any questions about this program, please contact Dr. Denberg at email@example.com, or contact your Pinnacol-assigned provider relations specialist at firstname.lastname@example.org.