A Survey of Workers' Compensation Claims Adjusters: A Report Card

Treatment of workers' compensation claimants constitutes a substantial portion of the average DC's practice; however, a recent survey of claims managers and supervisors reveal a number of problems of which doctors should be aware. The authors interviewed the major compensation carriers in the San Diego area for their candid opinions, and were asked to give chiropractors a report card. What follows includes the good, the bad, and the ugly.

Communication

Almost universally, the claims people we talked to cited poor communication as a major problem. While many reported that DCs were more likely to call an adjuster to discuss a case than other providers, they also reported that DCs were less likely to provide them with the information they needed in writing.

Carriers are entitled to a complete history when relevant, such as previous low back problems in an industrial low back injury case, or information about previous auto accidents in a worker with neck pain. Such information will not necessarily mean authorization to treat will be denied, but it will allow the adjuster to more properly manage the case, and may explain why more care is needed. Since the goal is to return the patient to a preinjury status, your history needs to establish the preinjury baseline. If you have not documented their status prior to their injury, it will be very difficult to know when you have returned them to this level.

Adjusters expect reliable, informative reports which assist them in determining how much funding to set aside to provide for future treatments, rehab services, and disability benefits. They do not expect you to forecast the future, but do expect reasonable predictions based on the patient's subjective complaints, objective findings, and your experience. When your reports do not include the information they need to assist the worker, they must request it from you. If you are unsure of what they need, call and ask them. This should not be a signal to refer them to an attorney. None of the carriers we talked to were "anti-chiropractic." All of them had DC consultants and treating doctors to whom they referred regularly. They use these doctors because they get reliable, timely, and accurate reports from doctors who understand the workers' compensation system.

Reports

The law requires a progress report every 45 days, although we suggest every 30 days or whenever a significant change occurs in the patient's condition. Common complaints were reports which stated "patient is subjectively and objectively 60 percent improved" one month, "70 percent improved" the next month, etc. These reports are meaningless. Describe what is better. Use visual analog scales for pain. Better still, learn the meaning of "slight," "moderate," "frequent," and "severe." These terms have legal definitions, and your inappropriate use of them immediately tells the adjuster that you are not familiar with the workers' compensation system. Describe reproducible objective findings in your reports. Learn what tests, measurements, and findings are expected in reports.

Most adjusters we talked to decried the use of check-mark forms, and several stated that the reports they received from DCs were "embarrassing" and "unprofessional." Ask yourself what image your report projects when the majority of the reports an adjuster reads are typewritten, dictated reports. Your reports are the major basis on which adjusters form opinions about you and your practice. What do yours say? Are they all the same? Do they help the adjuster do his job?

Providing adjusters with the information they require before they have to ask, and providing rational bases for prolonged care is the simplest way to enhance your credibility and prevent being "cut off."

Understanding Terminology

If you hope to have an active workers' compensation practice in the 1990s, you must understand and be able to use certain terms with accuracy and authority, such as:

Preinjury status, permanent and stationary, MI, minimal, slight, moderate, severe, work restrictions, occasional, intermittent, frequent, constant, QIW, voc. rehab., TTD, TPD, and apportionment.

The California Chiropractic Association through its educational arm, the CCF, has an excellent program designed to teach DCs the meanings of these terms and their appropriate use. You can take the complete IDE course and apply for QME status, or simply take the introductory course to learn how to work within the system and be paid for your services.

Treatment

A universally cited complaint was that "chiropractors never seem to release their patients." Nowhere does chiropractic philosophy collide with insurers more often than in the workers' compensation arena. Carriers are required to provide benefits to "cure or relieve" injured workers but only for the injuries they sustained on the job. If a patient had occasional low back pain before his work injury, once he is returned to the same level of pain, discharge him from workers' compensation and have him continue care on a cash or group insurance basis. Similarly, if you have treated a patient for a reasonable period of time and he has reached a plateau, and your adjustments are only temporarily relieving his pain, that patient has reached a "permanent and stationary" level and should be discharged.

On the positive side, most adjusters said they felt chiropractors were able to return the worker back to the job more quickly than other providers, and that patients were generally more satisfied with their care and their doctor.

Diagnoses

Many of the adjusters we spoke with complained about the diagnoses DCs provide. They cited 30 word diagnoses, or multiple, vague, and ill defined diagnoses. Keep your diagnosis short, concise and clear. If a patient has multiple diagnoses, define which are industrial and which are not.

Cooperation

The adjusters we interviewed told us they preferred doctors who were not afraid the call them to discuss cases, and to ask for advice, although they felt orthopedists were more likely to do so. Don't be afraid to say you're not sure what to do next.

Billings

Your fees should parallel the Relative Value Fee Schedule. If not, be prepared to justify your fees in writing, or be ready to write off a lot of fees. Standards of practice are currently being developed for many of the conditions we regularly treat. If your peers treat an uncomplicated low back strain over 2-3 months for under $2,000, and you usually bill $10,000, you have a problem. The WCAB and "green liens" are not likely to solve your problems indefinitely. The adjusters at one company we interviewed refer to doctors, who have high fees, excessive treatment schedules, and who never release their patients, as "businesses," and were careful to distinguish these providers from "doctors." Which are you?

Conclusion

In summary, none of the adjusters we interviewed were anti-chiropractic, though they felt DCs, as a group, have a lot of room for improvement. However, most related that they also experienced many of the same problems with MDs. The purpose of our survey and this article was to help DCs who treat injured workers become more familiar with the problems they may unwittingly be creating and, ultimately, more effectively interface with the workers' compensation system. If you have recognized yourself here, we encourage you to educate yourself, not only to reduce the problems you encounter, but more importantly to better help your patients obtain the care and benefits they deserve.

We would like to thank the many supervisors, managers, and claims adjusters who candidly offered their opinions and assistance.

Wayne M. Whalen, D.C.
Alan R. Tuthill, D.C.
Santee, California