A Hidden Challenge in WORKERS COMPENSATION

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1 Published by the Public Risk Management Association A Hidden Challenge in WORKERS COMPENSATION APRIL 2015

2 A Hidden Challenge in WORKERS COMPENSATION By Dr. John Robinton 2 PUBLIC RISK APRIL 2015 W W W.PRIMACENTRAL.ORG

3 In workers compensation, electrodiagnostic tests known, as Electromyography (EMG) and Nerve Conduction Studies (NCS), are invaluable tools in determining the existence and extent of muscle and nerve damage in injured employees. For example, if an injured worker is suspected of having a back injury or carpal tunnel syndrome, a treating physician would likely order an EMG or NCS to confirm the diagnosis. EMG and NCS then provide the physician with a roadmap to treat the injury, and it also rules out other potential medical conditions. However, the industry may not realize that there are no barriers to entry in this field. Essentially, any licensed provider is allowed to perform an EMG or NCS. As a result, outcomes can vary widely from physician to physician due to their training, experience, and the accuracy with which these tests are performed. In this article, we present a study that examines quality or lack thereof in these tests. We will look at several cases that illustrate how these tests can go awry, and how this can lead to inappropriate treatment plans. Finally, we ll cover what can be done to ensure quality EMG and NCS, including provider credentialing, ongoing monitoring, and obtaining second opinions. STUDY RESULTS CONFIRM UNRELIABILITY AMONG TESTS In workers compensation, a significant percentage of providers who perform EMG and NCS have not undergone any type of evaluation, qualification, or credentialing process. As a result, tests performed by these uncredentialed or non-prequalified providers may not be medically useful in determining the next step in treatment. In 2009, a study was presented at the annual American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) meeting, which confirmed this hypothesis. The study reviewed 140 reports to assess the medical usefulness of EMG and NCS reports performed by providers who had not undergone a pre-qualification process. Each report was graded by an American Board of Electrodiagnostic Medicine board certified neurologist who was also certified in clinical neurophysiology. Failure to satisfy medical usefulness was determined by factors that included, but were not limited to: a lack of adherence to AANEM guidelines, incomplete examination information, and data inconsistency and unreliability. Out of the 140 NCS/EMG reports reviewed, 68 percent were considered not medically useful. As a result of this quality review, surgeries were cancelled in a number of cases, and repeat studies were requested by other physicians. Among workers compensation claims, it s estimated that approximately 40 percent of providers performing EMG and NCS are not qualified to administer consistently accurate examinations. Obviously, this can impact the accuracy of a diagnosis, as well as a claim s overall costs and outcomes. A PATIENT EXAMPLE Perhaps the clearest, most compelling way to examine this diagnostic challenge is to look at an actual patient example. In this particular case, an injured worker claimed to have sustained a back injury during an unwitnessed fall. The provider who performed the initial EMG did not undergo a pre-qualification process to very his credentials or the quality of his EMG reports. His test results asserted that the patient required back surgery. The surgery was performed, but it did not alleviate the patient s pain. Instead, the surgery actually made the patient s condition worse. Since the patient was still experiencing significant pain, a second EMG was performed. This time a credentialed provider performed the examination. This meant the provider met a rigorous set of qualifications and his medical reports were confirmed to meet quality standards. This second test revealed that the patient had a diabetesrelated condition, which caused the pain and which would not have been compensable under workers compensation. However, due to the initial inaccurate test results and the inappropriate surgery, the worker was categorized as permanently and completely disabled with projected costs of more than $2.5 million dollars over the life of the claim. Since the workers compensation insurer had authorized the back surgery, it was liable for the full cost of the claim. In short, this example illustrates some key EMG testing challenges: Use of a provider who lacked proper training and credentials. In the initial EMG, the wrong muscles were studied. ELECTRODIAGNOSTIC TESTS Electromyography (EMG): In this test, the physician inserts a small needle into the muscles to assess general health of the muscle and to test if the nerve supplied to that muscle is intact. Muscle activity is evaluated both while the muscle is at rest and during voluntary contraction. Nerve Conduction Studies (NCS): These exams are essentially a quantitative measurement of nerve function. A mild electrical stimulation is applied directly over the nerve(s) in increasing strength to elicit a response from motor and sensory nerves. APRIL 2015 PUBLIC RISK 3

4 A Hidden Challenge in Workers Compensation Inaccurate test results led to a misguided treatment plan, unnecessary surgery, and a costly permanent disability claim. Poor quality of care for the injured worker. PROVIDER CREDENTIALING AND QUALITY REPORT STANDARDS Although the quality of EMG and NCS providers varies widely, the good news is there are guidelines and solutions to help workers compensation programs ensure the medical usefulness of their test results. Today, specialized diagnostic networks utilize a rigorous credentialing process to ensure that EMG and NCS providers meet and continually adhere to quality guidelines. This credentialing process includes a clinical review of sample tests to ensure adherence to report standards. With this pre-qualification process, the network identifies and selects only quality, qualified neurologists and physiatrists to perform all exams. An ongoing quality program continually monitors providers to ensure ongoing adherence to quality guidelines and reporting standards. Through this monitoring, deficiencies can be detected and corrective action can be outlined so providers can improve outcomes. This type of quality delivery model for EMG and NCS in workers compensation is essential. In addition to improved diagnosis and better care for injured workers, the cost savings delivered from a quality-driven program can be significant in light of today s skyrocketing medical costs. GETTING A SECOND OPINION If payers are in doubt of EMG or NCS, or about to authorize an expensive procedure, such as a surgery, they should consider getting a second opinion. By requesting a second opinion, an organization can confirm that the EMG or NCS was appropriately performed, and that the test results are medically useful, reliable, and accurate. Let s look at an example of how a second opinion can help ensure quality: A 34-year-old carpenter reported experiencing hand pain and occasional weakness in the fingers of both his hands. The patient was sent for an initial evaluation. It s important to note that the EMG and NCS were performed by a provider whose qualifications had not been assessed or verified. The test results supposedly revealed the presence of abnormalities consistent with carpal tunnel syndrome. The patient was given a trial treatment of splinting, but little improvement was experienced. At that point, surgery was recommended. However, the claims adjuster assigned to the case was aware of the variability in quality among EMG and NCS providers and ordered a second opinion to verify test results. The second set of tests was performed by a provider who was credentialed and served as a leading specialist in his community. He determined that the initial test results and 4 PUBLIC RISK APRIL

5 If payers are in doubt of EMG or NCS, or about to authorize an expensive procedure, such as a surgery, they should consider getting a second opinion. By requesting a second opinion, an organization can confirm that the EMG or NCS was appropriately performed, and that the test results are medically useful, reliable, and accurate. diagnosis of carpal tunnel were incorrect. Although the test observed abnormalities consistent in a carpal tunnel case, there was information that indicated the study was not performed appropriately. In fact, it was likely that the initial study was performed on a hand that was cool in terms of temperature a factor that can affect the accuracy of results. This case shows that many providers are untrained and inexperienced in the many variables that can affect the accuracy of EMG and NCS test results, including but not limited to these factors: A test may be performed too early, when it should take place 17 days after an injury. The wrong nerves or muscles may be studied. Electrodes may be placed incorrectly. EMG and NCS providers may fail to monitor limb temperature, which must be 32 degrees centigrade or higher for upper extremities, such as the hands. For this patient, a second set of tests was performed at the correct temperature. The results indicated normal activity. In other words, carpal tunnel did not exist. In the end, the patient was determined to have early manifestations of rheumatoid arthritis. Given an oral medication, the patient s symptoms cleared up, and he was able to resume work without experiencing any additional symptoms. ENSURING QUALITY: NOW & INTO THE FUTURE Neurological injuries present significant challenges chief among them is finding a quality EMG/NCS practitioner who can provide accurate test results. This article has given examples in which poorly trained, unqualified providers conducted an initial EMG and NCS, which led to an inaccurate diagnosis and inappropriate recommendation for surgery. In the first case, the insurance company was on the hook for a $2.5 million disability claim, but in the second case, by using a second opinion with a quality credentialed provider, the insurance company saved more than $38,000 for the cost of surgery, rehabilitation, and time-off from work. The advantages of working with quality EMG and NCS providers are numerous, with reliable test results leading to an accurate diagnosis, appropriate treatment plan and quality care for injured workers, as well as cost savings, improved outcomes, and early return-towork results. Dr. John Robinton is a neurologist based in Montclair, New Jersey, and medical director of neurodiagnostics at One Call Care Management. The cost of the medication and medical treatment for rheumatoid arthritis was unrelated to any type of workplace injury, and as a result, all the costs were covered by the patient s general health insurance. Published in Public Risk, April Copyright All rights reserved. This file is for web posting and distribution only; may not be used for commercial reprints. Provided by The Reprint Outsource,

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