Workers incur different types of injuries in the course of their employment and these may typically involve long-term pain and the need for pain management. Long-term pain is caused by nerve damage (neuropathic) or by tissue damage (nociceptive). Workers’ compensation may cover pain management treatment, but this may vary with different U.S. states. In any case, medical record review and medical review services have an important role to play in helping to determine the nature of the pain, its severity, and the treatments that may be necessary to help the injured worker get back to work at the earliest. Among the most common workers’ compensation injuries that involve pain are strains, lacerations, contusions, sprains, punctures, burns, broken and crushed bones, soft tissue injuries, repetitive stress injuries such as generalized back pain and carpal tunnel, acute back injuries, and different types of traumatic injuries.
Why Medical Records Analysis Is Required
Within the workers’ compensation system, the description of pain that the treating physician provides can have a significant impact on the injured worker’s eligibility for workers’ compensation benefits. Pain may become part of an injury diagnosis, and this will be substantiated by the relevant medical note or record made by the physician. Pain management treatment may be categorized under two workers’ compensation law categories such as:
- Medication treatment, including the prescription of pain medication to treat the injury
- Injections and other forms of interventional treatment provided to relieve pain
When is pain management service provided? Typically, pain management treatment is provided
- When other treatment methods fail to treat the injured worker’s chronic pain
- If the injured worker’s primary care physician has not successfully diagnosed the cause of the worker’s pain and refers the patient to a pain management specialist for further evaluation and treatment.
What Medical Records Are Reviewed to Determine Insurance Eligibility?
The treating doctor may request different medical tests to rule out other possible causes of pain.
- X-rays that can show bone density loss, or microfractures
- Blood tests to exclude inflammation or infection as a cause of pain
- MRIs that can reveal irregularities or damage in soft tissue
- Ultrasound scans to eliminate blood clots as a reason for the pain
- Electrodiagnostic testing to measure the electrical activity of body parts to determine whether nerves or pain receptors are being stimulated
Following a comprehensive medical record review, if the injured worker is found eligible for pain management treatment, pain management physicians may recommend treatments that include the following.
- Physical/occupational therapy
- Nerve block, trigger point, and epidural injections
- Spinal cord stimulation
- Facet joint/ sacroiliac joint injections
- Radiofrequency neuroablation
- IDET or Intradiscal Electrothermal Therapy
- Intrathecal pump implantation
Medical records related to the above are also important for health insurers to determine whether the treatments provided were medically necessary and were in line with the identified cause of pain.
How Chronic Pain Can Be Debilitating
Workers’ compensation is required to provide all reasonable and medically necessary treatment for a work-associated injury. This may include pain management treatment as well that is provided for relief from chronic pain.
- Sometimes, the chronic pain may be severe enough to be determined as stemming from a whole-body impairment.
- If such a finding is made by the treating specialist, the worker may be entitled to permanent partial or permanent total disability benefits provided that the chronic pain doesn’t respond to treatments or other palliative care.
- Chronic pain can also lead to considerable mental and emotional trauma that interferes with the worker’s ability to work or carry out tasks of daily living. In such cases also, the loss of quality of life of the worker, lack of focus on anything, anxiety and depression and other concerns could entitle the worker to pain management benefits.
Since chronic pain conditions are poorly understood, often insurance coverage may be denied for pain management treatments. Therefore, workers may be required to obtain an official diagnosis of their pain and connect it to the work-related injury. This could highlight the treatment as reasonable and necessary. Pain management treatments are more likely to be approved for workers’ compensation if the following criteria are met.
- The pain management providers have a well-defined plan to provide relief from chronic pain.
- The treatments have low costs, and in case they are expensive, they require only a few sessions.
- If the treatments prescribed are for the long term, they should be provided on an as-needed basis rather than on a set schedule without reviewing the continuing need for treatment.
- The prescribed treatments do not duplicate other pain management options such as physical therapy that could provide relief from pain.
The Joint Commission has issued a pain protocol that serves to eliminate addiction in victims of work injuries. This is to counter the problems associated with the use of doctor-prescribed opioids. Opioids are often abused and could lead to extreme addiction. Healthcare providers accredited by the Joint Commission are following this new protocol so as to eliminate the suffering associated with addiction and encourage a better and more effective approach to managing pain.
- This updated pain protocol aims at managing pain via a biopsychosocial perspective.
- It encourages chronic pain sufferers to review their biology, psychology, and social life to help manage the common symptoms of pain.
- The main objective is to manage pain without the use of medication, especially addictive opioids.
In keeping with this protocol, healthcare providers are encouraged to study their patient’s pain levels and provide a customized pain management program. This in turn is expected to prevent healthcare providers from over-prescribing addictive drugs, and follow healthier treatment solutions.
Why Medical Review Services Gain Significance
Workers’ compensation system that varies from state to state is quite complex and difficult to understand. Attorneys handling workers’ compensation cases require accurate medical record review, preferably by a provider of professional medical review solutions. Only then can the legitimacy of the case be determined and the worker’s long-term pain management needs worked out correctly. Workers’ compensation laws require that any pain management treatment be approved by the employer or the employer’s workers’ compensation insurance company.
Disclaimer: The content in this blog is meant for informative purposes only, and does not constitute professional legal opinion. Please contact an experienced attorney for a professional opinion.