Putting a positive spin on accidents

Workers' comp program brings profits to practice

Workers' compensation patients are either very annoying or very profitable, says John Nosek, MPA, CMPE, administrator of the Greensboro (NC) Orthopaedic Center. "You used to just care for these people like anyone else, but now employers are more cost-conscious. They want a an aggressive rehab program that starts immediately. They are worried, not just about the doctor's bill, but the pay they have to give to the employees while they are off. And because the law allows workers' comp patients to defer payment on other bills, there are other people who also demand good programs."

It might seem to some that a workers' compensation program - with all the paperwork associated with it and the many masters that such a practice must serve - is not a good bet for a practice. But Nosek has found it is a profitable part of their business.

How have they done that? Nosek points to five things:

r The reputation of the practice.

"We have been around since 1955," he says. "We have provided high quality care since then."

r Independence of the program.

In some states, Nosek has seen practices that have relationships with specific attorneys who refer patients to their practice. Nosek thinks that's a bad idea. "We have no relationships with attorneys. While we welcome inquiries from lawyers, we make it clear that nothing will compromise the doctor-patient relationship."

Likewise employers, who have nurse case managers for workers' compensation cases, are welcomed to come discuss specific cases. "If they have a question about our treatment, they can get a second opinion. If you have a good practice with good protocols, then you don't have a problem of being pressured to change your mind."

The cooperative nature of the practice has helped cement relationships. "Case managers know that if we can't find an injury, or we feel the patient is faking, we will tell them. We have to be careful how we say it, but we tell them there is no indication as to why a patient is in pain, and they need to look at alternatives."

Sometimes, the employer goes to a private investigator, who will send the practice video surveillance tape for evaluation. "If [the patient] says he or she can't lift something and the video shows [the patient] lifting, then we can say that based on the claim, the person shouldn't be able to do that activity. That usually gets [the employee] back to work faster."

Nosek says he also makes sure people know that the practice is thriving without the workers' compensation patients. "We aren't married to the workers' compensation money."

r A high success rate.

"We actively market the tools we have to rapidly return the patient to work," Nosek says. "We practice standard orthopedic protocols. Good medicine is the key." But he acknowledges that workers' comp has to tread a "delicate line. You want to get people back to work fast without interfering in the physician-patient relationship. But you also have to keep your ethical standards and let people know if a patient isn't ready to go back."

r An understanding of problem areas.

Nosek says it's simple to deal with a laceration or a fractured disk. Problem cases usually involve pain or something else that doesn't show up on an X-ray. "Then you go through the steps - we evaluate pain, measure range of motion, look at other health issues of patients like weight or smoking, and we determine whether the patient really has a problem."

Another area of difficulty is the high expectations of patients, says Nosek. "If you have to have rehabilitation for a bad back, you may want to get them back to 100%. But what is 100% for a 50-year-old man who is 40 pounds overweight?" he asks. "You have to make all the parties understand the realities of a situation."

r A willingness to put convenience first.

Nosek's goal is to turn around data, reports, and paperwork within 24 hours. "We prioritize it before any other dictation," he says. "That is an excellent selling point for us."

Other conveniences for the payers and patients include having an acute care clinic that runs from 1 p.m. to 5 p.m. daily. Scheduled appointments are in the morning hours only, Nosek says, which allows injured patients to get right in during the afternoon.

After seeing a patient, the practice fills out a form that is given to the patient, the employer, and the payer describing any limitations in work or physical activity. "The key is quick evaluation, correct evaluation, and timely feedback to employers and insurers"

Nosek has also put a nurse ombudsman in place to deal with any problem that arises. "If a piece of paper is missing, she deals with it," he says.

Getting the word out

One way Nosek has marketed the practice is by having yearly workers' compensation seminars. An attorney and one or two physicians will talk about the legal issues and the medical aspects of diagnosing injury and ascertaining pain and limits to range of motion. Those qualify as continuing education hours for nurses who work as safety managers at area businesses. "It also allows a social setting - we have dinner during the lecture - that shows everyone who we are and how we handle things." About 125 people come every year, and new business comes out of it annually. "But mostly it just reinforces our relationships."

It must be working: Nosek says his practice is the No. 1 organization in town for workers' compensation cases.

But there are drawbacks. Nosek is trying to make his practice paperless (see related story, p. 89) and in North Carolina, claims for workers' compensation cannot be filed electronically. "They have to be on paper and must have a copy of the written notes. It is a high-cost administration program."

And you have to understand that you serve two masters - the patient and the employer - who each may have different desires. "But you can make it work if you are systematic," Nosek says. "You have to have good doctors who practice good protocols and are concerned about being cost effective. And that is a common message in health care generally today."

There are more calls and more documents, and in some states such as North Carolina, the money is tied up longer because it has to go through more layers of administration before payment is made. But it can be a much more lucrative - and much less discounted - business for a practice.

That said, the rules differ from state to state. In Washington, for instance, there is virtually no market for workers' compensation because the fees are tied to Medicare reimbursement rates. Your best bet, says Nosek, is to contact your state's workers' compensation commission, attend any seminars that are available, and contact your state bar association to get names of lawyers who might be able to educate you on the topic. "Then it's just trial and error. You see the injuries and start up the practice."

· John Nosek, MPA, CMPE, administrator, Greensboro (NC) Orthopaedic Center. Telephone: (336) 545-5000.