IME Docs' Perspective

 This past weekend (November 7-9, 2014), I spoke twice at a conference of the American Academy of Orthopedic Surgeons.  Orthopedic doctors from various states attending the particular sessions I taught were mostly older, and many were hired by industrial insurance adjusters to do independent medical exams on claims where attorneys were involved.   I had just blasted so-called IME's in Nevada in my last blog post, so it was interesting that I now had to face a group of doctors for two hours each day to lecture and answer their questions about how a  claimant's' attorney analyzes work comp medical issues.  I hope it was a learning experience for the doctors.  I know that I learned a lot and think I will be a better claimants' attorney having this opportunity to interact with these doctors. 

My first impression of this group of doctors was that their opinion of claimants' attorneys was very negative.   Many of them truly thought I would agree to represent someone  who had no medical evidence to support an injury claim so long as I thought I could earn a fee. Others thought that the longer I was able to keep an injured worker off work, the more money  I made.  

Former defense attorney, David DePaulo, Esq., co-taught both seasons with me.  He now runs, a website with a wealth of information on all states' and federal work comp systems.   He is an engaging and highly knowledgeable speaker. I enjoyed working with him. 

Continue Reading...

Injured Workers Wrongfully Billed for Medical Care

 If you are an injured worker with an accepted workers' compensation claim in Nevada, you should not be receiving bills from hospitals, radiologists, labs, doctors, or physical therapists for treatment that was authorized by your adjuster. In fact, it is against the law for medical providers  on claims they know are accepted to bill the injured worker if they don't get paid quick enough or at all by the workers' comp. insurer. NRS 616C.135.

Sometimes, I see bills that have a stamp that says the work comp insurer has been billed and that because it hasn't been paid, the injured worker should show the bill to the employer.  This too is wrong, because the employer isn't responsible for the bill.  Nor is it likely that an employer will actually get after the insurer to pay the bill.  Instead, the injured worker worries, and even pays the bill that he or she shouldn't have to pay.

I also see cases where the medical provider sends the bill to collections against the injured worker when the work comp insurer fails to pay bills on accepted claims.  I'm trying to track just how prevalent this occurs so I can do more about it.  The law referenced above says that the DIR can fine a medical provider $250 for violating the law.  Big deal!!  What is $250 to a billion dollar corporation?  How much money has already been wrongfully collected from injured workers,  and how many have had their credit ruined?  I want to know.

Until I can find a better solution for injured workers, I recommend that you file a complaint with DIR, attaching a copy of your claims acceptance letter and the bill you receive from a medical provider.  Also attach any collection notices.  Please note that this statute only covers situations where you can show that the medical provider knew that they were providing services on a workers' compensation claim that was already accepted.  I would really like to hear from you if this has happened or is happening to you so that I know how frequently this occurs. 

(Please note:  This is not to be interpreted as any promise to provide you with legal representation.  I am simply trying to determine how serious this problem is for injured workers at this time.)

--Written by Virginia Hunt, Hunt Law Office

Nevada Insurers Often Wrong About Pre-existing Conditions

 Any injured worker over the age of 30 with a serious work injury is likely to find some reference in  his or her medical records to degeneration of the body part being examined.  Degenerative disc disease, for example, is actually a normal  part of the aging process.  But insurers and their third-party administrators start to drool when they see those words in x-ray and MRI reports, because it gets them thinking about how they might reduce medical expenses or subtract from  the PPD award on the claim.  

Some insurers are very aggressive about denying claims for the reason that the injured worker has a pre-existing condition.  Most physicians, not knowing what Nevada law says about pre-existing conditions, don't help the situation.  Many doctors on the insurers' exclusive provider lists simply shrug their shoulders when their requests to perform surgery are denied.  They tell the patient that they will have to use their private insurance or pay out of pocket to have a surgery for a work injury that aggravates a pre-existing condition.  If the patient was probably going to need surgery at some future time anyway, these doctors think that the insurer is justified in limiting the scope of the claim.  However, under Nevada statutory law and Nevada case law, many of those types of injuries should be treated under the workers' comp claim.

Continue Reading...

Dr. Maureen Mackey Dies

One of the best physicians to care for Nevada's injured workers died recently following a long battle with cancer. I first met Dr. Maureen Mackey when I was working as an attorney for the State Industrial Insurance System, and she was employed as a physical rehabilitation doctor for the Jean Hanna Clark Rehabilitation Center in the building now occupied by the dental school on Charleston Boulevard in Las Vegas.

Dr. Mackey was particularly known for her extraordinary compassion when treating people with traumatic brain injuries and spinal injuries that prevented them from ever returning  to any kind of employment after a work accident. When she left the JHCRC to open her own medical practice at a shabby little office on the corner of Sahara and Eastern, she continued to treat many of those permanently and totally disabled injured workers. I know that she didn't get paid much, if anything, for continuing to care for many of them. That made it impossible to decline when Dr. Mackey called to ask if I could help one of her homeless or brain-injured patients who needed legal help for free. 

She had one  "good" chair  for visiting lawyers who didn't want to ruin their suits on her ratty old chairs when their clients were rated for impairments. Regardless of what  injury she was rating, Dr. Mackey always gave the injured worker an eye exam, and she always scolded those people who were neglecting their health.   She wasn't liked by everyone because she  spoke her mind, and she didn't back down when she thought she was right.  

I remember one rating exam when my client, who had three failed back surgeries, asked her whether he would ever get better.  This client had correctly guessed  that Dr. Mackey was someone who would tell him the truth. Dr. Mackey looked him in the eye and said, "No, only prayers will help you now. Shall we pray together?"  The client smiled and said, "Sure."   Dr. Mackey, who was a bit overweight and with bad knees, then held the client's hand, ordered me to kneel (as I was the only one in the room who could kneel), and she said a prayer aloud for the client.  We could use some more doctors like her. 

--Written by Virginia Hunt, Hunt Law Office

Bad Law on Doctor Choice for Nevada Injured Workers

 Change Needed to Nevada’s Law on Physician Choice for Injured Workers

A.     A Short History of the Law

In 1913, Nevada first enacted the Nevada Industrial Insurance Act and the Nevada Occupational Disease Act, now known as NRS Chapters 616A-D, and NRS Chapter 617.  It was administered by the NIC (Nevada Industrial Commission).   The NIC was a monopolistic state agency.  No private insurers were allowed to provide policies to employers, and there were no self-insured employers.   In 1973, the legislature directed the NIC to appoint a panel of physicians statewide who were competent to treat injured workers, and the NIC could add, suspend or remove doctors from the panel.

 In 1979, large employers were allowed to become self-insured, and the Dept. of Administration took over the Hearings Division from the NIC.  In 1981, the SIIS (State Industrial Insurance System) replaced the NIC.  The Division of Industrial Relations, a sub-agency of the Dept. of Business and Industry was given regulatory authority over the SIIS and self-insured employers.  During that period of time, the NIC, and then the DIR, continued to maintain a panel of physicians from which the injured worker was free to choose a treating doctor.  Almost all doctors licensed to practice in Nevada were added to the panel.  Healthcare providers were reimbursed based upon a fee schedule developed by DIR and based upon customary billings procedures.   Providers were paid their full bill or the amount allowed under the fee schedule, whichever was less.

In 1993, SIIS management claimed that it was unable to pay its long term liabilities.  The alleged insolvency became a crisis since SIIS was a state agency.  Sweeping legislative changes were made to reduce the perceived deficit, including managed care.  SIIS was authorized by the legislature to contract with a limited number of providers.  The idea was that competition to become a provider on the insurer’s panel of doctors would result in providers agreeing to substantially lower fees for service.  The legislature also abrogated the right of the injured worker to choose any doctor from the DIR’s panel of physicians.  It passed NRS 616C.090, requiring an injured worker to select a treating doctor from the employer insurer’s MCO plan.  

In 1999, SIIS was privatized, and the state fund was replaced by a mutual insurance company called Employers Insurance Company of Nevada (EICON). Private insurance carriers were also allowed to underwrite policies.  More large employers went self-insured.

In response to complaints by labor advocates regarding the lack of choice of treating doctors available to injured workers under the managed care provision, the legislature passed a law in 2003 allowing DIR to adopt regulations concerning the adequacy of physicians on provider panels.  DIR was to hold a public hearing and then adopt regulations ensuring that injured workers had a meaningful choice of physicians. Private carriers, EICON and self-insurers were still authorized to contract with a limited number of providers while seeking the lowest charge possible for medical services, but DIR was supposed to determine what adequate provider panels were.  However, DIR never adopted regulations.

In 2007, the Nevada Supreme Court upheld NRS 616C.090, the law that requires an injured worker to choose a doctor from the insurer’s MCO provider list, even if that meant the injured worker had to change doctors whenever the MCO’s provider list changed.   The court stated in Valdez v. EICON, 162 P.3d 148 (Nev. 2007) that while the right to receive medical treatment is a statutory right, limits on physician choice is not.  Instead, the physician choice law is a procedural mechanism for managing the workers’ compensation system.

In 2009, the legislature clarified that an injured worker could make an alternative choice of doctor from the insurer’s provider list within the first 90 days of the claim.  It also provided that the insurer should give a specific reason for denying any requests to change doctors after 90 days.  Insurers and TPA’s were also required to send a DIR-approved notice regarding the law on choice of physicians to injured workers.  The provider list is available to an injured worker within 3 working days if the request for the list is in writing.  This remains the law today. 

B.     Why the Law Should Be Changed

Allowing insurers, self-insureds, and their third-party administrators to require that injured workers treat only with doctors on their exclusive provider lists is unfair to injured workers and to physicians.  In order to get on an exclusive provider list and stay on it, a physician must agree to accept fees for services that are less than what the Nevada fee schedule provides as reasonable and customary.  These exclusive provider lists change at the whim of the insurer or its TPA, depending on whether the insurer or its TPA likes the way the physician is diagnosing injuries, providing care, and is releasing the injured worker to  full duty or is stating that there isn’t a likely ratable impairment.   The quality of care to the patient is compromised by undue pressure on physicians to satisfy the insurer’s cost-cutting measures and early claim closure practices.  It isn’t unusual for an injured worker to report that his physician told him he couldn’t request more physical therapy because it would anger the insurance company, or that his physician told him the insurer wouldn’t allow him to take the patient off work. 

Under the current law, the injured worker only has an absolute right to change doctors to another on the particular insurer or TPA’s provider list within the first 90 days of the claim.   After 90 days, the adjuster can deny the request to change doctors.   Although the law requires the adjuster to have a valid reason for denying these requests, adjusters routinely deny request for a new doctor after 90 days.   One of the most significant problems with medical treatment under a workers’ compensation claim is the length of time it takes for an adjuster to authorize diagnostics and specialty consultations.  The claim may be 4 months old, for example, before the adjuster authorizes an MRI and schedules the worker with an orthopedic physician after the clinic doctor has been requesting this for 3 months.  If the injured worker doesn’t like the orthopedic surgeon the adjuster chooses to see him, and wants a consultation with another one, the adjuster may deny the request.  It then takes time to appeal this denial.   An injured worker ought to be able to choose which doctor will perform a surgery on her. 

It is unfair to have a law requiring that injured workers treat only with the insurer’s exclusive medical providers, while insurers often rely on opinions from physicians who are not on their provider lists to deny surgeries and to deny other treatment recommended by the authorized treating doctor.  Utilization review doctors aren’t on insurers’ provider lists, but these are the doctors the insurers rely on when an insurer doesn’t agree with the treatment recommendation of their own provider physicians.

Amending the law so that the injured worker can choose as her physician any doctor who is in good standing on a provider list maintained by the DIR, whose doctor agrees to accept the Nevada fee schedule, would be a fair way of ensuring adequate medical care at uniform and reasonable costs.   DIR would have the authority to remove any doctors from the panel for good cause, thereby addressing any concerns the insurers or injured workers might have about doctors who are disciplined,  or doctors who aren’t following regulations on how to treat injured workers.

 The historical reason for adopting managed care with provider lists controlled by insurers was to avert a supposed financial crisis facing the state-run SIIS.  That reason is no longer valid.   The DIR is in the process of reviewing its fee schedule so that it is reasonable and in step with customary medical charges.   Doctors who want to be on a DIR-controlled panel of providers can easily be educated as to what the law requires of doctors who treat injured workers.  Good doctors who refuse to accept less than what the fee schedule provides can again treat injured workers, and no doctors will feel pressured by insurers to adjust patient care decisions just to remain on an exclusive provider lists. 

Thank you to Ray Badger for help with the history.

--Written by Virginia Hunt, Hunt Law Office

What To Do About Delays In Getting Medical Care


1. First, know how long the adjuster has to approve or deny your doctor's request. 

  • Your adjuster has 30 days to accept or deny your Nevada work comp claim.  Expect only emergency care and clinic visits in the interim. 
  • If your doctor doesn't think that diagnostic tests or treatment are necessary now, your only option is to ask for a provider list of alternate doctors.  If you ask in writing within the first 90 days of your claim, the adjuster must approve it.  The next doctor may agree that diagnostic tests  
  • Prior authorization is required for MRI's, more than 6 physical therapy visits, surgery, neurological testing, or specialty consults. 
  • Nevada law gives the adjuster 5 working days from receipt of the doctor's request form to approve or deny it. NRS 616C.157. 
  • Adjusters routinely ignore the 5-day rule by scheduling a second opinion consultation.  Or, the adjuster may ask for a review by an outside doctor hired to control claims costs, particularly if a low back surgery is requested.

2. Find out why there is a delay.

  • Don't assume it’s the adjuster's fault.  Ask your doctor's staff when they faxed the authorization form.  It may not have been faxed for several days after you saw your doctor.  Make sure they faxed an authorization form.
  • The adjuster will also need the doctor's dictated report if an expensive medical procedure is requested.  The adjuster may also ask the doctor answer questions about preexisting conditions or what injuries were caused by this accident.
  • Politely ask the adjuster whether she received the authorization form.  If she didn't get it, confirm her fax number, and ask your doctor to re-fax it to the correct number.  If the adjuster claims she already returned the form, ask her to please re-fax it. Many delays are due to wrong fax numbers, misplaced faxes, or the doctor's failure to send the necessary authorization form.
  • Don’t resist any second surgical consultation the adjuster schedules. It will just delay things further and could result in a suspension of your benefits.   However, if the adjuster wants multiple consults, she is probably going to deny your doctor's treatment request.  Get legal help soon.
  • Using abusive language or calling the adjuster daily will only result in purposeful delayed action by the adjuster.   

3. For denied or indefinite delays, you must write (or get help).

  • If authorization is denied, don't waste time arguing with the adjuster.  Quickly file a request for hearing, and get your doctor's reports to present your position to the hearing officer. 
  • For an indefinite delay send a fax to the adjuster, stating that NRS 616C.157 allows your doctor to proceed as if the request was approved when there is no response within 5 working days.  When your doctor won't proceed without a signed authorization, file a request for hearing with the Hearings Division.  Attach a copy of your fax to the adjuster and a copy of the request form your doctor sent. 
  • Secondly, send DIR a complaint letter about the delay. Copy the adjuster.   Attach your supporting documents.  DIR may not be helpful, but the adjuster won't want to take the risk of getting fined for a violation of the law.   The adjuster will now quickly authorize the request or deny it, giving you the right to file an appeal.  Promptly file any appeals within the 70-day time limit.



--Written by Virginia Hunt, Hunt Law Office

Injured Workers Should Get Their Medical Records


All injured workers should get a copy of their medical records at some point.  Remember that your employer is being copied by the adjuster on all his/her letters to you and on some of your medical records.  You should know what your doctor says about you and your injury, particularly if you are having problems with your claim. 

NAC 616C.120 confirms that the injured employee has the right to inspect or obtain his health care records pursuant to NRS 629.061.   That law allows a patient to request a copy of records from any health care provider, which includes therapists.  The law states that the provider may charge the patient or their representative (attorney) a copy charge of 60 cents a page.  Call ahead and allow the provider's office staff a few days to get your records copied and ready for you to pick up. 

Medical providers, including physical therapists, who tell injured workers that they must get a copy of their records from the adjuster are wrong in not allowing a patient to obtain records directly from the provider. 

What an injured worker ordinarily gets from their doctor after each office visit is a Physician Progress Report, a one-page form which may or may not be slightly modified by individual doctors.  This Physician Progress Report (PPR) gives a brief diagnosis, treatment plan, any work restrictions or off work instructions by the doctor, and the date of the next office visit.  In addition to this form, the insurer receives a dictated report by your doctor after each visit.  Rarely is this dictation ready immediately following an office visit.  You must specifically request a copy of it from either the doctor's office or from the adjuster handling your claim.  

Continue Reading...

Dr. Dettling Talks About Shoulder/Knee Work Injuries

 Orthopedic surgeon James Dettling, M.D. specializes in shoulder and knee injuries.  About half his patients are injured workers treating under a Nevada workers' comp claim.   He and long-time medical assistant, Patrick Boland, and their indispensable office manager, Diane,  stopped by my office today to meet my assistants and to chat over lunch.  I've known Dr. Dettling to give straightforward, honest opinions over the years, and I see excellent surgical results  .  I enjoyed having the lunch hour to ask Dr. Dettling about the problems he has treating work comp patients.

 We commiserated about the increasing use of retired out-of-state orthopedic doctors hired by insurers to do peer review of treatment requests.  (In Nevada, surgeons must request pre-authorization from adjusters for all non-emergency surgeries, for diagnostic tests like MRI's, and for physical therapy.)  Shoulder and knee surgeons aren't second-guessed as much as the spinal surgeons, but  Dr. Dettling noticed that he too was having to deal with  denials from  doctors who cite outdated treatment guidelines. For example, he told me that  according to current orthopedic standards, physicians should be prescribing many more physical therapy visits than the number allowed by industrial insurers following rotator cuff repairs.

Dr. Dettling and any doctor who actually provides  care has a legal  doctor/patient relationship and must adhere to current and real peer treatment guidelines.  Hired-gun doctors for insurers are not accountable for their  judgment errors in denying treatment requests by treating doctors.  Moreover, under Nevada law, an injured worker cannot sue an industrial insurer for bad faith or negligent claims administration, so it is essential that treating doctors maintain their integrity and continue to request treatment according to their best judgment, regardless of anticipated denials by the insurer.  An experienced work comp attorney can deal with the denials so long as the treating doctor continues to make the requests for the best treatment. 

Dr. Dettling stressed that with a surgical patient, a successful outcome does not just depend on his skills.  Equally important is the expertise of the post-surgical physical therapist assigned to rehabilitate the patient.   For that reason, he asks for particular therapists to work with his patients.  I had not realized that, so that is something I can keep an eye on for my clients to make sure that the therapist the doctor wants is approved by the insurer. 

Dr. Dettling and I  agreed that the lengthy delays in obtaining necessary MRI's and surgery approvals on comp claims cost patients more than lost wages.  He is particularly frustrated when he sees a patient with a bicep tendon rupture that could have been surgically treated if the patient had been referred to him soon after the accident.   

 Patrick and Dr. Dettling complained about adjusters who don't sympathize with patients who cannot drive themselves to work after shoulder surgeries.  Likewise, he characterized as cruel those employers who want him to substitute a non-narcotic pain medication just so the hurt employee can report for a mindless light duty job just days after surgery.

We also talked about the power of the third-party administrators and insurers to  control their provider lists.  He stated that he would support a legislative change that would allow injured workers to treat with any doctor who is willing to accept  what the Nevada fee schedule allows. 

Diane, the office administrator, and Dr. Dettling impressed me with their knowledge of what is required to reopen a Nevada claim.   They accept cash pay from former clients who need a letter from the doctor documenting a worsening of the industrial injury, and then refund the payment to the patient if the insurer reopens the claim and pays the doctor.  Thank you,  Dr. Dettling, Patrick and Diane for an informative luncheon.                





--Written by Virginia Hunt, Hunt Law Office

Physical Therapist Karen Crawford Knows Nevada's Injured Workers (And She Cares!)

One of the benefits of being self-employed  and writing my own blog is that I can express my opinion  on what is right with Nevada's workers' compensation system, and what needs improvement or overhauling.  I accept no "favors" from medical providers I mention as providing superior service to injured workers.  I like to let hurt employees know which doctors and facilities I like in the hope that it may benefit my readers.  Obviously, people will disagree with my opinion, and they may have different experiences.  I am always happy to hear about your particular experiences, and encourage you to write to me about which medical providers have been helpful, and who haven't been.

I've known physical therapist Karen Crawford, owner of MML Physical Therapy, for as long as I've been practicing workers' comp law, and she is the real deal.  When you first meet Karen, you are immediately impressed by her passion for helping injured people get well.  She genuinely cares about her patients, and she is forthright and direct in her opinions.  Her obvious commitment to her patients sets her apart from the many physical therapy options in the Vegas Valley where the patient may or may not have just a few minutes of the actual therapist's time.  Karen's integrity is exceptional, and you can count on getting an honest opinion from her, whether you agree with her or not.

Karen offers more than her experiences as a certified physical therapist licensed in Nevada and Texas.  She is a board certified pain management specialist, and is affiliated with the national associations that research chronic pain, reflex sympathetic dystrophy, fibromyalgia, and sports medicine.  She has a reputation among both the more experienced claims managers and claimants' attorneys as a therapist who can evaluate and treat the most difficult chronic pain patients.   Her triple Masters of Science in Psychology, Mental Health Counseling, and Physical Therapy allow her to gain insight into treating the patient as a  whole person. She consequently gets  phenomenal results in restoring miserable patients to better health and happiness. 

Karen understands the politics of the workers' compensation system better than most.  She tells me that she knows her business has taken  a hit financially because she doesn't bend to pressure from adjusters who want to tell her how to treat her patients.  She spends time listening to each patient, and refuses to sacrifice quality treatment in order to obtain a quantify of referrals from insurers.

Like a few of the other larger, established physical therapy providers in Las Vegas, she is asked to perform Functional Capacity Evaluations.  FCE's are used by doctors to determine what an injured worker's permanent work restrictions should be.  Only, Karen goes one step further.  She has seen a disturbing  increase in the number of invalid FCE's by other therapists.  An invalid FCE occurs when the therapist conducting the test does not think the patient has passed over 70% of the validity criteria built into the test.  Validity criteria supposedly reveals whether the patient is trying their best to physically perform  the test.  Most doctors release the patient with a full duty work release if the FCE is invalid.  However, the doctor gets the ultimate say on whether the patient should have work restrictions or not. 

 Karen  has observed an increasing number of invalid FCE's done  by other therapists. She doesn't think that all of of those injured workers are deliberately trying to appear more disabled when taking the test.  She therefore has graciously agreed to re-test injured workers on a FCE for the reduced price of $500.  (A FCE normally takes several hours of the therapist's time, and they cost over $750.)  Karen understands that  injured workers who are released full duty based on an invalid FCE are out of work, don't have any money to challenge their insurer, and will not get any retraining benefits until they can obtain a valid FCE to present at a hearing.   This is truly a humanitarian service that Karen  offers injured workers who need a second FCE.  There is no guarantee that the injured worker will pass a second FCE, but at least Karen offers a second chance at a reduced price.

MML Physical Therapy is located at 1701 Bearden Drive, Suite 201, Las Vegas, NV 89106.  The business phone is (702) 384-6330; Fax (702) 384-2668; email   

--Written by Virginia Hunt, Hunt Law Office

How to Stop Getting Medical Bills on Your Nevada Work Comp Claim

  Injured workers with accepted workers' compensation claims should not be getting bills for medical treatment from  hospitals, doctors, an anesthesiologist, or radiologist.  You know whether you have an accepted claim or not by whether you have received a letter from your self-insured employer or from a third-party administrator that says your claim is accepted.  (An acceptance or denial letter must be sent by the adjuster handling your claim within 30 days of the adjuster receiving a copy of the C-4 Claim for Compensation form you completed when you first went to the clinic or hospital for treatment of your injury or occupational illness.)

The most important benefit under the Nevada workers' compensation laws is the right of the injured worker to obtain medical treatment without having to pay a co-payment or deductible.   However, many of my clients who have accepted claims still get bills from medical providers.  

One reason a medical provider may be billing the patient instead of the workers' compensation adjuster is that the provider never got good billing information from you or your doctor when you were treated.  A phone call to the provider who sent you the bill with the name, address, phone number, and fax number of your workers' compensation adjuster, along with your claim number should take care of that problem.  I always send a letter with this information in addition to the phone call to have a record that I have notified the medical provider that this is an accepted workers' compensation claim and who to bill.  I also copy the adjuster on this letter so that she knows that there is a medical provider who  needs to be paid on the claim.  

Do not ignore the bills and collection letters.    Your credit can be adversely affected, and it will be a tremendous hassle to undo that damage later.   Ambulance services rarely have the correct billing information if you are unable to respond to their questions when you are injured.  Call and write to them with the correct billing information on your claim. 

Sometimes the medical provider has the correct billing information for your workers' comp adjuster and still bills the injured worker.  This is a violation of the law.  NRS 616C.135 states that a provider who accepts a patient for treatment of an industrial injury or illness may not charge the patient, but must charge the insurer.  That law also states that if the health care provider violates this law, the Division of Industrial Relations shall impose an administrative fine of not more than $250 for each violation.  

I just wrote a letter to the DIR on behalf of one of my clients who was billed by a radiology company where the bill stated on its face the correct name of the third-party administrator handling the compensation claim, with the notation "w/c", meaning workers' compensation.  There was no explanation on the bill why the radiologist was billing the patient as opposed to the known work comp administrator.  It will be interesting to see whether DIR does something with my complaint and actually fines the radiologist. 

I'm wondering how many injured workers who don't have legal representation have paid bills they weren't required to pay, particularly to radiology companies who are notorious for billing injured workers.  Let me hear from you if you think you have paid bills that really weren't your responsibility.  Did the medical provider reimburse you?

--Written by Virginia Hunt, Hunt Law Office

Concussions from Work Accidents

Obtaining appropriate medical treatment for  post-concussive symptoms  from a work accident can be as frustrating as the symptoms of a concussion.  A concussion is the term use to generally describe a head injury that may or may not result in the loss of consciousness.  It is unusual for someone who has a severe blow to the head, such was when a freight elevator door hits the top of the skull,  not to remember or be sure whether they lost consciousness.  

The most frustrating thing about concussions is that the CT scan of the brain may be normal, and there may be no other diagnostic evidence of an injury, but the post-concussion symptoms may persist.  Those symptoms may include migraine-type headaches, dizziness, difficulty waking in the morning and sleepiness throughout the day, blurred vision, fatigue, and even depression.  Because the cut on the head that was visible to co-workers is gone does not mean that the more troublesome symptoms are healed and gone, too.  

Neurologists, the specialty physicians who are best trained to treat concussions,  cannot predict exactly when an individual's symptoms will subside.  Other than prescribing pain medication for the most severe of the headaches, there is little the neurologist will do after ordering diagnostic testing to determine whether there is bleeding in the brain.  However, a good neurologist can properly diagnose what symptoms you are having that may be caused by the work accident, and whether an injury to the cervical spine (neck) might also be involved and the cause of your pain.  A neurologist will also educate you about your concussion and reassure you that barring any additional blows to the head soon after your accident, most concussions do not result in permanent brain injury.  

It is difficult to rate post-concussive symptoms for permanent impairment under the  AMA Guides to Evaluation of Impairment, 5th edition.  Subjective pain complaints are not ratable.   If the diagnostic tests ordered by the neurologist do not show a physical brain injury, testing by a neuropsychologist may nonetheless demonstrate a physical brain injury that can be rated.   An individual would have to have supporting medical reports of a continuing brain injury for the adjuster to even schedule a rating evaluation.  Then,  the rating physician, who should be a medical doctor, will be looking for any disturbance in the level of consciousness or awareness that affect the activities of daily living, impairments related to memory loss and an inability to function, and any verifiable emotional or behavioral impairments. 

--Written by Virginia Hunt, Hunt Law Office

What Happens When You Refuse Treatment on Your Work Comp Claim

 Nevada injured workers with neck or back injuries frequently ask about what will happen to their claim if they refuse a particular treatment recommendation.   Usually those Nevada injured workers have not noticed improvement in their neck or back injuries after several sessions of physical therapy, medication  and job restrictions. Their treating doctor may then refer the patient for an epidural injection, an invasive procedure.  Or, perhaps the injured worker already  had one or more epidural injections that did not help, and the treating doctor next recommends surgery.  What happens to the claim if the injured worker doesn't want an epidural injection or surgery? 

An injured worker has the right to refuse injections or surgery.  The adjuster or treating doctor cannot threaten to cut off benefits if the claimant doesn't want to risk the side effects of an injection, or simply doesn't like needles, or does not want to undergo surgery. 

However, be aware that there are only several treatment options for neck or back injuries that are routinely authorized by industrial insurers. (Treatment guidelines rarely allow for experiemental or controversial treatments.)  A treating  doctor cannot keep a claim open indefinitely if  the patient is not getting any active treatment and the  injury isn't getting any better or any worse. Therefore,  If there isn't anything else your doctor has to offer you  after you decline particular treatment, your doctor will have to state that you have reached a point of maximum medical improvement (MMI).   

Once you are MMI, the doctor checks a box on the physician progress report to let the adjuster know whether you have a likely ratable impairment and whether you have permanent work restrictions.  The claim then closes because there is nothing left to be done medically for you (except perhaps to prescribe more pain medication).  

I have seen cases where a treating surgeon has reported to the adjuster that the injured worker should not get rated for permanent impairment because the patient refused surgery.   Surgeons are wrong to report that there is no ratable impairment  solely because the patient declines surgery.  If the patient has continuing pain and loss of range of motion,  with positive findings of an injury on a MRI, the patient has a likely ratable impairment, regardless of whether surgery is declined. 

While an injured worker can choose whether or not to have particular treatment, he or she cannot prolong getting compensation benefits if there isn't anything else the doctor can do.  The doctor will usually allow the patient a reasonable period of time (2 to 4 weeks) to decide whether or not to get an epidural injection or to have a surgery.   

--Written by Virginia Hunt, Hunt Law Office

Common Spine Surgeries for Injured Workers

 Before an injured worker undergoes a neck or back surgery, he or she should be familiar with a few medical terms and what specific procedure the surgeon is recommending.   Ask your doctor to write down the name of the surgery, and have him explain exactly what will be done.  If you or your adjuster is requesting a second surgical opinion, make sure you understand whether the second surgeon is recommending a different approach.  The following are a few medical terms and procedures courtesy of materials from the Mayfield Clinic and local neurosurgeon Aury Nagy, M.D. :

  • Discectomy-  surgery to remove herniated disc material that is protruding through the disc wall and irritating the surrounding nerves causing pain.
  • Fusion- joining together two separate bones (vertebrae) to provide stability.       
  • ACDF (anterior cervical discectomy and fusion) - surgical procedure that removes a herniated or degenerative disc in the neck, and fusing the vertebrae above and below the disc space. The spine is approached from the front of the throat area.  The removed disc space is filled with a bone graft and the the vertebrae are immobilized with metal plates and screws.  Bone grafts may come from bone cells taken from your own hip, or from cadaver bone, or man-made substitutes.  Artificial disc replacement is also an option for some patients.  Both neurosurgeons and orthopedic surgeons do this surgery.
  • Foraminotomy-  surgical enlargement of the intervertebral foramen through which the spinal nerves pass.  Bone spurs, called osteophytes, that may be pressing on nerves may also be removed during this procedure.  
  • Posterior lumbar discectomy- surgery to move a herniated or degenerative disc in the lower spine where the surgeon approaches the spine from the back.  An open discectomy involves a 1-to 2-inch incision in the middle of the low back.  A minimally invasive discectomy has a very small entry wound. 
  • PLIF- posterior lumbar interbody fusion
  • ALIF- anterior lumbar interbody fusion where the surgeon accesses the spine through the abdominal area.
  • Laminectomy- this is the surgical procedure to drill a small hole through the lamina (a part of the bony vertebrae) so that the surgical can insert a surgical microscope to view and remove disc fragments.  It may be necessary to do on both sides (bilateral laminectomies).
  • OLIF-  Oblique lumbar interbody fusion.  This is a surgical procedure pioneered by local orthopedic surgeon Andrew Cash, M.D. where the surgeon enters the spine from the back, at an angle, near the pelvis and just above the iliac crest.  Read more about this in the article on Dr. Cash by Brian Sodoma in Las Vegas Life magazine, Spring 2013. 

    --Written by Virginia Hunt, Hunt Law Office




Does An Injured Worker Have to Go to Their Doctor?

     Injured employees in Nevada have a limited right to choose a treating doctor.  The workers' compensation insurer or third-party administrator for the employer has a list of doctors that have contracted to provide medical care at reduced fees.  Once the injured worker's claim is accepted, he or she has the right to ask for a different doctor on the provider list.  If the request is within the first 90 days of the claim, the adjuster handling the claim must approve the request.  Requests to change doctors made after 90 days can be denied, but the law says that the adjuster should have a good reason for the denial.  NRS 616C.090.  

     An injured worker who successfully changes her treating doctor may be surprised weeks or months later to get a letter from her adjuster scheduling her to see a different doctor for a consultation appointment.  That usually happens when the adjuster doesn't agree with the treatment recommendations of the treating doctor.  This type of consultation might also be scheduled when the treating doctor has taken the injured employee off work for a long time.  

     Nevada law does give insurers and employers the right to require a consultation appointment with a doctor chosen by the employer or insurer from the insurer's provider list.  This consultation examination is sometimes known as an IME (independent medical examination).  The letter from the adjuster  that notifies the injured worker of the appointment date and time will state that the injured worker's benefits will be suspended if he or she does not go to this appointment.  NRS 616C.140 (5) states that if the employee refuses to go to the exam or obstructs the exam, compensation benefits can be suspended by the insurer until the exam takes place.    

    The letter from the adjuster will also tell the injured worker that he or she has the right to file an appeal if they disagree with the consultation.  If this is the first time the insurer or employer has scheduled the employee for a consultation, a hearings officer is not likely to reverse the insurer's determination to require the consultation.  However, I have had cases where the insurer has scheduled several consultation examinations in an obvious attempt to get a particular opinion from a doctor.   If the number of consultations is unreasonable or the insurer is making unreasonable demands concerning cross-country travel to a consultation, a hearing officer will side with the injured worker.  Adjusters who schedule multiple consultations are usually gearing up to deny something- beware.

--Written by

More Unfair Tactics Against Nevada's Injured Workers

 The most important benefit under the Nevada workers' compensation system is the injured employee's right to get medical treatment.  I have prior blog posts about the limitations on that right that are written into Nevada law, such as the limited right to choose a treating doctor.  I also just wrote about insurers' attempts to deny an injured employee's right to change doctors by directing care to doctors who will release the patient from care within the first 90 days of the claim.  

In the past two months I have seen two insurers get even bolder by writing directly to the treating doctor and telling him to change his diagnosis to the  diagnosis accepted by the insurer.  For example, two clients with low back injuries were diagnosed with disc injuries as well as lumbar sprains by their treating doctors.  The administrator in both cases sent claims acceptance letters to the injured worker, stating that the claim was accepted for "lumbar strain only".  When the insurers saw the bills from treating doctors and physician progress reports that referenced a disc injury and a lumbar strain, the insurer wrote to the doctor advising him that the insurer was only going to pay for treatment for a lumbar strain.  

The injured workers were copied by the insurers on the letters that were sent to the treating doctors limiting treatment and payment of the bill to only a lumbar strain.  However, In one case, this letter to the doctor wasn't sent until months after the doctor had listed the disc condition on every physician progress report as one of the diagnoses.  The insurer had also specifically authorized and paid for injection treatment for the disc condition. It was evident that the insurer was trying to limit the diagnosis now that the claim was closing so as to avoid an impairment evaluation or a higher impairment rating.

In the second case, the insurer wrote to the doctor at the very beginning of the claim, and the insurer wanted to make sure that the only treatment the injured worker got was treatment for a strain.   In both cases, the copies of the letters to the doctors confused my clients.   It wasn't clear at all to them that what was happening was an attempt by the insurer to limit  their medical treatment  in the future or now, and an attempt to limit any impairment due to the work accident.

If you get a similar letter from the adjuster, or are copied on a letter the adjuster sends to your doctor trying to limit your claim, don't ignore it. You owe it to yourself and to your family  to understand  what is happening on your claim and how to obtain the best possible medical care under Nevada law. 

--Written by

Change Doctors NOW !!

Nevada law requires third-party administrators and self-insurers of workers' compensation claims to send accepted claimants a notice of their right to choose a different doctor from the appropriate provider list.  Not all TPA's and insurers are sending this notice.  If they do send it, most injured workers don't read or understand how important it is to choose a different doctor before their claim is closed.

I have been seeing too many  claims where adjusters are trying to deprive injured workers of their right to change doctors by having a doctor close the claim within the first 90 days of the claim.  What usually happens is that the injured worker is first directed to go to Concentra for initial medical care and to complete the C-4 Claim for Compensation form.   If the injury persists after 45-60 days, the adjuster sends the injured worker a letter  transferring their care  to a doctor the adjuster chooses.  These doctors are usually physiatrists-   physical medicine specialists who treat occupational injuries by prescribing therapy and medication, or by giving injections. If the injury is very serious, these doctors can request a consultation exam by a surgeon.  These doctors have agreed with insurers to treat at rates below the Nevada fee schedule in exchange for a  volume of business.  Their relationships with adjusters, and self-insurers  are  important to their businesses.  If an adjuster doesn't like it that the doctor is taking patients off work too much or is finding that claimants should be rated for impairment, the doctor is quickly removed from the provider list and loses business.

Injured workers have the right to change doctors within the first 90 days of the claim.  The injured worker must attend whatever consultation exams the insurer schedules, but within the first 90 days, the worker can refuse treatment with the doctor chosen by the adjuster and ask for a different doctor.  The catch is that the alternate doctor must be another doctor  on the insurer's provider list.  The worker must also know to request a copy of the provider list.

Continue Reading...

Chronic Pain: New Help with Peripheral Nerve Surgery

 A featured speaker at the WILG convention today was Dr. TimTollestrup, M.D., a Las Vegas physician who specializes in peripheral nerve surgery.    Dr. Tollestrup had recently operated successfully on one of my clients with a crush injury to his foot,  so I was interested in knowing more about him and his approach to treating difficult chronic pain cases.  Dr. Tollestrup is one of only several surgeons in the country who focuses on eliminating chronic pain by applying accepted surgical techniques to peripheral nerve decompression or segmental denervation (cutting a peripheral nerve to interrupt the pain response.) 

Peripheral nerves are all of the nerves in the body other than the spinal cord.  Dr. Tollestrup explained that most physicians, including orthopedic surgeons,  have very little training in the anatomy of the peripheral nerves.   When patients have severe pain lasting longer than six months following an injury or surgery to a knee, shoulder, elbow, hand or foot, a compression, stretching, laceration, or crush-type njury to a peripheral nerve may be cause of the chronic pain.  Surgery to treat the peripheral nerve injury may successfully eliminate the pain completely.  

Dr. Tollestrup stated that it was very satisfying to be able to  provide  relief  to a patient who may have had to take  narcotic pain killers for months or even years.  He also confirmed that it was very  frustrating to chronic pain patients to be passed from one doctor to another after unsuccessful pain management.

X-rays, MRI's, EMG and nerve conduction studies, are not very helpful in diagnosing  a peripheral nerve injury according to Dr. Tollestrup,  Instead, he depends on taking a careful history of the problem from the patient and on a hands-on clinical examination.  Peripheral nerve surgery is a relatively new field, and additional research must be done before it can be applied to treat spine pain. tt was particularly exciting to learn about its success in treating  complex regional pain syndrome and other types of chronic pain that have been baffling to physicians treating injured employees.  Dr. Tollestrup's website is

--Written by

Continue Reading...

Problems Obtaining Prescription Drugs



If your claim is accepted and your authorized treating physician prescribes medication for you, but your pharmacist tells you that there is a problem, follow these steps


1. Have a copy of your claim acceptance letter with your claim number and name and address of your third-party administrator or insurer in hand when you go to the pharmacy.

2. Do not confuse things by giving your pharmacist your health insurance card.  Instead, you want the workers' compensation carrier billed.

3. If the pharmacist tells you that your prescription has been denied, pay for the medication so that you can get it started if it is essential that you start it right away.  For example, it you just had surgery and need an antibiotic, don't wait.  Or, if you need pain medication right away, just get the medication, and then straighten out the problem.  It can take a day or two to get medication problems resolved, so don't drive yourself crazy by not getting the medication if you can afford it.   Keep a copy of the receipt that shows what medication you paid for, and send it to your adjuster, requesting reimbursement. 

4. Call your adjuster or fax or email the name of the medication, who prescribed it, and the name and phone number for your pharmacy.  Don't just leave a message or complain that you didn't get your medication authorization. Make sure you give the adjuster information she can use to fix the problem. 

5. If you have a nurse case manager assigned to you case, instead of calling the adjuster, you can call the nurse case manager. She is likely to be more familiar with what the doctor prescribed, and may be able to help you quicker. Again, give her your pharmacy phone number.

6.  Expect delays if the medication ordered is an expensive proprietary formula, as the insurer may question why generic wasn't prescribed, or whether other medications were tried first.  Maybe your doctor can give you some samples to start if he knows that insurers usually drag their feet on authorizing this particular medication. 

Unfortunately, I expect more problems in the future obtaining medication for injured workers.  According to an recent article in Business Insurance, there is a growing trend among states to creating medical guidelines for doctors prescribing opioid pain medications to workers' compensation claimants.   Additionally, many insurers now use intermediary companies that involve another step in the authorization process, and thus, more delays.

--Written by

Patient Advocate a Necessity If You Are Hospitalized

Most injured workers who call me for advice are frustrated with poor medical care or problems obtaining good care as a result of insurance issues.   Making sure that injured workers get the best possible medical care is what I do for a living, so I didn’t need a personal experience to convince me how important a patient advocate is when a person is ill and hospitalized. Nonetheless, last month I personally got a huge dose myself of bad medicine and lousy insurance practices when I was unexpectedly hospitalized. During my brief (thankfully) hospital stay, the following occurred:

  •      A typographical error in a CT scan report wasn’t caught until after I was given IV medication for another serious condition I did not have. 
  •      I was medicated and then strapped to a gurney and transported at midnight against my wishes to another medical facility from the hospital. My condition was actually worse when I was released from the hospital. This happened without any notification to my family.
  •        I was lied to by a doctor as to whether a prescribed IV antibiotic could be given at home as opposed to at the dirty secondary facility my insurance company supposedly required for another week.
  •     I was denied access to my own medical records for several hours while administrators grappled with what the law and their own policy says about patients’ rights to review their own records.

These  occurred during a 72-hour period when I was too sick to demand that I speak to insurance adjusters and hospital administrators. Fortunately, I have two highly-trained and very loyal legal assistants who stepped up to make sure that nothing worse happened to me.   When I was able to talk and demand better care for myself from my insurance company and from medical providers, things changed significantly for the better.  

At a minimum, if you or a family member need hospitalization, have someone go with you who can act as a patient advocate. That person should be comfortable  with asking a lot of questions, particularly during check-in and discharge.  Make sure that your advocate has a list of medications you take daily. Give the phone number of this person to hospital personnel and ask that this person be contacted if you are moved or scheduled for a surgical procedure. Bring a cell phone and a charger with you so that you have easy contact with your advocate and family. Bring a small notebook so that you can keep notes and write down important phone numbers. 

Do not be intimidated, and be persistent in getting answers to your questions as to what is happening to you. Make sure that you understand what treatment you are getting, what medications you are being given, and who ordered them for you.  Do not assume that people know what they are doing.  Finally, bring a huge bottle of hand sanitizer with you. The AARP Bulletin, March 2012, has frightening statistics on the number of people who are victims of hospital mistakes, and what else you can do to protect yourself when hospitalized.

--Written by

Unfairly Surprised by Your Doctor's Work Release?

I caution all injured workers to look carefully at the physician progress report (PPR) they are handed at the end of each  visit to their doctor assigned to treat their industrial injury.  Most doctors and clinics that are on the various third-party administrators' medical provider lists use the D-39 form approved by the DIR.    Sometimes the clinic or doctor will use a form that looks different, but all PPR's used by Nevada medical providers must show whether the doctor is taking the patient off work completely, or is giving work restrictions until the next scheduled appointment. 

If the doctor does not hand you a PPR showing you what your work status is, ask for  a copy  before you leave the doctor's office.  It is important that you get a copy of the PPR so that you know for certain whether the doctor has released you to return to work, and if so, whether you have work restrictions.  If the doctor's assistant tells you that you don't need a copy, and that they will fax a copy to your insurer and your employer, nicely explain that you are entitled to your own copy. 

Unfortunately, there are a few doctors on the Nevada provider lists that take a cowardly and unprofessional approach to releasing workers' compensation  patients back to work.  Instead of explaining to the patient that the doctor thinks it's time to return the patient to work, or to any available light duty job, the doctor says nothing when in the examining room with the patient.  If the patient doesn't get a copy of the physician's progress report, and the doctor didn't discuss work  release status, the patient only learns about what his doctor has done when he doesn't get his next  compensation check in the mail. 

These doctors shirk their responsibility to their patients because they want to avoid an argument from the patient.  The doctor may have good reason for changing the patient's work status, and if so, the doctor should be willing to discuss the reason with the patient.  Otherwise, It is extremely unfair and bad medical care not to inform the patient of his changed work status.

If this has happened to you, or you suspect that your doctor may not be up front with you later, be aware that you have an absolute right to change physicians within the first 90 days of your claim.  After 90 days you may still request it, but it will be harder if the insurer denies your request and you have to go to hearing. It is also very hard to change doctors after a doctor has just performed surgery on you. Just don't ignore your gut feeling that your doctor is not concerned with your well-being and at least get a free legal consultation to discuss what you can do to protect yourself.  Finally, please help other injured workers learn about their rights regarding choice of physicians by sharing this resource and the DIR's website information.   

Neck Pain Update on Physical Therapy

I promised to give my honest assessment on whether the McKenzie Method used by the physical therapist I am seeing is helping me.  Today, back at work with many people needing to get back on track with their medical care and benefits on their claims after a long holiday weekend, my neck is stiffer than ever.  I have only been able to schedule physical therapy appointments once a week with the two holidays, so I should mention that. On most accepted Nevada workers' compensation claims, physical therapy is scheduled for three days a week, and that may make a huge difference.  (I do not have a workers' compensation claim.  My neck problems are related to age, hours spent in sub-optimal postures in front of a computer, reading late into the night in bed, a few rear-end fender benders over the years, and several significant horse-back riding injuries).

I'm finding that it is frustrating that I am forgetting to do the exercises I have been taught by the therapist at least five times a day.  The exercises probably take all of ten minutes to complete, so I don't have a good excuse for not remembering.  I think I will simply have to set the alarm on my phone today to make myself do them. Of course, it would be so much easier to take a pill of some sort and have the problem with decreased range of motion, stiffness and pain just disappear.  However, I cannot do that.  I want to remain clear mentally and crisp with my reaction time for my horse-back riding. 

I see that I reported that my range of motion was improved when I actually did the exercises, so I will resolve to make a better effort this week.  I did do a lot of horse-back riding the past five days.  The type of riding I do is strenuous- jumping and advanced English riding (dressage) on a young Thoroughbred who is emotionally the equivalent of a teenage boy.  I also had to survive a New Years Eve party at my house for my son's 22 birthday.  This last holiday wasn't exactly relaxing for me.   So, here's to trying to  take more personal responsibility for my own health in 2012. 


Neck and Low Back Pain- Does Physical Therapy Help?

I've had a couple clients referred by local neurosurgeons to a particular physical therapist who is certified in  the McKenzie's Protocol, and I decided to investigate this personally.  I've got  chronic neck pain from various horse-related accidents over the years, and am always searching for ways to increase my range of motion.  I also want to decrease the pain and stiffness that extends from neck into the right scapula.  Being able to turn my neck better is essential for my riding, as well as  my driving. 

I know that long hours seated in front of the computer adds to the problem, and the older I get, the more important it is to get up every half hour, stretch and walk around a bit.  But stretching on my own, and even the addition of a weekly yoga class hasn't been enough since I re-injured my neck in Ireland during an unlucky fall from a horse.  I also added a massage from a highly trained masseuse once a month to keep my back and neck more mobile and comfortable, but that also is not enough.

I made an appointment with the certified McKenzie evaluator and therapist two weeks ago, and  I had a second appointment last  week.  The McKenzie Method  (sometimes called the McKenzie Protocol is described in detail in several books written by founder Robin McKenzie back in the early 1980's.    Robin McKenzie's is a physiotherapist from New  Zealand who developed his own treatment methods for spinal disorders.  I purchased two of his books, Treat Your Own Neck, and  7 Steps to a Pain-Free Life: How to Rapidly Relieve Back and Neck Pain.   These  books, available at, are easy to read.  If you need to borrow my copies and promise to return them, call my office and ask  my assistant to send me reminders to bring the book to the office for you.

The first book states that it is meant for people with straightforward recurring mechanical problems, and that self-treatment exercises taught by a certified therapist are the key to maintaining neck pain.  I do think it is important to invest in at least a couple of sessions with a certified therapist to make sure that the exercises are safe and right for you.  The therapist will also want your doctor to prescribe this particular therapy for you (and to get your insurance to cover the sessions if you no longer have an open claim.)

McKenzie emphasizes that there are two types of stresses that can occur to cause neck pain:  1) an accident that results in overstretching of the ligaments and other soft tissue that hold the cervical vertebra together from an outside force, and 2) overstretching caused by postural stresses that place less severe strains on the neck over longer time periods.  It is this second type of stress, the one that we exert on our self that can be self-treated for the prevention of neck pain. 

Examples of the exercises in the book prescribed for me by the McKenzie therapist include retracting the neck back into the chin, extending the neck backwards, side bending of the neck, and laying on an examining table with the neck extended off the edge of the table.    While the book walks the reader through the exercises, and they are very simple, I strongly advise that you first have a certified McKenzie therapist walk you through them.

After the first week of doing neck retraction exercises, I had increased neck pain and even less mobility from placing my neck in very different positions  After the second session, the neck pain was improved, and I had a little less pain, but range of motion was still very limited.   Then, I miraculously got better about remembering to do the exercises the prescribed  5 times a day.  I also became more aware of my posture as I sat at my computer.  I also remembered to pick up a new bedside lamp at Home Depot so that I had better light as I continued my bad habit of reading in bed late at night.  In other words, I started to take some personal responsibility for making my neck better instead of simply whining about it.

Today, I'm back at work, in front of the computer, but I don't have pain extending into the right shoulder and scapula for the first time in months.  The neck pain is lessened, although I still hear a lot of snap,crackle and pop when I go through the range of motion checks.   Whether the improvement is due to these particular exercises, my remembering to actually do some stretching and exercises, or a wonderful, relaxing Christmas with my friends and family, I really don't know.   But, I intend to give these exercises a good try, and will return to see the therapist tomorrow. 

I remain optimistic that this therapy will also keep my clients off  the operating table.  The number of injured workers who tell me  they "want to be fixed" by a surgery  concerns me.  While I'm not a doctor, I see many people with chronic neck and back pain that might be able to significantly help themselves manage their pain with some guided, concerted effort on their part .  Exercises require consistent effort (although these are very easy ones).  This isn't a quick fix, but it might be a huge relief once I train myself to do them daily.   I will keep you posted.  Feel free to post a comment if you have experience with the McKenzie Method exercises. 

Nurses and Attendants at Risk for Low Back Injuries

 Back injuries, followed closely by shoulder injuries, are the most common job-related injuries for my clients in the nursing field.  Nurses, and those employed as nursing attendants are at high risk for these injuries primarily because they must transfer patients from beds to gurneys or to wheel chairs, or to baths.

A new law in California requires hopsitals to establish a "safe patient handling policy", meaning that lifting devices must be used instead of manually lifting patients and that staff must be trained better.  The Santa Cruz reported that studies done by hospitals that had already established those policies in 2004 showed that the rate of injuries among nurses dropped 15%.  Handling  overweight patients was a particular concern as the population continues to be more obese.  

Most hopsitals in Nevada have instituted training on how to transfer and move patients using correct body mechanics.   The policy at each hospital may differ on when a nurse is required to use lift equipment.  Prevention of these injuries is certainly the key to reducing  the number of  low back sprains, disc herniations, and back injuries in general that afflict workers in the nursing field.  If your hospital does not have good patient lifting policies, you might want to speak to your supervisor or director to see what can be done to obtain new equipment or to get additional training to  prevent future injury to yourself and your co-workers.

What if you are a nurse and you do hurt your lower back while transferring  a patient?   Follow all of the ordinary steps for filing a claim and getting medical care as directed by your employer.  You should notifiy your nursing director or supervisor immediately in writing if you think you may have hurt your back, even if you don't think you need to see a doctor right away.    Many times a person may not know how serious the back injury is, thinking that they have a  muscle strain that will feel better in a day or two.  Report the injury anyway on a Notice of Injury form.   The law requires injured workers to report injuries in writing within 7 days of the accident.  

The law also requires that an injured worker obtain medical care within 90 days of the accident and complete the C-4 Claim for Compensation if the worker ever intends to pursue a claim.  After you notify your employer of the incident causing you back pain, make sure that you go to the clinic where your employer directs you for a work-related injury once you realize that you need medical attention.  Be clear on that form about the date you injured your back and how you injured it.  Be as specific as possible about how the accident occurred.  If you only think you might have injured it work, but aren't sure about how and when you injured it, the claim will be denied.  Remember, there is no claim until you complete the C-4 form at a doctor's office.

Once the claim is accepted, if your back injury is not getting better following some physical therapy and anti-inflammatories,  I recommend that you request a transfer of care from the intitial clinic to either a physiatrist or a spine specialist on your insurer's provider list.   You are entitled to ask your adjuster for a copy of the insurer's provider list so that you may select a physiatrist,  or an orthopedic physician, or a neurrosurgeon.  Most back injuries will heal in time, but if yours requires surgery or is so debilitating that you may not be able to return to your profession in the nursing field, you may want to consider a consultation with an attorney to make sure you know your rights. A  book that provides a good discussion of treatment options for low back injuries is Your Aching Back, by August A. White III, published by Simon and Shuster, and available at www.


Depression and Work Injuries in Nevada

If you have a work injury in Nevada you are more likely to become depressed.  If you do need a study to prove that there is a higher incidence of depression among workers with orthopedic injuries, you will be interested in the linked article from  California psychologist Stephen Pfeiffer, Ph.D.,  He cites a study reported in the Annals of General Psychiatry, Dr. Pfeiffer  frequently writes about depression and other  psychological conditions affecting California's injured workers. 

Unlike Dr. Pfeiffer,  I am not a doctor.  I am a lawyer who represents injured workers.  The following are my Top Ten  non-medical reasons injured workers tell me  why they feel depressed after their job accident:

  • They're hurt and in pain.  That alone makes them unhappy.
  •  A supervisor, or co-worker, or their adjuster acts as if they are faking their injury...
  • They are worried about whether they will still have a job when they are well again..
  • They are getting the run-around from whomever is supposed to be handling their claim.
  • They know they aren't getting good medical care, but don't know what to do.
  • Authorizations for medical care take forever.
  • They are worried about how they will make a living if they can't go back to their line of work. 
  • They're financially behind on bills as a result of late compensation checks, no compensation checks, or inadequate compensation checks.
  • They hear stories that they might get a settlement at the end of their claim, but have no idea what to expect, or whether to hope for anything.
  •  They are worried about needing medical care in the future if the injury ever worsens after the claim is close.
  • They know they need information, but don't know who to trust for advice.

Depression is serious.  If you are feeling completely overwhelmed or suicidal, please tell your doctor immediately, or call 911 and ask for  the suicide prevention hotline.  While it can be difficult to obtain psychological treatment for depression on a worker's compensation claim, it  can be done under the right circumstances.  More importantly, many  feelings of helplessness go away once you are armed with knowledge about how the claims process actually works.   If you  feel too lousy to actually meet with a lawyer for a free consultation, at least help call for a free guide so that you have a better understanding of Nevada workers' compensation law.   

Your Right to Choose a Doctor

I just saw a TV ad that asks injured workers whether they know that they have a right to choose their own doctor.   Enough wasn't said in this ad in my opinion.  The actual law,  NRS 616C.090, gives injured workers just a limited right to choose a different doctor. 

An employer can require that  their injured employees first go to specific clinics to report a claim and to get initial treatment.   Concentra, Fremont Medical, Harmon Medical Center, and Industrial Medical Group are  examples of  clinics that many insurers and self-insured employers use for that purpose.  If you don't want problems in getting your claim accepted, you should go where your employer tells you to go to file your claim and to get evaluated by a physician.  Then, you can change doctors after your claim is accepted.

Injured workers who want to change doctors have the right to request a different treating doctor, but they must request the name of one who is already on their  particular employer or insurer's provider list.  Injured workers  cannot just make an appointment with a doctor of their choosing to treat their job injury or occupational illness.   If it isn't an emergency, an employee with with an accepted claim must  go through his or her adjuster to first ask which doctors are on the provider list, and to then ask for a change of doctors.

Most injured employees simply don't k now to ask for a copy of the employer or insurer's provider list.  If you ask for it writing, they must give it to you.  First get this, then request a change of doctors so that you aren't wasting your time asking for a doctor who isn't on the provider list.

Also,  if the injured worker asks to change doctors after 90 days following the date of the accident, the adjuster may refuse to grant the change.  This is a very important right that  injured workers have, but one that few use.  If you are dissatisfied with your initial treating doctor, and many injured workers aren't happy with the quality of care, get immediate legal  help in transferring your care if you don't feel capable of doing it yourself. This is the single most important decision you will make on your claim-  who will be your doctor?  And ideally,  this decision should be made within the first 90 days of your claim with the help of someone who is knowledgeable about each of the doctors on the provider list.    For more information on the law on choice of physicians, and to read what the Nevada Supreme Court said about this choice, read my earlier blog post when they changed this law in 2009.