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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.
1. Going along with bad medical care
You don't have to accept substandard medical care just because you were injured at work. It is hard to correct a botched surgery. If you feel reluctant or have a gut feeling that the surgeon the insurer has assigned to you isn't very good or isn't listening to you, change doctors. You have the absolute right within the first 90 days of your claim to change to a different doctor on the insurer's provider list. And even after the first 90 days, you may still request a different doctor. Make your request for the provider list in writing, and make your request to change doctors in writing.
2. Getting unreliable information about the claims process
Instead of relying on friends and co-workers to educate yourself about the Nevada claims process, why not read the blog posts I've written on almost every topic concerning Nevada workers' compensation claims? If you want to research the law yourself, in addition to reading the statutes (NRS 616 and 617), and the regulations (NAC 616-617), you must be familiar with Nevada Supreme Court decisions interpreting the law. You must also know about the actual practice of the hearings and appeals officers to have some idea of what appeals officers, the district court judges, and Nevada Supreme Court justices are likely to do in your case. Take advantage of a free consultation with a reputable attorney.
3. Accepting a PPD award when you want more medical treatment
Even if you don't elect to receive your permanent partial disability (PPD) award in a lump sum, and the insurer is paying your PPD award in installments, you must appeal claim closure if you want more medical treatment. First ask the adjuster whether he or she will allow you to return to the last treating doctor for more treatment. If not, then go to any rating exam the insurer schedules so that your benefits aren't suspended. Also, you must file an appeal. You will have to get a report from your private physician to show the hearings officer that you need treatment. Don't wait, thinking that you can easily reopen your claim later. It's hard to reopen claims.
4. Waiting to add other injured body parts
Remember that you can't reopen a claim to get treatment for an injured body part if it was never accepted before the claim was closed. If your claim acceptance letter only references some of your injuries, notify the adjuster in writing. Ask the adjuster to at least allow your doctor to examine your other injuries before the adjuster outright denies these injuries to other body parts. File an appeal on time (within 70 days) of any letter the adjuster sends denying injuries to other body parts. You may also need to go to your own doctor using your health insurance if other injured body parts are denied.
5. Not planning for your vocational future
Be realistic and honest with yourself and your doctor when discussing whether you are going to be able to return to your job at a later date. If you know or think you might not be able to return to your usual occupation, try to find out now whether your employer is likely to offer you a permanent modified job or not. If you or a family member is dependent on the health insurance your employer provides, then you must start being creative and persistent now in persuading your employer to keep you despite any permanent physical work restrictions. Your employer does not have to find you permanent light duty work. Alternatively, start thinking about retraining programs and start visiting schools that have 9 to 18-month vocational programs.
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 Amazon.com, 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.
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 Sentinel.com 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. amazon.com.
Part A
The NCCI is an organization that keeps statistics on work injuries in the various states. A recently released August 2011 NCCI Research Brief by Lipton, Laws and Li focused on prescription costs. According to this study, prescription drugs are 19% of the medical costs on an average claim. The study showed that it was not the price of drugs that was responsible for increased prescription costs. Instead, increased drug costs were attributable to doctors prescribing more drugs and more expensive drugs. Also responsible was the growing trend in many states by treating doctors to sell prescription drugs in their offices. Additionally, the study also found that physicians who sold drugs in their office were charging more for drugs than local pharmacies,
This trend, which is particularly popular with California physicians, hasn't caught on in Nevada yet, According to NCCI's statistics, Nevada presently has lower prescription costs per medical claim than most other states, and relatively few doctors in Nevada sell the drugs they prescribe.
The NCCI study did not suggest that doctors were doing anything wrong by selling prescription drugs to patients, or that they were wrong in selling drugs at prices higher than pharmacies. The study mentioned why pharmacies are able to sell drugs at lower prices, and the study suggested that some doctors wanted to dispense small amounts of drugs for the benefit and convenience of their patients. The study listed wanting to make more money as a reason doctors were now dispensing prescriptions. However, the study did not fully explore the subject of physician profits from this practice.
The negotiated fees paid to doctors for their treatment of injured workers on Nevada claims seems ridiculously low to me. Unfortunately, some physicians try to make up for low rates by scheduling more and more patients in a day. In Nevada, most insurers won't keep a physician on their provider list unless the physician agrees to accept less than what the Nevada fee schedule allows. I wonder whether the profit margins earned by Nevada physicians on workers' compensation claims will cause them to start selling prescription drugs to their patients.
The NCCI study didn't delve into the ethics of physicians establishing a secondary profit center at their offices selling prescribed medication to patients. I haven't researched this topic, so I don't know whether there are existing rules or regulations that govern the conduct of physicians who do this. It just doesn't seem right to me, though. The study also found that doctors were prescribing more drugs and more expensive drugs. Even if the physician is completely ethical, won't patients wonder whether the physician is prescribing a particular medication just for the purpose of selling it? Maybe I've been lucky with the physicians I've seen in La's Vegas for my own health care. Many have given me free samples of prescribed medications so that I could avoid or reduce prescription costs.
For me, the NCCI Prescription Drug Study, 2011 Update, raised many questions about the future role of physicians on workers' compensation claims. If Nevada physicians join the trend in dispensing prescriptions form their offices, it is likely that medical costs on the claim will increase. Injured workers do not have to pay for prescriptions on an open, accepted claim in Nevada. However, if claims costs increase for insurers, insurers will be looking for ways to save money. That could mean rushing the injured worker through second-rate medical care, denying authorizations for diagnostics or treatment, or trying to short-change the claimant on his PPD award or his vocational program.
Stay tuned for Part B on Prescription Drugs and how to handle problems obtaining necessary prescriptions on your claim. Meanwhile, I would like to hear your opinions on the subject of physicians selling prescription drugs that they prescribe.
Delays in getting medical care authorized are the reason most injured workers contact me for help on their claim. Here is some additional information about treatment delays and what you can do to get proper medical care on time on your Nevada workers' compensation claim.
Most industrial insurers will schedule injured workers for a second opinion before authorizing an orthopedic surgeon or a neurosurgeon's request to do a spinal fusion. It is a good idea, even if the insurer isn't requiring it, to get a second opinion on whether a spinal fusion is the best treatment for you. Many injured workers immediately agree with their treating physician's recommendation for a fusion because they are still in pain after physical therapy and a course of medication, or because injections didn't work. A fusion surgery is not something that should be done simply because a patient is still in pain and the doctor doesn't know else to do. It should be done only after careful consideration of all treatment options and only if there are clear-cut objective indications for this surgery.
Some injured workers mistakenly believe that that their benefits will be terminated if they don't agree to have surgery. An adjuster cannot terminate benefits solely because a claimant decides not to have a surgery. The adjuster may close a claim because the doctor has exhausted all treatment options. The adjuster will not let a claim remain open indefinitely while a claimant takes months to decide whether to have surgery or not. However, most adjusters will agree to allow a second opinion if the adjuster hasn't already decided to get one.
If you feel that you are being pressured into making a rushed decision on having a spinal fusion by your treating doctor, discuss this with the adjuster and request that he schedule a second surgical consultation. Remember that you may request a copy of the insurer's provider list to see what other spine surgeons are on the the insurer's provider list. Do some research so that you are informed about the surgeons before you request a particular one, or before the insurer chooses a second opinion physician for you.
Virginia L. Hunt is a Nevada attorney with over fifteen years’ experience in workers’ compensation law. She began in thisMore...
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