Washington Hospital Services employs many different forms of medical management. The following list includes some of the techniques we use to pro-actively process claims.

Telephone Calls
Direct contact with the injured worker, physician and hospital personnel are made to obtain basic background on injury, work status and any investigation necessary to determine compensability of claim. Our goal is to make a call to each injured worker who has a time loss claim or whose injury is to the neck, back, or major joint within 48 working hours of receipt of the claim. Any claim with questionable circumstances or serious potential will also result in a call, regardless of work status.

Diary System
Maintenance of a diary system for review of claims is an important tool. Claims are diaried every 14 days for active time loss claims and other time loss and treatment only claims are diaried at the time of expected medical information. Most diaries are seen every four-six weeks.

Investigations
We employ several techniques in the use of outside investigators. We direct these outside investigators in the type of work we require. Services include use of recorded statements or written statements from injured workers or witnesses, travel to various locations to obtain copies of medical records, court documents, bankruptcy records, divorce records or police reports. We employ investigators to do activity checks on injured workers as well as surveillances, if our records and information from the hospital personnel warrant it.

Attorney Referrals
Washington Hospital Services will assign a case to an attorney when complex medical and/or legal issues arise. We will discuss preparation of the case for litigation and follow the attorney's recommendations.

Separation/Retirement Form
Washington Hospital Services worked with an attorney to devise this form. In some cases, where the employee left the hospital to retire, a claim which is open, or is filed after leaving can become a pension claim. Had the motivating reason been clearly documented on why the employee left, the employer would have had an opportunity to modify the work or assign the individual to another position. The employer would then also have complied with Washington Discrimination laws and the Americans with Disability Act (ADA). This form should be used in an exit interview and only forwarded to our office when the employee has an open claim.

Separation/Retirement Form [.pdf]

Progress Reports
If the condition of the injured worker appears to warrant ongoing treatment, we establish the name of the recognized attending physician to obtain monthly progress reports.

Self-Insurers Medical Progress Report/SIF10 [.pdf]

Disability Cards
We use disability cards to obtain a quick response on progress of the worker. The information verifies ongoing treatment and possible release for work or any restrictions in work activities and is also used as a tool to obtain information from the injured employee regarding any other benefits such as unemployment compensation they are receiving while on time loss.

Certificate of Disability [.pdf]

Independent Medical Examinations (IME)
Use of the IME is an important medical management tool. As attending physicians sometimes provide limited information in progress reports and office notes, we use the IME to obtain documentation of all aspects of an injury. Typical IME reports tend to be 4-5 pages in length including results of physical testing for objective findings and the examiners' comments on the physical assessment of those tests. The IME is used for a second or third opinion in cases of surgery, questionable causal relationships, pre-existing conditions or preponderance of medical opinion. Results and reports are then sent to the attending doctor for comments. Most IME's are either with an orthopedist or neurologist or both and may occasionally include a psychiatrist. These are usually scheduled away from the community in which the injury occurred to obtain an objective opinion from a doctor who neither knows the attending doctor or the injured worker. This, of course, necessitates some travel.

Nurse Consultants
Nurse consultants are assigned to cases where the medical issue has become complex, the injury tends to be of a serious nature, or when two or more doctors are involved in the care of the injured employee. We also employ nurse consultants on cases where emotional issues have become a prominent focus of the claim. We ask them to visit the injured employee in the home to obtain a sense of the home situation and advise us of any factors which will increase difficulty of resolution of the claim. We ask nurse consultants to be available to the injured employee for emotional support when circumstances warrant it. Nurse consultants will visit doctors at our request to discuss medical management, appropriate referrals and enhance open communication with the Washington Hospital Services program. Many times workers need an objective medical person to talk to and the nurse consultant can fill this role.

Vocational Rehabilitation Counselors (VRC)
We assign a VRC when it is determined by the attending doctor or an independent examiner that the injured employee will not be able to return to same job at the time of injury. We ask the VRC to assess the worker and contact hospital personnel to review all jobs at the hospital to determine if a modified position or a new position would be available to the injured worker. This approach assists the hospital in meeting requirements of Washington Discrimination law and Americans with Disability Act (ADA) which became effective June 1992. If the hospital cannot reasonably accommodate any restrictions on the worker, the reasons are documented and transferable skills are assessed as well as short-term training or on-the-job training for new positions at either the hospital or a new employer.

Pain Clinic Referrals
Pain Clinic Referrals are made when claim resolution does not appear inevitable using the usual medical management techniques, or there are many complex issues and conditions affecting the resolution of the claims. Pain clinics can be quite costly so we tend to use them sparingly. However, our referrals usually go for the initial evaluation no later than one-two years after the injury. We have had some referrals as soon as six months post injury. We either attend weekly staffings if the clinic is local or have weekly telephone conferences with the doctor(s) if the clinic is out of town. Representatives involved in these meetings for Washington Hospital Services will include vocational counselors and/or nurse consultants. Results of the pain clinic evaluations and progress reports are sent to attending doctors. Our focus is to have the injured worker job-ready when the pain clinic sessions are completed. We work with the hospitals to have a position available or another job at a new employer identified.

Claims Management Procedure

Overview [.pdf]