No Consensus on Treatment
on the involvement
of risk managers
for injured workers.
By Susannah Levine
Treatment guidelines recommend surgical, therapeutic and pharmaceutical responses for many worker injuries.
Even as the nation’s 50 states inch towards consistency in medical treatment guidelines for workers’ compensation injuries, there is no consensus on the role of risk managers in enforcing them. Dr. Robert Goldberg, chief medical officer, Healthesystems, a national workers’ compensation benefits management provider, said
risk managers should delegate oversight of treatment guidelines and compliance to
those for whom it is a core competency.
“Why should risk managers know anything about treatment guidelines?” he
“Management of care is in the capable hands of physicians, nurse case
managers, insurers, TPAs (third-party administrators) and utilization review (UR)
Anne Kirby, chief compliance officer and vice president of care management,
Rising Medical Solutions, said it’s impractical for risk managers, with their myriad
tasks, to also take on micromanagement of thousands of pages of treatment
For example, ODG’s treatment guidelines — the most widely used — include
46 pages related to opiod usage.
“It’s too much for any single risk manager to know.” Instead, she advised risk
managers to “do due diligence on the UR company.”
Ettie Schoor, president, Prism Consultants, said, however, that risk managers
shouldn’t offload responsibility for enforcement onto their TPAs or carriers
because of the risk of errors, She noted that TPAs have a lot of turnover, carriers
are always hiring new adjusters, and both have very high caseloads.
2017 Power Broker® Dennis Tierney, a senior vice president in Marsh’s claim
practice, said that risk managers should “have some familiarity” with guidelines for
the body parts where their exposures are highest, as well as rely on the expertise of
their TPA, carrier and broker claims consultant partners.
“Should risk managers be aware of guidelines?” asked Mary O’Donoghue, chief
clinical and product officer, MedRisk. “Absolutely. Should they expect TPAs to
administer medical review appropriately? Absolutely.”
She advised risk managers to focus their attention on unusually long, complex
and expensive claims.
Many states and a few Canadian provinces have adopted, adapted or developed
medical, surgical, therapeutic and pharmaceutical treatment guidelines for a
number of workers’ compensation maladies.
The most common claims, according to The National Law Review, are strains
and sprains ( 30 percent), cuts or punctures ( 19 percent), contusions ( 12 percent),
inflammation ( 5 percent) and fractures ( 5 percent).
DO TREATMENT GUIDELINES WORK?
The cautious consensus is that, overall, treatment guidelines usually work.
“In states where care is managed and guided using excellent guidelines and
strong utilization, workplace injuries
may be handled at a higher level of care
with a higher expectation of recovery,”
And in states with limited or no
guidelines, “injuries may linger and lead
to longer disability, higher indemnity
payments and loss of return-to-work,”
ODG points to statistics proving the
effectiveness of guidelines.
States that adopted ODG guidelines,
its website claimed, reported medical
The extensiveness of treatment
guidelines make it “too much
for any single risk manager to
— Anne Kirby, chief compliance officer and vice
president of care management, Rising Medical
• Many states have adopted
treatment guidelines for workers’
• Guidelines may not be the best
route for complex cases.
• Risk managers should
understand guidelines related to
their most costly exposures.