Here are the trends I’m currently observing:

Unemployment is skyrocketing: US unemployment claims soared to last week—far above the expected 5 million. We have had weeks in a row of unemployment claims and have lost about 10% of the workforce in that time. The graph below, which reflects only the first week of the three (the next two were both significantly higher) shows the scale of this crisis. Less workers means less premium for carriers, less taxes for the government, and less volume for providers of workers’ compensation services. James Bullard, the president and CEO of the Federal Reserve Bank of St. Louis, has ,which is higher than the ever hit at 25% unemployment. Bullard’s prediction would mean a 30% drop in new claims for workers’ compensation in general, as already evidenced by many noteworthy companies Ěý±đłľ±č±ô´Ç˛â±đ±đ˛ő.

Accidents are decreasing: Given the daily news, one might think the overall national death rate is soaring. However, it appears any increases in deaths from COVID-19 are being more than offset by reductions in fatalities from car and workplace accidents, for instance. For weeks 9 through 11 for the four prior years (2016 – 2019), the nation averaged 170,555 deaths. For weeks 9 through 11 this year, the total was 153,015—meaning 17,540 fewer people died in America during the first three weeks of March 2020 than could be reasonably expected. The final will take some time to come out, but the current trends make sense. Fewer people are driving and physically at work, thereby reducing situations where injuries can occur. Some automobile insurance carriers have to their policyholders because risks and injuries are so far down. California and other states are starting to . Moreover, driving injuries may be reduced permanently as more people and companies adapt to work from home arrangements effectively.

Medical treatment is declining: People cannot or will not get live medical treatment due to social distancing or fear. Elective surgeries are being put on hold nationwide. This can be seen in the financials of hospitals. With the COVID-19 outbreak, one may assume that hospital systems would be overwhelmed but making money. Instead, they are , laying off workers, and experiencing . There are even articles such as “?” I spoke to a neighbor who sells surgical implants and is often in operating rooms with doctors. His company is currently conducting rolling furloughs. He said all the hospitals are bleeding money.

Layoffs Usually Drive More Workers’ Compensation Claims: People who fear being laid off or fired sometimes file false (or minor) workers’ compensation claims. This could lead toward a short-term spike in new claims.

COVID-19 Covered: For positions that are required to treat patients, including hospital staff and first responders, it is likely COVID-19 will be covered under workers’ compensation policies.

Supply Chain Returning to the US: Due to the difficulties many companies have had (and will continue to have) with various supplies chains, I expect many companies will be hesitant to keep all production and suppliers off-shore in the future, especially if China is involved. While it does not change much in the short-term, we could see a long-term increase in US manufacturing and on-shore workers’ compensation services.

Shift to In-Home Medical Services: Medical care at home will become more accepted and needed.  911łÔąĎ has increased our level of telemedicine and telephonic case management (TCM) to ensure patients continue receiving care during these times. We have also increased in-home services like mail order prescription fulfillment and mail order medical supplies,durable medical equipment (DME), and home health modifications to get patients the care they need outside of hospital settings.

Like every industry, the workers’ compensation and auto markets will retract dramatically in size for as long as our nation is shut down and for some time afterwards. Finding safe and healthy ways to return to normal life is the challenge before us.

Stay safe, stay strong.

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Admittedly, the law only recently went into effect. But given that SB 1160 passed in October 2016, organizations have had nearly two years to prepare. So why are so many still not compliant?

My answer is twofold: effort and expense. 911łÔąĎ first navigated the complex path to URAC accreditation in 2008 and has undergone three reaccreditations since. We know firsthand how time consuming, resource intensive, and financially demanding the process is for an organization. It is an enterprise-wide commitment. In addition to daily processes the UR team must document and follow, our Technology, Compliance, Talent Management, and Marketing departments must also enact and adhere to detailed protocols. The cross-departmental efforts and sophisticated infrastructure needed to establish and maintain URAC accreditation, coupled with the financial investment necessary to meet the accreditation’s requirements, is likely why so few California providers have pursued it.

What remains to be seen is how long these non-accredited providers can hold out. According to the WorkCompCentral article, the California Division of Workers’ Compensation is drafting new regulations which may include penalties to ensure organizations comply with the law. But no amount of penalties can expedite the URAC accreditation process, which takes 10 to 12 months with no guarantee of success.

I urge companies currently processing California work comp claims to verify their UR vendor’s accreditation status. For those who discover their vendor is among the non-compliant 40 percent, now is the time to consider an alternate solution. With the lengthy accreditation timeframe and the likelihood of increasing provider disputes over the validity of UR determinations by non-accredited UR organizations, it’s wise to be proactive.

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Many providers contend the shift is the result of sicker patients coupled with the widespread implementation of electronic medical records, as treatment and documentation of more complex cases requires greater time and effort. But the persistent increase in costlier codes has made pursuing potential billing abuse a Justice Department priority.

One area of focus for federal investigators has been upcoding, the practice of deliberately billing for more extensive and costly services than were actually performed.

In February 2017, nationwide hospital staffing provider TeamHealth Holdings agreed to plus interest to settle allegations that its hospitalist group practice, IPC Healthcare, submitted upcoded bills to Medicare, Medicaid, the Defense Health Agency, and the Federal Employee Health Benefits Program.

In June 2017, Carolinas Healthcare System agreed to to resolve allegations that it billed federal health care programs for “high complexity” urine drug tests when the tests conducted were only of “moderate complexity.” According to court documents, this upcoding persisted for four years and cost the government an extra $80 per test.

In October 2017, multi-location New York Spine & Wellness Center agreed to to resolve improper billing claims after a federal inquiry determined the practice routinely billed for moderate sedation services – which require physicians spend at least 16 minutes with patients – despite its doctors not meeting the minimum time criteria.

But upcoding is not exclusive to tax-payer funded health care. In the case of New York Spine & Wellness Center, for example, a private insurer first detected the Center’s sedation upcoding in January 2015, initially rejecting two claims that fell short of the 16-minute rule. A subsequent audit by the same insurer resulted in more rejections, but the Center continued its upcoding abuse for two more years until the U.S. Attorney’s Office intervened, seeking to recover overpayments by the state’s Medicaid program. Indeed, of the $1.9 million settlement, more than $660,000 will be returned to the New York Medicaid coffers.

Outcomes such as these are terrific news for taxpayers, but such retrospective vigilance by the Feds has little to no impact on private insurers, employee organizations, and individual payers.

While the government concentrates on recouping federal dollars post-payment, medical cost containment firms must protect private payer clients from overpaying upfront. For example, 911łÔąĎ uses tools such as in-depth bill review by certified coders and nurse auditors and pre-negotiated, bundled rates to wean out upcoding and other billing abuses on a transactional level. Such proactive approaches are a key core competency of medical cost management, and continue to be as important today as they have been historically.

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To help combat this crisis, organizations such as the Official Disability Institute (ODG) and The American College of Occupational and Environmental Medicine (ACOEM) have released guidelines for prescribers in the appropriate use of opioids for treating pain specific to workplace injuries.

In a published in a recent edition of the Journal of Occupational and Environmental Medicine, researchers at the ReedGroup and Kaiser Permanente retroactively applied ACOEM’s April 2017 guidelines to 7,840 patients who underwent carpal tunnel release (CTR) surgery from 2007 to 2014. Of the 70 percent of cases prescribed an opioid, 29 percent were contrary to the guidelines, which recommend no more than a five-day supply of short-acting opioids for acute postoperative pain for new users. Patients given greater dosages averaged disability durations 1.9 days longer and medical costs $422 higher than their ACOEM-compliant counterparts.

While these cases were not exclusively workers’ compensation related, given the volume of injured workers who require CTR surgery annually, it’s easy to see how following the guidelines could substantially benefit payers and patients. The study estimates if 29 percent of the 577,000 CTR procedures performed annually were prescribed an opioid according to ACOEM’s guidelines, the potential medical cost savings is $71 million per year with a reduction in disability durations by 124,000 days. Incredible.

Clinicians at the Center for Surgery and Public Health at Brigham and Women’s Hospital took guideline research a step further by analyzing more than 200,000 postoperative opioid prescribing patterns to define the ideal prescription length by procedure type. Their , published by JAMA Surgery, determined the optimal length of opiate prescription was four to nine days for general surgery procedures, four to 13 days for women’s health procedures, and six to 15 days for musculoskeletal procedures.

While it’s too soon to know the time and monetary impact these guidelines could yield if implemented, it’s heartening to see that the risk of prescription opioid misuse is being considered when looking to alleviate temporary acute pain. We must all be mindful of what is in the patient’s long-term best interests and limiting opioid prescription duration is a critical step in that process.

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At Kaiser Permanente, virtual patient encounters now outnumber in-person visits. , his health system saw more than 110 million people last year, with some 59 million connecting through online portals, virtual visits or the health system’s apps. That figure represents more than half of the organization’s total 2016 visits.

“We are going through a major transformation in healthcare,” said Tyson.

At (NYP), their suite of telemedicine services includes adult and pediatric emergency and urgent care, virtual follow-up visits for surgical and psychiatric patients, and a second opinion program.  Such telehealth adoption has yielded dramatic results. In the ER, for example, low-acuity patients are now seen virtually by an ER physician elsewhere in the health system, reducing average wait times from 2.5 hours to 31 minutes.

Moving forward, NYP aims to make 20 percent of all patient visits virtual, a goal that seems readily attainable given its volume of virtual visits has increased 100 percent every month since it began piloting telehealth services in 2015.

Although telemedicine has yet to significantly impact workers’ compensation or auto, its day is coming. Workplace health clinics, such as the kind operated by , are now augmenting onsite occupational care with telemedicine services. Consider the case of a California factory worker with a blistery hand rash who had her condition treated via a teledermatology visit at her employer-sponsored clinic. It’s only a matter of time before onsite injury assessments, follow-up status calls, and prescription management are conducted virtually, with great cost, comfort and convenience benefits for all parties involved.

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International Classification of Diseases (ICD) was created by the World Health Organization (WHO), which has served the healthcare community for over a century. While most industrialized countries moved to the ICD’s “tenth revision” – ICD-10 – ago (1983), the United States only transitioned in October 2015.

There are differences, however, between what WHO publishes and what the US actually utilizes.

WHO’s ICD-10 classification system is for diagnosis codes only, and does not contain any procedural codes.

ICD-10-CM (Clinical Modification) is a US clinical modification of WHO’s ICD-10, developed to support US health information needs. ICD-10-CM is designed for classifying and reporting diseases in all US healthcare settings. WHO gave the US permission for these modifications.  I have not been able to find out or what specifically was modified, but the technology systems of US healthcare organizations that operate internationally – either now or in the future – will need to accommodate for both the US ICD-10-CM codes and the WHO’s standard ICD-10 codes.

ICD-10-PCS (Procedure Classification System) was developed by the Centers for Medicare & Medicaid Services (CMS) and is not based on WHO’s coding system. ICD-10-PCS replaced the ICD-9-PCS and are only required for facilities reporting procedures on hospital inpatient services.

When speaking of these new classifications in the US, the term “ICD-10” is often used for both code sets (ICD-10-CM and ICD-10-PCS), but it is important to understand that they serve very different purposes.

…On the forefront, WHO has already released a BETA version of ICD-11.

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There is a picture now circulating of a fee charged to a mother for holding her child after birth. “Skin to Skin after C-Section” is what the hospital called it, and apparently it cost them $39.35 to provide.

The article’s author states that the mother holding her baby after a C-Section requires a second labor and delivery nurse to come into the room to ensure the baby’s safety. This could be a hospital regulation or a federal regulation, but it makes no sense to me personally. If there is already a nurse present who no longer has to hold the child, I cannot see how (other than mindless bureaucracy) it would require adding another nurse to the room.

Regardless, for thousands of years, mothers have figured out a way to hold their children after birth – for free. Now, it’s a service that requires two medical professionals and a bill charge.

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It is disheartening to see the purposeful overutilization and advantage taken of the elderly, poor, and mentally disabled in the story. I was especially saddened to read that patients were purposely addicted to drugs so they could continue the billing cycle scam.

“Defendant [Esformes] and his co-conspirators preyed upon his beneficiaries addictions by providing them with narcotics so that the beneficiaries would remain in Esformes Network facilities, allowing the cycle of fraud [to] continue,” prosecutors said in a court filing.

This is a hard reminder that there are unfortunately a number of “bad players” in healthcare and our industry needs to stay vigilant to prevent the fraud and abuse that can arise out of the system.

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Large group health insurers are attempting to merge in order to increase efficiency and gain more leverage in negotiations with providers. This time, in an ironic turn of events, it is the .

I am an advocate for more choice in the marketplace, and merging the few remaining large group insurance carriers is not beneficial for consumer choice or our healthcare costs in America.

While there are some positives to the Affordable Care Act – like advancing value-based care – many of its regulations are a baby step to universal healthcare, which favor a small number of very large insurance companies and the consolidation of provider/hospital systems. Let’s hope the and maintain some level of choice for us as consumers.

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The tragedy at Orlando’s Pulse nightclub was horrific, with 50 total deaths.  Everyone can understand and see the sheer scale of the largest shooting in US history.

Our nation has 8,000 times that many people die each year from medical mistakes – or 400,000 deaths annually. That’s equivalent to 22 of these shootings…every single day of the year. These deaths may not be making daily headlines, but they are happening – one person at a time, one treatment at a time, all across the United States.

A recent news story on the subject shows how easily it can happen. If you , the story of how this child died is at the end of the clip. She was given the wrong medicine, a compound medication, 20+ times stronger than what she needed. The pharmacist signed off, without making it or reviewing it. Her father found the IV bag in the trash, so it’s likely nobody would have told him had he not caught it. It’s also very telling that his settlement would have been significantly higher had he agreed to a confidentiality clause, but he thought it was important for the memory of his daughter to speak out. These cases are usually not spoken about publicly.

I am a big proponent that less is usually more in healthcare. I am very proud of what we do at 911łÔąĎ. For patients involved in 911łÔąĎ’s medical care management, utilization review and surgical care programs, every unnecessary medical service we prevent could be the one that saves a life. Every surgery we keep out of a hospital can reduce the risk of error or infection and increase the odds of a successful recovery. There is no doubt that these precautions help reduce devastating health issues for our patients every day.

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