Changing horses in the middle of the stream


I’m suggesting to you that changing horses in the middle of the stream can actually be a good thing. Particularly if you can trade for a less expensive horse! Our complex claims review claimant suffered a back injury resulting in a lumbar laminectomy in 2003.  Complications from that surgery resulted in a bladder/urinary disorder that required aggressive treatment, not the least of which was a bladder stimulator implanted in 2007, removed in 2008, re-implanted in 2009 and removed yet again in 2010.


All of this was related to the workers’ compensation surgery and was rightly paid by the comp carrier. But once a work—related injury affects a certain part of the body, it seems that the medical system thinks every other issue related to that body part is the responsibility of comp as well. For example, if you’ve had back surgery, we tend to believe everything that ever happens to your back from this point forward will be the result of your injury.


Often, that’s not the case.  In this case the claimant developed other urinary system issues. He developed a number of kidney issues as well as prostate problems. All were billed to and paid by the comp carrier. Upon investigation, however, OMCA physicians suspected that a substantial amount of the treatment was due to issues that were non-occupational.


ln a peer to peer conference between the treating physician and OMCA’s urinary specialist, the treating physician quickly acknowledged the non-occupational nature of much of the treatment and offered to begin submitting that care to the group medical carrier. This will save about $10,000 per year on a 52-year old claimant. A 7-year old case with very extensive medical expense can still be improved upon. Just because our claimant suffered an injury, it does not follow that we are responsible for Al; care for _A_l._I= time.


No litigation, no subrogation, no medical fee disputes; these can be the advantages of effective peer-to—peer intervention.


Let us know if you’re interested in changing horses…wherever you are in the stream.

Call us for help with your ugly cases.

We can do better.


William V. Faris, JD

Chief Executive Officer

Posted in Group Benefits Programs, Medical Cost Containment, Workers’ Compensation