A Holistic Approach to Workers' Compensation Medical Reviews

In the workers’ compensation realm, insurance carriers play a pivotal role in ensuring that injured employees receive the care they need while managing costs effectively. One crucial aspect of this responsibility is peer review medical necessity analysis, which involves evaluating the necessity of medical treatments and procedures. At Medical ReviewStream™ by Concentra®, we are transforming the landscape of workers’ compensation by taking a holistic approach to peer review medical necessity analysis. Our unique approach goes beyond the conventional methods by considering the co-occurrence of chronic pain and anxiety/depression in injured employees. This comprehensive methodology not only enhances the quality of care; it also optimizes cost management for insurance carriers by confirming the recommended care is:

• Medically necessary
• Related to the injury that occurred at the workplace or in a work-related capacity
• Provided in a timely manner

The challenge: chronic pain and mental health in workers’ compensation

Workers’ compensation cases often involve individuals who have suffered work-related injuries that result in chronic pain. Chronic pain — one of the most common reasons adults seek medical care — has been linked to restrictions in mobility and daily activities, dependence on opioids, and poor perceived health or reduced quality of life.¹ Population-based estimates of chronic pain among adults range from 11 percent to 40 percent.² Simultaneously, the emotional and psychological toll of these injuries can lead to anxiety and depression.³

These co-occurring conditions pose a significant challenge in the management of workers’ compensation claims. Traditional, peer review systems typically evaluate the necessity of medical procedures in isolation, ignoring the potential interplay between physical and mental health.

Because chronic pain can be the source of mental and emotional trauma, the impact it can have on an injured employee’s injury recovery must be factored into the workers’ compensation claims equation. Underplaying its significance could yield undesired injury outcomes and thwart the workers’ compensation claims management process.

Our solution: a holistic approach

Medical ReviewStream by Concentra recognizes the intricate connection between physical and mental well-being. Our holistic approach to peer review medical necessity analysis acknowledges that chronic pain and mental health conditions are often intertwined. By considering both the physical and emotional aspects of an employee’s well-being, we empower insurance carriers to make more informed and compassionate decisions regarding treatment plans and claims management.

Benefits of our approach

1. Enhanced Patient Outcomes: By considering the co-occurrence of chronic pain and anxiety/ depression, we enable a more thorough evaluation of the medical necessity of treatments. This approach ensures that injured employees receive the appropriate care, improving their overall well-being.
2. Cost Efficiency: An accurate assessment of medical necessity leads to the avoidance of unnecessary procedures and treatments, reducing claims costs for insurance carriers. Our approach helps carriers strike a balance between quality care and financial prudence.
3. Reduced Litigation: Workers’ compensation claims often lead to disputes and litigation. Our holistic approach mitigates the risk of legal conflicts by ensuring that medical decisions are evidence-based, transparent, and focused on the best interests of the injured employee.
4. Increased Stakeholder Satisfaction: By taking a compassionate and comprehensive approach to peer review, insurance carriers demonstrate their commitment to the well-being of injured employees. This approach fosters positive relationships with employees, health care providers, and stakeholders.

See the full picture during a workers’ compensation medical review

Medical ReviewStream by Concentra is leading the way in redefining the peer review medical necessity analysis process in workers’ compensation. By considering the co-occurrence of chronic pain and anxiety/depression, our holistic approach recognizes all aspects of an injured employee’s well-being during the medical review process. Our comprehensive approach helps to ensure injured employees receive the care they need while helping insurance carriers manage costs effectively. As the industry continues to evolve, it’s clear that a more comprehensive, patient-centric approach is essential. If you want to revolutionize your company’s approach to workers’ compensation claims management, make a meaningful difference in the lives of injured employees, and improve your company’s bottom line, partner with Medical ReviewStream by Concentra. Together, we can build a brighter future for all stakeholders during the workers’ compensation process.

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References:

1. Rikard, S. M., Strahan, A.E., Schmit, K.M., and Guy, G.P. Chronic Pain Among Adults - United States, 2019–2021. Morbidity and Mortality Weekly Report. April 14, 2023. 72(15), 379-385. https://doi.org/10.15585/mmwr.mm7215a1.
2. Dahlhamer, J., Lucas, J., Zelaya, C., Nahin, R., Mackey, S., DeBar, et al. Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults - United States, 2016. Morbidity and Mortality Weekly Report. September 14, 2018. 67(36), 1001–1006. https://doi.org/10.15585/mmwr.mm6736a2.
3. Raja, S. N., Carr, D. B., Cohen, M., Finnerup, N. B., Flor, H., Gibson, et al. The Revised International Association for the Study of Pain Definition of Pain: Concepts, Challenges, and Compromises. Pain. September 1, 2020. 161(9), 1976–1982. https://doi.org/10.1097/j.pain.0000000000001939.