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By PETER ROUSMANIERE, an expert on the workers' compensation industry

Tracey Carragher filed her workers' compensation claim in August 2010. Four months later, she underwent surgery. She's better now. She thinks that her recovery should have been much swifter, however, with fewer twists and turns.

Her claim began with a fall on a sidewalk curb in New York City on Monday, August 2. Within a few days, back in her home state of Ohio, she searched for an appropriate doctor, finding one at the renowned Cleveland Clinic on August 4.

On September 29, a Clinic orthopedist said that he would request permission from her insurer, the Ohio Bureau of Workers Compensation, for an MRI. On December 15, she had surgery on her right shoulder.

Over these months, pain and restrictions in movement seriously affected her work and private lives.

Count below the missed opportunities and delays. Keep in mind that she is a claimant outlier who knows first-class service. She is CEO of Breckenridge Insurance Services, an insurance wholesale brokerage, and former CEO of the third-party administrator then known as Cambridge (since absorbed by XChanging).

When she tripped on the curbside, she was walking from a room of venture capitalists to her hotel.

Not her fault, but she did not go initially to an occupational medicine clinic. Rather, she went to an urgent-care clinic and then to her primary-care doctor, where she reported discomfort in her ankle and right shoulder. Arguably, though not certainly, she might have received a more thorough workup by an occupational medicine doctor and referral to an orthopedist sensitive to the value of tight timelines in treating work injuries.

Her orthopedist at the Cleveland Clinic appears to have considered a rotator cuff tear and urged conservative treatment with the hope that she would recover in a month. Conservative treatment is, in fact, best practice. In a case with multiple physical complaints, the one really serious problem may not become apparent for over a month.

When the insurer and its managed-care vendor, Careworks, first looked at Carragher's case, they saw no flags for assigning a case manager. She did not want to take time off. She had no co-morbidities. The initial diagnostic codes failed to specify a problem with her shoulder. In other words, this is a teachable case of a false negative in a screen for high-risk patients.

Physical therapy failed to resolve her shoulder pain. The Ohio Bureau of Workers Compensation learned about a rotator cuff problem on October 6.

From this milestone on, the bureau's claim notes and Carragher's notes record over two months what happened when getting the correct diagnosis into the claims system and ordering surgery. It took weeks for the insurer and Careworks to add the diagnosis and assign a case manager. Her doctor requested in late October an MRI, which Careworks approved in a week. The MRI on November 15 revealed a full rotator cuff tear. Surgery was performed a month later. This timeline is within the range of normal.

But could these two and a half months been compressed into a few weeks? Probably yes, if the bureau and Careworks had used a tighter network of preferred doctors for whom pre-approvals were waived and communication between provider and claims-payer were smoother, and if a nurse were put on the case promptly with the first indication of a rotator cuff tear.

Is this asking too much? Not if you ask Carragher. Her expectation for first-class treatment was such that she asked for the bureau to pay for someone to walk her dogs.

And not if you ask Tina Kielmeyer, chief of customer service for the Ohio Bureau of Workers Compensation. Kielmeyer has been working for some time on straightening the claims labyrinth. She says that Carragher's claim had to go through a complicated series of steps before the final, correct diagnosis was approved. The bureau has been working on the review and approval processes and introducing what in effect is a fast-track process. Kielmeyer confirms that better arrangements with preferred medical providers would help prevent errors and delays.

Read more at the WorkersComp Forum homepage.

March 23, 2011

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