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Claims Management

Using Evidence-Based Guidelines in the Treatment of Injured Workers

Evidence-based guidelines include nationally-recognized treatments and return-to-work practices used to evaluate the necessity and effectiveness of medical care. We identify the most frequently used guidelines and their potential impact on medical management and disability duration. ";}

October 10, 2022

Evidence-based guidelines help review injured worker treatment requests, comparing them against evidence-based standards. Treatment decisions are then guided by recommendations supported by the best available evidence. The most frequently used guidelines are regularly reviewed and updated based on claim data analytics.

“Medical providers, managed care organizations, insurance carriers and claims administrators can all use evidence-based guidelines to deliver the most appropriate, quality care to injured workers,” said Rita DeRuntz, Senior Medical Manager at Safety National. “They are essential in identifying crucial benchmarks, unnecessary and costly procedures and potentially, harmful medications where alternative treatments are offered.”

What Disability Guidelines are Most Frequently Applied?

While different evidence-based guideline tools are available, all rely on extensive data collection and analysis to benchmark disability, treatment and claim costs outcomes. Some of the most frequently used guidelines include:

  • Official Disability Guidelines (ODG) – ODG provide medical treatment, return-to-work and disability guidelines to optimize outcomes for injured workers. Their claims analytics tools can provide a better understanding of the impact a condition may have on the employee.
  • American College of Occupational and Environmental Medicine (ACOEM) – ACOEM guidelines can provide diagnoses, determine if an injury may be work-related and help manage medical care effectively.
  • State-specific guidelines – There is substantial variation in what treatment guidelines are applied across the country. Not all states require the utilization of evidence-based guidelines for workers’ compensation.

What Questions Can Help Ensure Appropriate Treatment?

Disability guideline tools can provide the expected recommended, reasonable treatments based on specific diagnosis codes. Claims examiners can use these to examine if a physician’s treatment request is reasonable based on the diagnosis, asking:

  • Is the diagnosis accurate?
  • Should additional diagnostics be performed?
  • Should another physician re-evaluate the injured worker?
  • Would a peer review be appropriate?
  • Would it be beneficial to involve a nurse case manager?

How Can Guidelines Assist in Return-to-Work Targets?

Disability guidelines can provide data-based targets for light-duty and full-duty return to work based on scientific evidence involving a worker’s diagnosis, job category and comorbidities. After securing a release to work from a treating physician, these guidelines can outline the appropriate modifications necessary for restricted duty.

Based on the targets provided, claims examiners can identify when restrictions are not progressing, involving the treating physician and re-evaluating the authorized time loss. These targets can also assist in determining if there are other factors contributing to an excessive disability, and help develop a strategic plan of action if a benchmark is exceeded. Return-to-work targets can help keep a claim on track, ensuring that progression does not stop once a modified duty release is obtained.