ODG ANNOUNCES GUIDELINE
EXCEPTION PROTOCOL
March
10, 2010 – Encinitas, CA – Work Loss Data Institute
(WLDI), in collaboration with the Texas Department of Insurance, Division
of Workers’ Compensation, announces the release of Appendix D to Official
Disability Guidelines Treatment in Workers’ Comp (ODG) entitled
“Documenting Exceptions to the Guidelines.” The purpose of this
section is to outline a process for providers and insurance carriers
within states and provinces that have adopted ODG for healthcare provided
under workers’ compensation to ensure appropriate medical treatment for
injured workers in the rare instances where a procedure is not covered or
necessary care falls outside of the recommendations in ODG.
Though ODG
covers over 99% of cases seen in workers’ comp, there are still times
when uncommon situations can occur which are not addressed in the standard
guidelines. For example: certain treatments, though not typically
recommended, may be warranted due to extenuating circumstances; patient
comorbidities may dictate a need for treatment outside the guidelines; or
additional treatment or therapy beyond the recommendations may be in
order.
According to
Phil LeFevre, Senior Account Executive at WLDI who works with many states
and provinces that have adopted ODG, “Medical treatment guidelines, done
right, are a delicate balance. Guidelines that are too restrictive may
control costs in the short term, but limit necessary medical care to
injured workers, who suffer unnecessarily, while outcomes fail to improve.
Non-productive UR costs skyrocket when denials and friction clog the
system, as good providers stop taking workers’ comp patients because
they can’t get necessary medical care approved. Guidelines that are not
restrictive enough, on the other hand, have little net effect. While ODG
is unique in striving for and generally achieving this balance based on a
thorough and ongoing review of the medical evidence, we still think it is
important to allow for the possibility of exceptions.
This new instructional answers when and how those exceptions should
be handled together with explicit case study examples, providing the
framework to ensure timely and appropriate medical care even for the
unconventional injured worker.”
The process
for documenting exceptions to the guidelines is supported by medical
research. According to a study published in the February 2010 edition of Annals
of Internal Medicine,
funded by the Agency for Healthcare Research and Quality, exceptions to
the guidelines that are documented by physicians during their regular
workflow and reviewed by peers are appropriate most of the time. In
total, 94% of exceptions to the treatment guidelines were determined to be
medically appropriate, only 3% were inappropriate, and 3% were of
indeterminate appropriateness. When physicians report exceptions to
standard practices, it affirms their ability to make decisions and helps
them aim for high performance levels while avoiding treatment delays, the
study authors noted.
For
ODG subscribers, Appendix D, “Documenting Exceptions to the
Guidelines,” may be accessed from the ODG Treatment Index as well as
from other prominent locations on the Website. It can also be accessed
directly from this link: http://www.odg-twc.com/odgtwclist.htm#AppendixD
For
persons who do not subscribe to ODG, “Documenting Exceptions to the
Guidelines” is available upon request by contacting WLDI, publisher of
the ODG product line with contact information on www.worklossdata.com.
WLDI is an independent database development company focused on workplace
health and productivity, based in Encinitas, CA.
