Administrative Services

Monica Racanelli

I. SUPPORTIVE SERVICES

The treatment and care of patients do not cease at the time they are discharged from the hospital. The support a patient receives postoperatively is critical to their ultimate outcome. Making arrangements for such supportive services is an important component of patient care. There are many home nursing care agencies in the United States. They provide a wealth of services to orthopaedic patients, including skilled nursing care, rehabilitation, personal care, and social work.

Skilled Nursing Care

Injections: A skilled nursing staff can help with administration of injectable anticoagulants and offer training for patients and their caregivers.
Wound Care: A wound care clinical nurse specialist can be arranged to provide in-home wound care for patients with slow-healing surgical wounds. For patients that are discharged from the hospital with negative pressure wound therapy systems (VAC), the wound care nurse specialist will provide appropriate VAC dressing changes and will often work in close collaboration with the provider. The VNS nurse may take digital photographs of the wound and securely e-mail them to the health care provider.
Administering Medications: This service is especially useful for patients that require postoperative antibiotics via PICC line.
Obtaining Labs: Patients receiving antibiotics often require frequent labs to monitor drug levels and inflammatory markers. These labs can be drawn at home and the results can be sent to the provider.
Monitoring Vital Signs: Clinical measurements are taken to monitor temperature, blood pressure, pulse, and respiration rate.

In-Home Rehabilitation

Physical Therapy: Physical therapists help restore strength, flexibility, coordination, and general function, all while patients remain at home in safe, comfortable, and familiar surroundings. The therapists follow a plan of care established by the physician and provide updates of changes in the patient’s condition. These services are especially important for patients with joint replacements and those with fractures that have various comorbidities that make it difficult to get to an outpatient therapy location. Several studies have found that patients who followed acute hospital care with home care achieved clinical outcomes and quality of life scores that were similar or better than those who went to inpatient rehab facilities.¹,²
Occupational Therapy: Occupational therapists work with the patient to identify and eliminate environmental barriers and enhance participation in activities of daily living. They focus on enhancing fine motor skills, modifying tasks, and adapting the environment. They develop a specialized plan to meet the individual patient’s need and work closely with the physical therapist and nursing staff.

Personal Care

Cooking
Bathing
Grooming
Laundry
Housekeeping
Shopping/Errands
Companionship
Escorting to and from doctor’s visits.

Social Work

Patient Care Coordination: The social worker helps coordinate the patient’s care with all members of the home health care team to ensure a safe and timely discharge of home care. Such coordinated care and in-home services improve patients’ overall compliance with the designed treatment plan.
Supportive Counseling for Patients: A skilled social worker can provide the patient with guidance to enhance coping skills, reduce stress, and improve overall outlook.
Caregiver Support: Social workers can provide the patient’s family members with resources to help prevent burnout, strengthen coping skills, and increase the family’s support systems.

II. THE FAMILY MEDICAL LEAVE ACT

The Family Medical Leave Act is a federal law that provides eligible employees up to 12 work weeks of unpaid, job-protected leave in a 12-month period. It requires employers to maintain group health benefits for the employee during this leave.³ The FMLA also grants special provisions for military families, which include 26 weeks of FMLA leave in a single 12-month period to care for service member with a serious injury or illness.⁴ The orthopaedic conditions that qualify for FMLA leave include:

Conditions that incapacitate the employee or a family member for more than three consecutive days. The patient may receive ongoing treatment during this time, including appointments with health care provider, physical therapy, pain management, etc.
Conditions that require an overnight stay in a hospital or medical facility. This includes multitrauma patients that require hospitalization, patients in rehabilitation institutions, and employees that require inpatient surgery.
Chronic conditions that cause occasional periods of incapacity and require treatment by health care provider at least twice a year. For example, this may include patients with degenerative joint disease that requires periodic cortisone injections or patients with delayed union of fracture that require periodic radiographic evaluation.

There are several eligible reasons for employees to seek FMLA protection. In the specialty of Orthopaedics, there are typically three common reasons your patients may ask you to complete an FMLA form:

The first and most common reason you will be asked to complete an FMLA form is when a patient needs to take a medical leave and is unable to work owing to his own FMLA-qualifying serious health condition. This leave can be taken as an incapacity for a single continuous period of time, or the patient may choose to work part-time or on a reduced schedule while attending follow-up treatment appointments. There are several occupations that accommodate their employees with light duty or allow a reduced work schedule. This is an important discussion to have with the patient prior to completing the FMLA form.
The second reason you may encounter the FMLA form in your practice is for an immediate family member of the patient you are treating. The FMLA allows eligible employees to take a leave of absence to care for a relative with a serious health condition. Under FMLA, the definition of a relative is generally limited to a spouse, daughter, son, parent, and under certain circumstances, a sibling. A parent “in-law” is not a qualifying relative.
The third reason you may be asked to complete an FMLA form is for intermittent leave, which allows the patient to take a medical leave in separate blocks of time for a single qualifying
medical condition. This is often completed for patients with chronic, ongoing medical conditions. For example, a patient with degenerative joint disease of the knee may have episodic flare-up preventing him or her from performing their job functions. The patient may need to take a day or two off from work to rest, ice, and elevate their lower extremity. In this case, an FMLA form would be completed specifically for intermittent leave and it would provide FMLA protection for 12 months period.

III. WORKER’S COMPENSATION AND NO FAULT INSURANCE

Worker’s Compensation is an insurance that provides cash benefits and medical care for workers who are injured as a direct result of their job. Employers pay for this insurance. The employer’s insurance carrier will pay weekly cash benefits and provide medical care for the injured worker. In a Worker’s Compensation case, no one party is designated to be at fault. A claim is paid to the injured worker if the employer or insurance carrier agrees that the injury is work related. If the employer or insurance carrier dispute the claim, a Worker’s Compensation Board judge will decide who is right. The Worker’s Compensation Board is a state agency that processes the claims and will determine whether the insurer will reimburse for cash benefits and medical care and the amounts payable.

Documentation

Proper documentation in the office note is essential when dealing with patients with worker’s compensation insurance. Although the office visit forms and billing process may vary by state, there are generally four questions that need to be addressed by the provider in patient’s office note at every visit:

Was the incident that the patient described the competent medical cause of the injury?
Are the patient’s complaints and objective findings consistent with his/her history of injury?
Has the patient reached maximal medical improvement (MMI)?
What is the current level of disability/impairment?

Although the terminology may vary by state, in general, there are four categories of disability:

Temporary partial disability (Example: The patient is working reduced hours or light duty while recovering from injury.)
Temporary total disability (Example: The patient is unable to return to work for a temporary time period owing to work-related injury.)
Permanent partial disability (Example: The patient has a permanent impairment, but is able to return to work in some capacity.)
Permanent total disability (Example: The patient has a severe permanent impairment and will not be able to return to work in any capacity.)

Tip: These questions can be easily addressed by creating a WC template in your electronic medical record. The template can be inserted in the office note for patients with worker’s compensation insurance. Here is a sample template:

“The work-related incident the patient described is the competent medical cause of this injury. Patient’s complaints are consistent with the history of the injury. Patient’s history of injury is consistent with the objective findings. There was no pre-existing condition. He/she has not yet reached maximal medical improvement. His/her current disability status is ____.”

Prior Authorizations

Every state has different laws regarding Worker’s Compensation prior authorizations. Several states require the physician to obtain prior authorization for surgical procedures, physical therapy, and specialist consultations. The requirements and process of prior authorization may vary from state to state. For instance, in
New York State, as of July 11, 2007, special diagnostic tests such as MRIs and CT scans that cost more than $1,000 require prior authorization. Prior authorization is not required for studies that cost less than $1,000.⁵ If prior authorization is required in your state, be sure to request the service on the correct form. For example, in New York State, diagnostic services are requested on a C-4 Auth Form, whereas treatment such as hyperbaric oxygen therapy or acupuncture must be requested on MG-2 form. The health care provider’s familiarize themselves with the worker’s compensation process and commonly required forms in their state. Once the request is submitted, the insurance carrier typically has 30 days to respond to a request. During this period, the carrier may obtain an IME or records review. In order to deny a preauthorization request, the carrier must show a conflicting medical opinion.

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