VIsIonsVolume 21, Number 4

January/February 2011

The Periodical of the

National Association

of Oc cupa t iona l

Health Professionals

“The good physiciantreats the disease.The great physiciantreats the patient whohas the disease.” —Sir William Osler,M.D., 1949-1919

By Karen O’Hara

Assume you are 57 yearsold, a little overweight

and have non-specific lowback pain you believe is exac-erbated by your job. Yourhobbies are bowling andwoodworking.

Scenario 1: You take a sick day and go

see your primary care doctor.He recommends a non-steroidal anti-inflammatorymedication and stretchingexercises and waits to see howyou do. You cut back on thehobbies, lose some weight andkeep working. Eventually youget better.

Scenario 2: You complain to your

supervisor about your backpain and file a workers’ com-pensation claim. An occupa-tional medicine physicianexamines you, recommends

work restrictions, an NSAID,exercise and physical therapy.You go through the course oftreatment while on temporaryalternative duty, enroll in aweight-loss program, take aleave from the bowling team,adjust your woodworking sta-tion and gradually return tofull function.

Scenario 3: Your back is “killing” you.

You despise your supervisor,are estranged from yourspouse and embroiled in a dis-agreement with your siblingsabout how to handle yourmother’s serious illness. Youare depressed because youcan’t enjoy your hobbies. Youfollow the same course oftreatment as in Scenario 2.Your pain does not diminish;instead you feel debilitated by it.

You undergo a series ofdiagnostic tests that rule out aspecific reason for your pain.Four months later you are onthe verge of transitioningfrom an acute state to achronic one, a state in whichyou are statistically morelikely to end up on narcoticmedications, hire an attorneyand be designated as perma-nently partially disabled –generating considerable monetary and societal costsalong the way.

The Question: Would the outcome be

different in the third scenarioif you were identified as “atrisk” during the diagnosticprocess and your treatmentplan addressed not just physical but functional andpsycho-social aspects of yoursituation?

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Experts Target Claimants at Risk of Chronic Disability

InsIde

2 NAOHP News

3 Member Mentions

10 Outcomes

12 TrendsettersSolutions to Common Coding, Billing Mistakes

13 Recommended Resourcess

14 Legal Advisory

16 RegulatoryAgenda

19 Calendar

20 Vendor Program

24 Job Bank

To: NAOHP MembersRe: Winter Quarter

Conference CallFrom: Stacey Hart, NAOHPMember Services Coordinator

The NAOHP Board held its winterquarter meeting via conferencecall Feb. 10, 2011. Board

Members Karen Bergen and LeonardBevill were unable to attend. ExecutiveDirector Frank Leone and staff membersKaren O’Hara and Stacey Hart werealso in attendance.

Opening CommentsMr. Leone welcomed new members

Dr. John Braddock and Troy Overholtto the board. Board President JewelsMerckling thanked all the board mem-bers for their participation on the call.

Nashville Seminar and2011 National ConferenceNashville: Ms. O’Hara reported top-

ics for RYAN Associates’ April 14-15Profiting from Product Line Diversity sem-inar are onsite services and blendingurgent care and occupational healthservices. Board members were encour-aged to attend.National: Ms. O’Hara reported that

two focus groups were held with pastconference attendees and board mem-bers to get feedback and suggestions onformat, curriculum and networkingopportunities at RYAN Associates’ 25thannual national conference, Oct. 17-19,in Atlanta. She said the program isbeing designed by a curriculum committee and the agenda will be finalized soon.

Member Recruitment Board member Mike Schmidt and Ms.

Hart reported NAOHP membershiprenewals have been sent via hard copyand email over the last few months andrenewals are coming in at a steady rate.Members who have not yet renewedwill be contacted by NAOHP staff andboard members.

Vendor ProgramMs. McGuire suggested it would be

helpful to reach out to the AmericanAssociation of Professional Coders toencourage NAOHP vendor member-ship. Last year each board member waschallenged to bring in a new vendormember; it was decided to re-issue thechallenge this year.

Staff and ClinicianRelationships

Ms. Merckling inquired about plansto offer a Medical Review Officer(MRO) training course in conjunctionwith the American College ofOccupational and EnvironmentalMedicine at RYAN Associates’ nationalconference again this year. Staff wasdirected to follow up with ACOEM.

Ms. Merckling suggested more exten-sive use of social networking to increasevisibility for RYAN Associates’Professional Placement Service.

Member ServicesMs. O’Hara reported the NAOHP is

preparing to publish 2010 nationaloccupational health program surveyresults in comparison to prior years.

BenchmarkingBoard member Tom Brink advised the

board that he and Ms. O’Hara havescheduled a conference call with PressGaney to explore the possibility ofdeveloping a patient satisfaction surveyinstrument specifically designed foroccupational health programs. On aparallel track, Ms. O’Hara reported sheis working with two NAOHP members,Dr. Richard Covert, who has developeddashboard metrics, and Kim Gladstoneof the BJC Health System in St. Louis,to further refine and pilot test metricsbefore they are more broadly introducedto members.

Information ManagementMs. Merckling noted that historically

there is a lack of communicationbetween payers and providers in the

occupational health industry. Sheexpressed an interest in pursuing stan-dardization and automation in this area.

PublicationsMs. O’Hara reported that the Clinical

Care Update, Occupational HealthStrategies and the monthly Sales andMarketing Advisor have been replaced bya new publication, Product LineIntegration Quarterly, as well as private,quarterly telephonic sales and marketingconsultation conducted by Mr. Leone aspart of a New Millennium Package ofpublications/services.

Ms. O’Hara announced she haslaunched an industry blog and encour-aged board members to become follow-ers by visiting: http://onthebeam-occhealthinsights.blogspot.com

ScheduleThe next telephonic NAOHP board

meeting will be held May 2011.

2

Executive EditorFrank H. Leone

Editor in ChiefKaren O’Hara

Graphic DesignErin Strother • Studio E Design

PrintingOjai Printing

VISIONS is published bi-monthly by the National Association of

Occupational Health Professionals,226 East Canon Perdido, Suite M

Santa Barbara, CA 93101(800) 666-7926 • Fax: (805) 512-9534

Email: info@naohp.com • www.naohp.com

NAOHP and RYAN Associates are divisions of Santa Barbara Health Care, Inc. © pending VISIONS may not be copied in whole or in

part without written permission from NAOHP.

Volume 21, Number 4January/February 2011

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PureSafety Nashville, TN, has acquired Maine-based Occupational Health Research (OHR).

PureSafety provides comprehensive, web-basedsoftware for training, safety, health, and medical,case and claims management. OHR, an occupationalhealth management software company, serves morethan 800 hospitals and occupational health carefacilities nationwide. Its SYSTOC® software plat-form supports employee and occupational healthclinic operations.

Both companies are members of the NAOHPVendor Program.

“From its development nearly 30 years ago, OHRpioneered best-in-class tools for the employee healthmarket and has always been a market leader andrespected competitor,” said Bill Grana, presidentand chief executive officer of PureSafety.“PureSafety is driven by a similar vision to offer the industry’s most complete suite of solutions tomanage all facets of occupational safety and health.Adding SYSTOC to our existing software suite creates a total solution that is unmatched in theindustry.

“We are extremely excited to welcome OHR andits employees to PureSafety and look forward to providing their clients with the technology and services they trust, but with the added benefit of alarger, more broad-reaching enterprise to supporttheir success.”Dr. Bill Newkirk, founder of OHR, will serve as

PureSafety’s medical director.“Building this company has been a labor of love

for me,” Dr. Newkirk said. “To see it reach this levelof success and join forces with PureSafety isthrilling. This acquisition will be a transformativeevent in the field of occupational medicine andemployee health.”

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SYSTOC® 7.30 ReleasedPureSafety and OHR announced an upgrade that

incorporates a PDF engine into SYSTOC, freeingusers from the need to purchase additional softwareto complete or sign forms. The forms now reportedlyopen and save more quickly.

A new version of tap2chart® for SYSTOC 7.30moves rapidly between sections and has more picklists and design tables. A new outline button allowsusers to review and edit the medical record line by line. The data library automatically opens to thecorrect folder for the section the user is writing,developers said.

In Memory of Sue ClarkSue Clark, 51, founder and president of Alpha

Pro Solutions, Inc., St. Petersburg, FL, a memberof the NAOHP Vendor Program, died Feb. 11 ofcancer. Sue was an exceptional resource on drugand alcohol testing. Through a sister company,Alpha Protection Solutions, she promoted handsanitation rules and devices for health care profes-

sionals. More importantly,Sue was a great friend andmentor. The companyannounced it will continueto carry out her vision oftraining excellence. To viewher obituary and sharedmemories, visit www.memo-rialparkfuneralhome.com.

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Sam’s Club Aligns with U.S. Preventive Medicine

Sam’s Club has agreed to give its Business, Advantage and Plusmembers across the country free monthly in-club health screenings andaccess to a new health management benefit, The Prevention Plan fromU.S. Preventive Medicine, a member of the NAOHP VendorProgram.

Sam’s Club is offering The Prevention Plan, a personalized, step-by-step health management program designed to help people take controlof their individual health, for $99. The plan features access to anonline health assessment and at-home blood test, followed by a person-alized plan to address risks. Personal health coaching, a variety of sup-port tools and a plan-wide health challenge are provided to help keepmembers motivated to maintain a healthy lifestyle, officials said.

u u u

Physician Assistants’ Group Issues Call for MembersTom Powell, P.A., former assistant director, St. Joseph Occupational

Medicine Clinic, Bryan Texas, has joined with other physician assistants in a plea to save the Occupational Medicine Section of the American Academy of Physician Assistants by recruiting moremembers.

“As we prepare for AAPA’s 39th Annual Conference (June) in Las Vegas, the oldest specialty constituent chapter is facing some hard choices,” he said. “AAPA-OM is suffering from dwindling membership, which not only impacts our finances but our ability to represent the many.”

For information, visit either www.aapaoccmed.org or http://campaign.r20.constantcontact.com.

The Answer: “Very likely, yes,” according to

experts who spoke at a recent three-day conference, MusculoskeletalDisorders and Chronic Pain: Evidence-based approaches for clinical care, dis-ability prevention and claims manage-ment, sponsored by the CanadianInstitute for the Relief of Pain andDisability and the American Collegeof Occupational and EnvironmentalMedicine.

A key focus of the conference wasthe identification of high-qualityresearch evidence that, if imple-mented into policy and practice,would improve clinical outcomesand prevent disability for adults withmusculoskeletal disorders andchronic pain.

Who Is ‘At Risk?’A workers’ compensation patient

who is “at risk” may start out with“just a backache” and end up withchronic pain and disability, notbecause of their physical condition,but because of a collection of otherconfounding psychosocial factors(see related article on page 6),explains Gideon Letz, M.D., medicaldirector at U.S. Pain(www.uspain.com), a pain manage-ment company based in NewportBeach, CA, and independent med-ical consultant.

An occupational medicine physi-cian, Dr. Letz said “we have a lot tolearn” in order to adequately addressa key question: “How do we bringthe patient’s total bio-psychosocial

picture into the decisions we makeabout health care?”

Having recently finished nearly 24years as medical director at theCalifornia State CompensationInsurance Fund, the state’s largestworkers’ compensation insurer, Dr.Letz has observed that the problemis multi-dimensional in nature:• The vast majority of high-cost

claims are not severe injuries.They are strains and sprains and/or degenerative conditions of thespine and extremities.

• Patients develop disability andchronic pain when benign degen-erative conditions are labeledand treated as injuries.

• As the workforce ages, the num-ber of complaints of pain amongworkers with degenerative condi-tions increases.

• Practice patterns in the treatmentof back pain are not consistentwith scientific evidence. Dr. Letzcalls this “a medical disaster.”

• Evidence-based medical treat-ment is necessary but not suffi-cient for optimal outcomes.

“To prevent chronic pain and dis-ability, we need consistent applica-tion of methodology to identifyhigh-risk claimants, and we need toreward physicians for practicing evi-dence-based medicine in response tothose risks,” Dr. Letz said. “A lot ofwhat we call injury or disease isreally part of common, normaldegenerative processes. I want tofind a way to prevent over-medical-ization of these processes that getinappropriately treated.”

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Adverse ChildhoodExperiences Linkedto Poor Outcomes

Adverse Childhood Experiences(ACE) including abuse, neglect andexposure to traumatic stressorsincrease the likelihood of chronicdisability and prescription drugabuse in adulthood, a comprehen-sive government-sponsored studysuggests.Background: The Centers for

Disease Control and Preventionconducted an initial ACE study atKaiser Permanente from 1995 to1997 with more than 17,000 partic-ipants. Almost two-thirds of thestudy participants reported at leastone ACE, and more than one infive reported three or more ACE.Consequences include a multitudeof health and social problems. Theprospective phase of the ACE studyis now underway to assess relation-ships between adverse childhoodexperiences, health care use andcauses of death. Findings: As the number of ACE

increase, so does the risk for physi-cal and behavioral health problemssuch as alcoholism, drug abuse,depression and sexually-relatedincidences. A number of studieshave been published on the findings.Refer to:1. www.cdc.gov/ace/findings.htm2. Impact of Early Life Trauma on

Health and Disease: The HiddenEpidemic; R Lanius, E Vermetten, C Pain, eds.; Cambridge UniversityPress, 2010; in Chapter 8, VincentFelitti and Robert Anda writeabout ACE and the “relationshipof adverse childhood experiencesto adult medical disease, psychi-atric disorders and sexual behavior:implications for healthcare.”3. Adverse childhood experiences

and prescription drug use in acohort study of adult HMOpatients; R Anda et al.; BMC PublicHealth, June 4;8:198, 2008. ACEsubstantially increase the numberof prescriptions and classes ofdrugs used for as long as seven or eight decades after their occurrence.

VIsIons

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Bio-psychosocial ModelDr. Letz is among occupational medicine and pain management

experts who support the application of a bio-psychosocial treatmentmodel in at-risk cases and as an alternative to the use of interventionssuch as narcotic pain medications, injections and back surgery.Clinicians who spoke at the conference say a growing body of evi-dence suggests workers’ compensation patients who are identified earlyas “high risk” for chronic pain and disability, and who receive targetedmedical and behavioral interventions as a result, are more likely torecover function than those who do not.

Multi-disciplinary pain management programs based on the bio-psychosocial model involve collaboration among medical andbehavioral health professionals. The treatment team includes physi-cians, physical and occupational therapists, vocational experts andpsychologists. The goal is to reduce treatment costs, maximize function and improve quality of life for patients.

According to Steven Feinberg, M.D., a Palo Alto, CA-based physical medicine and rehabilitation and pain medicine specialist, the bio-psychosocial treatment model typically includes the followingcomponents:• assessment of an individual’s physical, functional and

psychosocial status;

• directed conditioning and exercise;

• cognitive behavioral therapy;

• patient and family education and counseling;

• functional goal setting; and

• ongoing assessment of participation, compliance and progress.

Ideally, “functional restoration means the patient takes personalresponsibility for his or her own physical and emotional well-beingpost illness or injury,” said Dr. Feinberg, who reports his patients areoften de-motivated, on high doses of narcotic pain medications andfeeling discouraged about their quality of life when they first present at his practice. He finds it is not unusual for these types of patients tohave medications costs ranging from $5,000 to $20,000 a month.

“My response to the skeptical patient is that while there are noguarantees, the functional restoration approach has improved qualityof life for many people with chronic pain, and with commitment,there is an excellent chance of success,” said Dr. Feinberg, whose topicat the conference was Recognition of Delayed Recovery and Cost-effectiveEarly Intervention Treating with a Functional Restoration Approach.

In some cases, limited or adjunctive use of pain medications may be recommended to support maximum functional improvement andminimize relapse, he added.

“The majority people I see do okay with lower doses, and they doeven better when they go off them entirely,” Dr. Feinberg said. “At the end of a functional restoration program, on average we see an 83 percent or greater reduction in opioid and benzodiazepine mediation costs and usage.”

A purely biomedical approach may result in unrealistic expectationson the part of the physician and the patient, he said. A bio-psychoso-cial approach allows practitioners to look at the whole person – theirpathophysiology, psychological state, childhood and life experiences,cultural background and belief system, relationships at work andhome, and how they view disability and health care, in general.

“It’s so important to get a sense of what these people are made of,”said Dr. Feinberg. “I am trying to figure out why they are in my office.It is my job to understand their beliefs about cause, meaning, impact,expectation, perceptions and goals.”

Cognitive BehavioralTherapy PaymentSources Constrained

A short questionnaire, early interventionand behavior risk assessment programdeveloped by Swedish Professor StevenLinton and colleagues is widely used bycompensation boards in many countries,according to a paper presented at a muscu-loskeletal disorders and chronic pain con-ference by Michael Coupland ofAssessAbility, West Palm Beach, FL.

The methodology is used to assesspatients’:• pain attitudes and beliefs;

• perceptions of work;

• mood/affect, catastrophizing;

• behavioral responses to pain;

• activities of daily living.

Following the assessment, patients areplaced into a low- medium- or high-risk category for chronic disability. Educationalmaterials on chronic pain are recommendedfor the low-risk group. Moderate-riskpatients are candidates for a self-managedworkbook-style intervention. High-riskpatients are referred to a cognitive behav-ioral therapy (CBT) intervention program(Linton & Andersson, 2000; Linton &Ryberg, 2001).

“The CBT approach to pain managementis based on the premise that chronic painbecomes established when a patient’s cog-nitions and beliefs, usually automatic andoften not conscious, create an impression ofthe pain event that has a profound impacton both short- and long-term adjustment topain,” Mr. Coupland said in the paper.

Studies have demonstrated that CBTintervention reduces risk for long-termleave from work by three to nine times andalso significantly limits the need for physi-cian and physical therapy encounters. In hispaper, Mr. Coupland theorizes that thisapproach, though shown in studies to beeffective, is not commonly used in the U.S.disability management system because psy-chosocial factors are non-medical in natureand the provision of CBT requires a psychi-atric diagnosis for treatment authorization.

“Payment has been within the psychiatricevaluation and management procedurecodes,” he said. “In this litigious, impair-ment model disability compensation system,these codes introduce impairment ratingsand compensation factors that, althoughunwarranted, become part of the claimssettlement process.”

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Following the MoneyDespite their apparent efficacy, bio-psychosocial

treatment teams are not widely available in the U.S.Instead, the vast majority of workers’ compensationclaimants with musculoskeletal disorders and pain-related complaints tend to shuttle from one providerto the next in search of relief. Observers attribute thisto a number of factors including the payment system,lack of stakeholder education and misplaced incentives.

“The entire system is based on people not gettingbetter,” said Doug Benner, M.D., occupational healthcoordinator and medical director of employee healthand medical provider networks, Kaiser PermanenteMedical Care Program, Northern California. “Theaverage carrier just passes the expenses along.” Hespoke at the conference on Applying Evidence-BasedCare and Measuring Their Outcomes.

On the provider side, incentives are misaligned.“Physicians are encouraged to do things to and forpeople rather than talk to them,” Dr. Feinberg said.“Until we change that, we are going to continue tohave problems.”

Dr. Letz believes education needs to occur at thepayer level before the paradigm can shift.

“We need to start out by making it very clear to thepeople who are paying to look at percentage of claimsand percentage of costs,” said Dr. Letz, whose topicwas A Collaborative Approach to the Prevention ofMedically Unnecessary Disability. “Regardless of thejurisdiction, the findings are consistent: Partial dis-ability represents more than 80 percent of costs, andmost of the high-cost claims we see today are peoplewho come in with a backache or sore shoulder that isnot severe from a medical point of view.”

Insurers tend to view multi-disciplinary care asexpensive care and are not well-educated about thepotential for a positive associated outcome, accordingto Jeffrey Livovich, M.D., medical director of themedical policy organization at Aetna, who spoke atthe conference on Chronic Pain Treatment from anInsurer’s Point of View. “It is really not in their vocab-ulary,” he said.

Using the team approach, the average treatmentcost is about $30,000 per case, Dr. Livovich said, and“that amount is in fact low” compared to the cost ofvarious interventions introduced over an extendedperiod of time without achieving marked functionalimprovement.

He said the insurer’s job is to control costs whilesimultaneously encouraging the use of evidence-basedcare. “We want to provide education and promotehealth and wellness. Insurers are much more inter-ested in the well-being of patients than you wouldimagine,” Dr. Livovich said.

At Aetna, clinicians decide what will be coveredbased on the evidence - or lack thereof. This includespolicies related to surgical interventions, acupuncture,electric stimulation and injections. Clinical claimsreview is primarily based on ICD-9 and CPT codes

Non-Medical Factors Contributingto Delayed Recovery, Disability inWorkers’ Compensation Cases

Some examples:The Employer:• Has a policy against light duty.

• Does not see transitional work as essential to timely recovery.

• Uses benefits systems (workers’ compensation, short-termand long-term disability) to manage personnel problems.

• Lacks information on bottom line financial benefits of return to work.

The Physician:

• Not trained to determine appropriate work restrictions.

• Lacks accurate information on physical demands of the job.

• Does not include transitional work in the treatment plan.

• Focuses on pain generator.

• Treatment goals aimed at “feeling better” rather improved function.

• Relies on biomedical rather than bio-psychosocial model.

• Misunderstands role as patient advocate.

• Underestimates the salutary benefits of work.

• Lacks education on impairment and disability.

• May be thinking about income-generation.

The Patient:

• Afraid of re-injury or pain aggravation.

• Poor coping skills.

• Low job satisfaction.

• Lacks incentives for return to work.

• Secondary gain/positive reinforcement for “sick role.”

• Reports distress, depression, anxiety.

• High pain ratings.

• Maladptive beliefs.

• Preoccupied with legal aspects.

• Somatization.

• Adverse childhood experiences.

• Difficulty accepting physical discomfort.

• Cure-focused.

• Seeks validation.

• Strong sense of entitlement.

• Self-medicates.

The Claims Adjuster:

• Focuses on benefit delivery rather than functional restoration.

• Has poor communication with providers, employers and injured workers.

• Lacks medical resources for appropriate/timely treatment authorization.

• Has too large a caseload for proactive management.

Sources: Dr. Gideon Letz and Dr. Steven Feinberg

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VIsIons

and reimbursement is largely automated, he said.Because of the challenges associated with establishing

charges for multi-disciplinary care in current paymentsystems, Dr. Livovich advises occupational medicineproviders to first identify all their costs and then attemptto negotiate a case rate with insurers.

“Start with contract negotiators in your region: ‘This is the program we would like to provide, these are ourcredentials, and these are our outcomes.’ Then work outwhat you will get paid for it,” he suggested.

For the bio-psychosocial model to gain recognitionand members of the provider community to be appropri-ately reimbursed for their expertise, Dr. Livovichbelieves providers need to give insurers:• More detailed information about the value of a

multi-disciplinary approach.

• A description of at-risk patient characteristics.

• Outcome data related to return to work, increasedfunction and other meaningful measures.

• Instructions on how to find and access multi-disciplinary teams with good track records.

• Insights on parameters for accreditation and credentialing of provider teams.

Red FlagsMost experienced

occupational medi-cine physicians saythey can instinc-tively spot a patientwho is at-risk forchronic pain anddisability and rec-ommend an appro-priate course ofaction. However,that is not alwaysthe case. For exam-ple, a workers’ com-

pensation claimant with a back complaint may havealready seen one or more less-attuned providers beforearriving at the occupational medicine clinic, eliminatingthe chance for early intervention, or they may notappear at first to fit the “typical” at-risk profile.

Because of the potential for confounding variables inany given case, Kaiser Permanente’s occupational healthteam has developed a coordinated approach to assessingpatients with musculoskeletal complaints.

“We do an intake questionnaire using various method-ologies by the second, and no later than the third, visit,”Dr. Benner said.

In addition to a questionnaire, the risk assessmentincludes consultation with the primary treating provider,other medical team members such as physical and occu-pational therapists, and the assigned claims examiner.

“Any one of the team members can classify someoneas high, moderate or low risk,” Dr. Benner said.

A simple functional improvement assessment is con-ducted on each return visit using CareConnections

Chronic Conditions Call for a Global Solution

Back pain costs Americans billions of dollars a year inmedical care and disability payments. As a nationalhealth problem, it reportedly is the third most expensivedisorder after heart disease and cancer.

Ultimately, experts say these costly conditions need tobe addressed in a more global way via changes in themedical delivery model – a monumental undertakingunderscored by the continuing health care reformdebate.

While the biomedical model works well when dealingwith acute conditions and episodic care, it is not nearly aseffective for the treatment and management of chronicdisease, pain and disability, said Kathryn Mueller, M.D.,medical director of the Colorado Division of Workers’Compensation, who spoke at a recent conference onMedical Care in the Next Decade: Changing the Structureof Health Care.

As reform-driven medical home and accountable careorganization (ACO) models of health care delivery takeshape, “medical care is going to radically change,” Dr.Mueller predicted. “This is not a gatekeeper or providernetwork model. The medical home will provide a certainset of services,” including chronic disease and disabilitymanagement.

“Physicians are not going to be allowed not to thinkabout disability. Right now the box we sit in doesn’t dealwith disability or societal impacts, and that is what weneed to be talking about,” she said.

Dr. Mueller believes the medical establishment in gen-eral, including MediCare, can glean valuable lessons fromoccupational medicine and the workers’ compensationrealm, where approximately 50 percent of premium costsare associated with disability and providers understandhow to evaluate function and make return-to-workdeterminations. As alternative medical models emerge,she expects this expertise to be particularly applicablebecause physicians will be partly rewarded on the basisof functional outcomes and patient satisfaction.

Meanwhile, although physicians typically are notinclined to dramatically change the way they practice inresponse to the availability of evidence-based guidelines,research suggests a growing number of physicians arebeginning to acknowledge the significance of the shifttoward performance-based medicine.

“They are starting to use that terminology now,” Dr.Mueller said. “So, we are moving forward, just not at therate we want.”

Workers’ compensation utilization review (UR) is arelated area Dr. Mueller believes is in need of an overhaul.

“We need to figure out a way to only review thosecases that need to be reviewed,” she said. “Physiciansreport they spend 20 or more hours a week dealing withthe UR process. If they consistently get prior authoriza-tion and demonstrate that they do things right, theyshould not be expected to do that. We need targeted URwith associated rewards, including decreased administra-tive costs for compliant physicians.”

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Outcomes System, a Therapeutic Associates product formerly known as TAOS,which allows clinicians and health plans to measure the impact of therapy serv-ices. According to the company, the system facilitates benchmarking of func-tional improvement, perceived pain and improvement, and return to work.(1)

In addition, in a collaborative effort to identify at-risk individuals, Safeway,Inc., a major grocery store operator headquartered in Northern California, andKaiser on the Job have introduced the use of a modified version of the StartTBack Musculoskeletal Screening Tool.(2) Developed at Keele University in GreatBritain, the tool is a brief validated questionnaire designed to screen primarycare patients with low back pain for prognostic indicators that are relevant toinitial decision making.

Keele University reports the instrument is used by clinicians to systemati-cally identify patients as low, medium (physician indicators) or high risk (phys-ical and psychosocial indicators) for persistent symptoms. The tool featuresnine statements to which patients answer “agree” or “disagree.” For example:“My back pain has spread down my leg(s) sometime in the last two weeks,” and“Worrying thoughts have been going through my mind a lot of the time.”

The Kaiser version of the assessment tool features two additional questionsrelated to job satisfaction and the patient’s perception of their supervisor’s con-cern about their condition. Research shows that the way an employer – partic-ularly an immediate supervisor – responds to an injured worker plays a signifi-cant role in return to work and delayed recovery.(3)

So far, the results, though not scientifically validated by a control group, arepositive from Safeway’s perspective: Of 66 at-risk employees with low back painwho were followed between 2006 and 2010, all of them returned to work; onlytwo had surgery and none of the cases became litigious.

Best PracticesWilliam Zachry, vice president of risk management at Safeway, explained the

impetus behind the at-risk screening program during a presentation on BestPractice with the Functional Restoration Project. While the company’s injury inci-dence rate was decreasing, he was concerned about the increasing level ofseverity among injuries that were occurring.

“Our medical director said he knew in the tum-tum by the second visitwhen he had a problem child,” he said. “Things were not happening. Recoverywas not taking shape as you might expect.”

Acting on the belief that such patients have “poor coping skills,” Safewaysought to develop a more consistent approach to identifying at-risk employeesand an associated protocol for physical and psychosocial interventions for thosewith “red flags,” including specialized training for medical examiners and storemanagers.

Mr. Zachry is so pleased with the results to date that he has tried to spreadthe gospel to other major employers and insurers. While he reports that corre-sponding changes in practice outside of his immediate locus of control seems tobe occurring at glacial speed, he has not given up trying.

Meanwhile, plans are in the works to implement musculoskeletal screeningand treatment protocols in other states and regions where Safeway has stores.Mr. Zachry said the company will pay an upfront flat fee to medical providerswho agree to use the questionnaire and corresponding follow-up protocols withthose who are identified as at-risk.

He also offered these lessons from Safeway’s experience to date:• Do not limit risk assessment to back complaints. Take into account “the sis-

terhood of the traveling body parts.” In other words, pain in patients withpoor coping skills may manifest itself in other parts of the body without amedical explanation.

• Keep claims examiners engaged. Examiners are inclined to ignore earlysigns that a case will require both medical and behavioral health interven-tions because of cost and complexity issues.

• Medical professionals, not insurance professionals, should make all med-ical decisions. At Safeway, a medical professional following evidence-

RAND, Kaiser Undertake CarpalTunnel Study

Kaiser Permanente and RANDCorporation will be conductinga five-year outcome studyinvolving up to 800 patientswith a new diagnosis of carpaltunnel syndrome (CTS), a com-mon and costly work-relatedcomplaint.

Based in Santa Monica, CA,RAND’s mission is to helpimprove policy and decision-making through research andanalysis. According to Dr. DougBenner of Kaiser Permanente,study subjects will answer, and18 months later repeat, anextensive questionnaire toassess and develop responses tosuch key issues as:• care quality in comparison to

established metrics;

• progress toward return to function;

• factors that make a measura-ble difference in outcomes;and

• economic impacts on individu-als, employers and insurerswith respect to earnings, ben-efit costs and productivity loss.

The phone survey will incor-porate dozens of quality indica-tors identified in a joint projectinvolving Kaiser Permanente,RAND and the California StateCompensation Insurance Fund.It also will feature critical-to-quality (CTQ) patient satisfac-tion monitoring and bench-marking and SF-12 surveys. (TheSF-12v2 is a 12-item subset of anSF-36v2™ survey that measureseight domains of health status.Refer to QualityMetric, Inc.:www.sf-36.org/tools/sf12.)

“In workers’ compensation,with the exception of low backpain, we are so far behind therest of health care in term ofdata collection and analysis,” Dr.Benner said. “This project willhelp us identify areas where wecan improve” and share findingsrelated to the diagnosis andtreatment of carpal tunnel syndrome.”

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Colorado TreatmentGuidelines IncludePsychological Testing

The Colorado Division of Workers’ Compensation’sevidence-based treatment guidelines for determiningwork-relatedness of upper extremity cumulativetrauma disorders (CTDs) include a recommendation for adjunctive personality/psychological/psychosocialevaluations.

According to the guidelines, such evaluations are“generally accepted and well-established diagnosticprocedures with selective use in the CTD population,but have more widespread use in sub-acute andchronic pain populations.”

The guidelines state: “Diagnostic testing proceduresmay be useful for patients with symptoms of depres-sion, delayed recovery, chronic pain, recurrent painfulconditions, disability problems, and for pre-operativeevaluation as well as a possible predictive value forpost-operative response. Psychological testing shouldprovide differentiation between pre-existing depres-sion versus injury-caused depression, as well as post-traumatic stress disorder.”

The guidelines recommended formal psychological or psychosocial evaluation of patients not makingexpected progress within six to 12 weeks followinginjury and whose subjective symptoms do not correlatewith objective signs and tests. In addition to an initialexam, the guidelines say evaluation of the injuredworker should specifically address the following areas:• Employment history;

• Interpersonal relationships — both social and work;

• Leisure activities;

• Current perception of the medical system;

• Results of current treatment;

• Perceived locus of control; and

• Childhood history, including abuse and family history of disability.

“Results should provide clinicians with a betterunderstanding of the patient, thus allowing for moreeffective rehabilitation,” it says in Rule 15, Exhibit 5 ofthe CTD Medical Treatment Guidelines. “The evalua-tion will determine the need for further psychosocialinterventions, and in those cases, a DiagnosticStatistical Manual for Mental Disorders (DSM) diagnosisshould be determined and documented. An individualwith a Ph.D., Psy.D., or Psychiatric M.D./D.O. credentialsmay perform initial evaluations, which are generallycompleted within one to two hours. When issues ofchronic pain are identified, the evaluation should bemore extensive and follow testing procedures as out-lined in the Division’s Chronic Pain Disorder MedicalTreatment Guidelines.

With regard to frequency, the guidelines state: “One time visit for evaluation. If psychometric testingis indicated as a portion of the initial evaluation, timefor such testing.”

Reference: www.colorado.gov/cs

based guidelines reviews recommendations on everydoctor’s report and approves/disapproves them withineight hours of receipt. This approach dramaticallyimproves return-to-work rates.

• Take early steps to avert litigious situations and legalescalation of disability claims by keeping lines of communication open among all parties.

• Retirement-related claims are another piece of the puzzle. A patient within a few years of retirement mayhave good coping skills but see disability as an early way out.

• Obesity has been shown to increase claims costs andlength of disability. Consider directing patients with elevated body mass indices to nutrition and weight-lossresources.

A fraud commission in California found in 20 percent ofworkers’ compensation cases that the treatment renderedwas fee for service, never authorized by a third party, norwas it evidence-based.

“I believe that early identification of individuals with poor coping skills is the way of the future in workers’ compensation, because that is what drives the problems,”Mr. Zachry said.

“We are talking about people’s lives. We miss the pointwhen we make it all about the money. It is extraordinarilyimportant to take care of these people and get them backto work. It is the right thing to do.”

References1. www.careconnections.com/outcomes/index.aspx.2. StartT Back Musculoskeletal Screening Tool, ©Keele

University; Hill et al., 2008;www.keele.ac.uk/research/pchs/pcmrc/dissemination/tools/startback.

3. Employee perspectives on the role of supervisors toprevent workplace disability after injuries; W Shaw, et al.,Liberty Mutual; Journal of Occupational Rehabilitation, Vol.13(3):129-142, 2003. This study found “there is no substi-tute for the involvement of immediate supervisors in thereturn-to-work planning process.”

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Study DemonstratesEfficacy of Early Physical Therapy

The American Physical TherapyAssociation (APTA) cites a newstudy on low back pain in Medicarepatients as part of its efforts toencourage the newly establishedCenter for Medicare and MedicaidInnovation to launch a demonstra-tion project on direct access tophysical therapy services.

The study, published in the jour-nal Spine, shows Medicare patientswho received physical therapy inthe acute phase following anepisode of low back pain were lesslikely to receive epidural steroidinjections, lumbar surgery or fre-quent physician office visits in theyear following their initial physi-cian visit as compared to patientswho received physical therapy later.

“This study has demonstrated adecreased usage of medical services inpatients who receive physical therapyearly after an acute low back painepisode,” said APTA President R. ScottWard, P.T., Ph.D. “Therefore, weencourage the Center for Medicare andMedicaid Innovation to swiftly under-take the direct access for physical ther-apy demonstration project recom-mended by the health care reform law.”

Researchers examined a nationallyrepresentative, 20 percent sample ofphysician outpatient billing claims. Themost common condition experienced bythe patients was non-specific backache(63.6 percent), followed by sciatica(14.5 percent), degenerative disc disease(10.5 percent) and spinal stenosis (6.2 percent).

The 431,195 enrollees were catego-rized into acute (having received physi-cal therapy in less than four weeks afteran episode); sub-acute (having received

physical therapy between four weeksand three months after an episode), andchronic (receiving physical therapybetween three and 12 months after anepisode) treatment groups. There wasalso a category of patients who did notreceive physical therapist treatment.

Researchers found that patients whowere initially evaluated by a “generalistspecialist” (internal medicine, familypractice, emergency medicine and gen-eral practice) were least likely to receivephysical therapy within a year as com-pared with patients who were evaluatedby physiatrists, whose patients weremost likely to receive physical therapyin the acute phase and also within oneyear of their initial evaluation.

“The study has also shown us thattreatment practices among those whoare utilizing less physical therapy,namely generalist specialties, may needto be modified since these providers also

are responsible for evaluating thelargest proportion of patients withacute low back pain,” Dr. Wardsaid.

Reference: ManagementPatterns in Acute Low Back Pain:The Role of Physical Therapy; AGellhorn et al.; Spine, Nov. 19,2010.

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Heart Problems Costly for Employers

Employees with heart problemsare particularly costly to employersand insurers, according to ananalysis of medical claims pub-lished in the January 2011 editionof the Journal of Occupational andEnvironmental Medicine, a publica-tion of the American College ofOccupational and Environmental

Medicine.Acute coronary syndrome (ACS),

defined as a range of conditions includ-ing myocardial infarction and unstableangina, costs more to treat than othercommon conditions such as asthma,high blood pressure and diabetes,reports a research team led by StephenS. Johnston of Thomson Reuters,Washington, D.C. Nearly half of ACSpatients are of working age.

The researchers found that medicalcare for workers with ACS was $40,000higher, on average, than it was for work-ers without ACS. Initial hospitalizationaccounted for about half of the cost.Meanwhile, 30 percent of workers withACS were found to have at least oneadditional heart disease-related hospital-ization within a year of their firstepisode.

ACS also was associated with higher

This edition of Outcomes features selected studies with findings relevantto occupational health programs, employers and patients.

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indirect costs for short-term disability:about $1,000 per year. Costs associatedwith work absence were not signifi-cantly increased, but this finding wasbased on a small number of cases, saidresearchers, who noted the comparativecost data will be useful in prioritizingresources for treatment and prevention.

Meanwhile, an American HeartAssociation expert panel reports thatthe cost to treat heart disease, whichaccounts for about 17 percent of overallnational health expenditures, will tripleby 2030. Lost productivity costs aloneare expected to increase by an estimated61 percent. By 2030, the cost of medicalcare for heart disease (in 2008 dollarvalues) will rise from $273 billion to$818 billion, the authors predicted.

Effective prevention strategies areneeded to limit the growing burden ofcardiovascular disease, the panel said.

“Unhealthy behaviors and unhealthyenvironments have contributed to atidal wave of risk factors among manyAmericans,” said AHA CEO NancyBrown. “Early intervention and evi-dence-based public policies are absolutemusts to significantly reduce alarmingrates of obesity, hypertension, tobaccouse and cholesterol levels.”

References: Direct and Indirect CostBurden of Acute Coronary Syndrome; S

Johnston, et al.; JOEM, Vol. 53, No. 1,January 2011.

Forecasting the Future ofCardiovascular Disease in the UnitedStates: A Policy Statement from theAmerican Heart Association;Circulation, January 2011;http://circ.ahajournals.org.

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Computer Use, DiseaseLink Questioned

Danish researchers conducted a sys-tematic review of studies to assess evi-dence for causal relationships betweencomputer work, carpal tunnel syndrome,and neck and upper extremity muscu-loskeletal disorders. Although computeruse has long been associated with paincomplaints, they found limited evidenceof a link with specific disorders or diseases.

“In light of the minor occurrence ofclinical outcomes and/or chronic pain,it is perhaps time to weigh the effort ofcreating huge cohorts in the office environment against other occupationalhealth concerns,” they concluded.

Reference: The findings were pre-sented in a paper at a conference spon-sored by the Canadian Institute for theRelief of Pain and Disability andACOEM. The study, Risk Factors forNeck and Upper Extremity DisordersAmong Computer Users and the Effect ofInterventions: An Overview of SystematicReviews of Risk Factors and InterventionStudies, was conducted by JohanAndersen of the Department ofOccupational Medicine, HerningHospital, Herning, Denmark, with Nils Fellentin.

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Clinical Trial FindingsLargely Ignored

The vast majority of published andrelevant clinical trials of a given drug,device or procedure are routinelyignored by scientists conducting newresearch on the same topic, a new JohnsHopkins study suggests.

In the Jan. 4, 2011 issue of Annals ofInternal Medicine, researchers who con-

ducted an analysis of published studiesreport such omissions potentially skewscientific results, waste taxpayer moneyon redundant studies and involvepatients in unnecessary research.

The Johns Hopkins team found thatresearchers, on average, cited less than21 percent of previously published, rele-vant studies in their papers. For paperswith at least five prior publicationsavailable for citation, one-fourth citedone previous trial; another quarter citedno other previous trials on the topic.Those statistics stayed roughly the sameeven as the number of papers availablefor citation increased. Larger studieswere no more likely to be cited thansmaller ones.

“The extent of the discrepancybetween the existing evidence and whatwas cited is pretty large and pretty strik-ing,” said Karen Robinson, Ph.D., anassistant professor of medicine at theJohns Hopkins University School ofMedicine and co-author of the research.“It’s like listening to one witness asopposed to the other 12 witnesses in acriminal trial and making a decisionwithout all the evidence. Clinical trialsshould not be started – and cannot beinterpreted – without a full accountingof the existing evidence.”

Reference: www.hopkinsmedicine.org/gim/faculty/robinson.html

Become aFollower onNAOHP Blog

The NAOHP has launched Onthe Beam Occupational HealthInsights, a weblog administeredby VISIONS Editor Karen O’Hara.The blog features timely industry news and commentary.Become a follower, visit the site frequently and post yourcomments:

http://onthebeam-occhealthinsights.blogspot.com

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By Terri Scales

In evaluatingoccupationalmedicine

clinic codingand billing practices, wehave noted thefollowing five

commonly occurring errors that can beresolved with appropriate action.

Mistake One: Documentation does not meet the

level billed. If you receive a denial stating

“Documentation is incomplete or insuf-ficient,” the documentation does notsupport the level of service billed. Thistype of denial can result in down-codingor outright denial by carriers.

Ultimately the documentation waslacking the required components for theEvaluation and Management (E/M)level billed. Additionally, documenta-tion does not guarantee reimbursement,although documentation does play acritical role in reimbursement.

To determine the appropriate level ofservice for a patient’s visit, it is neces-sary to first determine whether thepatient is new or established. Next, onemust understand the three key compo-nents for the 1995 and 1997 E/M guide-lines: history, examination and medicaldecision-making. With a new patientvisit, all three of the key componentsmust be met. Two of the three must bemet for an established patient.

Mistake Two: Medical necessity was not

established by the diagnosis.Linking the correct diagnosis to the

service billed might be a deciding factorfor claims payment. When billing an

insurance carrier, be sure diagnosiscodes accurately correspond with theservice provided. CPT and ICD-9 codelinkage is identified in box 24E on theHCFA 1500 form. Diagnosis linkagecommunicates to the carrier why it wasmedically necessary to perform the services provided.

Box 21 of the HCFA 1500 containsfour sub-sections where ICD-9 codes are used to describe the encounter. The primary diagnosis or reason for the visitshould be reported first, followed bycodes for other diagnoses listed indescending order of importance. In outpatient settings it is not appropriateto code for “suspected” or “probable”diagnoses.

Mistake Three: The biller decides not to appeal or

does not know how to appeal a denialfrom the carrier.

There are many reasons why medicalpractices do not appeal denied claims.The most common are the belief thatappealing claims will create an increasedadministrative burden on the practice,or the biller does not understand thedenial or coding guidelines. However,not appealing denied or partially paidclaims can be costly to the practice andwill result in decreased revenue.

The first step to appealing a denial isidentifying the reason for the denial.Was it a missing modifier, a diagnosiserror, or even a keystroke error withinthe patient’s demographic information?Familiarity with coding rules is neces-sary when developing an appeal strategy.The appeal process should be supportedwith strong provider knowledge ofapplicable state workers’ compensationlaws, CPT coding guidelines, ICD-9coding guidelines and even E/M guidelines.

The next step is verification of theprovider’s documentation. Remember

the adage: “If it wasn’t documented, itwasn’t done.”

The third step is to identify theappropriate address, fax number, phonenumber and email address to submit theappeal. If writing an appeal letter, indi-cate the date, date of service, claimnumber, amount charged and medicalprovider name. Describe the denial andexplain why you are writing and whatyou are requesting. Include any support-ing documentation, such as letters ofmedical necessity from your physician,medical records, progress notes, radiol-ogy or pathology reports, etc.

If you decide to call the carrier aboutyour appeal, it is important to documentthe name and title of the individualwith whom you are in contact. It is alsoimportant to document the date/time of your call and make notes of your conversations. A friendly tone will help smooth the way.

Beside obtaining appropriate reim-bursement, there is another prospectivepositive result from increasing the number of appeals a provider submits:disputing reduced or denied claims mayprompt a carrier to correct its claimsediting software and processes, which inturn helps streamline the entire process.

Mistake Four: The diagnosis was not coded to the

highest possible degree of specificity.Providers must select ICD-9-CM

diagnosis codes that provide the highestdegree of accuracy and completeness, orgreatest possible specificity. For exam-ple, it is not appropriate to bill for apatient with rotator cuff syndrome usingcode 726.1. You must use one of themore specific codes that are available:726.10 Disorders of bursae and tendonsin shoulder region, unspecified; 726.11calcifying tendinitis of shoulder; 726.12bicipital tenosynovitis; or 729.19 otherspecified disorder.

Solutions to Common Coding, Billing Mistakes

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Providers should also be aware thatcodes marked NOS (not otherwise specified) or “unspecified” indicate thatthere is insufficient information in themedical record to assign a more specificcode. NEC (not elsewhere classifiable)

indicates the code book does not have acode describing the condition.

Diagnosis codes range from three tofive digits. Most three-digit codesrequire a fourth or fifth digit, and somefour-digit codes require a fifth digit.Diagnosis coding is a three-step process.First, review the medical record toextract the reason for the visit. Second,look up the illness, signs and symptoms,or condition in Volume 2, AlphabeticIndex and locate the correspondingcode. Third, look up the correspondingcode in Volume 1, Tabular List andchoose the most specific code that accu-rately describes the patient’s condition.

Every clinic should have access to acurrent ICD-9 code book. These booksare updated annually, effective October1. After each ICD-9 annual revision, besure to update the diagnosis code infor-mation in your electronic billing/prac-tice management system and on anypaper documents.

Mistake Five: Your organization lacks a consistent

way to review coding. Appropriate steps should be taken to

incorporate checks and balances intoyour organization’s daily routine whenreviewing charges for possible errors andomissions. Coding errors result in pay-ment delays and underpayments andmay trigger a carrier audit. Educateproviders and staff (front and backoffice) on the time-consuming aspectsof claims appeals when errors occur andthe value of complete documentationand correct coding.

A “claim scrubber “engine” supportscoding processes and compliance, and it is an effective way to systematicallyreview claims prior to submission to the carrier.

Terri Scales, CPC, CCS-P, is regionaldirector of client services, Bill Dunbar andAssociates, LLC, and BDA Claim Correct,a member of the NAOHP Vendor Program.

Recommended Resources

CDC Health Disparities andInequalities Report: United States,2011; Americans’ differences inincome, race/ethnicity, gender andother social attributes affect howlikely they are to be healthy, sick ordie prematurely; Centers for DiseaseControl and Prevention;www.cdc.gov/mmwr.

Conflicts of Interest and theFuture of Medicine: The UnitedStates, France, and Japan; nationaldifferences in the organization ofmedical practice and the interplay oforganized medicine, the market andthe state give rise to variations in thetype and prevalence of such conflicts;M Rodwin; Oxford University Press,February 2011.

Competition in Health Insurance:A Comprehensive Study of U.S.Markets, 2010; 99 percent ofhealth insurance markets in the U.S.are “highly concentrated,” according

to 1997 U.S. Department of Justiceand Federal Trade CommissionHorizontal Merger Guidelines, indicating a significant absence ofcompetition among insurers; to order the study, visit https://catalog.ama-assn.org.

Employee Engagement Report2011; Blessing White survey ofnearly 11,000 employed professionalsshows employees are more likely totrust their immediate managers thansenior executives and suggests busi-ness leaders need to demonstrateconsistency, communicate often andwith depth, and create a culture thatdrives results and engagement;www.blessingwhite.com, a global con-sulting firm.

Environmental Public HealthTracking 101, a new CDC onlinecourse with 12 modules in three sec-tions; www.nehacert.org, enterTracking101 in the search box.

Multiple Chronic Conditions: AStrategic Framework; Department ofHealth and Human Services reportoutlines public-private collaborationto reduce risks and improve overallhealth of individuals with multiplechronic conditions; www.hhs.

Organizational Change andEmployees’ Mental Health: TheProtective Role of Sense ofCoherence; K Pahkin, et al.; a strongpre-merger sense of coherence con-sisting of comprehensibility, manage-ability and meaningfulness seems tobe a protective factor for mentalhealth when employees experiencenegative changes during an organiza-tional merger; JOEM, Vol. 53, Issue2, Feb. 2011.

Workers’ Compensation Laws,3rd Edition; extensive comparisonsin table format; InternationalAssociation of Accident Boards andCommissions; www.wcrinet.org.

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Court Supports Employer in JobAccommodation Case

A duty to reasonably accommodatean employee with a disability does notmean employers have to ignore theindividual’s ability to perform essentialfunctions of a job, a federal districtcourt in Washington ruled recently inMcEnroe v. Microsoft Corp.

The court ruled in favor of Microsoftin a case involving an employee claimof discrimination under the Americanswith Disabilities Act (ADA) and theWashington Law AgainstDiscrimination (WLAD), according toJackson Lewis, a national law firm spe-cializing in employment law.

The plaintiff, Lesann McEnroe, ahuman resources staffing associate forMicrosoft, worked from her home inKennewick, WA, for several years beforereporting she was disabled. She allegedshe was unable “to work at or travel tothe Microsoft campus” in Redmond,WA, or attend work-related functionsbecause she suffered from panic disorder,agoraphobia, post-traumatic stress disor-der and irritable bowel syndrome,among other conditions.

In 2008, Ms. McEnroe applied forfour higher-level positions at Microsoftthat required her presence in the com-pany’s Redmond office and extensivetravel to other Microsoft offices. In oneinstance, when asked if she could bepresent at various Microsoft offices toattend meetings and provide onsiteevent coordination, she responded,“Due to my disability, I am unable totravel or work on campus as you note.”She was not promoted to any of thejobs.

Ms. McEnroe filed a lawsuit allegingMicrosoft declined to consider her for ahigher-level position because of her dis-ability. She argued that the ability towork at the Redmond office and travelwas not an essential job function. Shealso alleged that Microsoft’s refusal toprovide her with a $4,000 annual

stipend to help cover her livingexpenses was a failure to accommodateher disability.

Microsoft argued that Ms. McEnroewas not a qualified candidate for thehigher-level positions because she couldnot perform the essential functions oftravel to and being present in Microsoftoffices. The court concluded Ms.McEnroe could not “show that anexclusive teleworking arrangementwould have been a reasonable accom-modation ...” The court also agreed withthe company that Ms. McEnroe’s claimfor a $4,000 annual stipend for her liv-ing expenses was not covered by thecompany’s policy. Implications for Employers:

Washington employers can feel confi-dent, at least for now, that in-personattendance standards still may be anessential function of a position withoutfear of running afoul of the state’s dis-ability discrimination laws. However,employers have a duty to engage in aninteractive process and should be pre-pared to demonstrate that their actionsfulfill their obligation to provide rea-sonable accommodation and equalemployment opportunities to qualifiedindividuals with disabilities, accordingto attorneys with Jackson Lewis.

Reference: Case No. CV-09-5053-LRS (E.D. Wash. Nov. 18, 2010) andwww.jacksonlewis.com

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Employers Advised to Comply with Health Reform

Many employers are looking for guid-ance on specific provisions of the healthreform law before making decisions ontheir benefits plans, but most are mov-ing forward with implementation, theSociety for Human ResourceManagement (SHRM) found in arecent survey.

In the third of a series of polls aboutthe implications of health-care reform

on employers and employees, SHRMfound about two-thirds of organizationswere not waiting to see if specific provi-sions of the law are repealed and three-quarters were not waiting for repeal ofthe entire law before making decisionsabout their benefits plans.

“A majority of organizations are notcounting on repeal. They are seekingguidance and moving forward to makesure they comply with the law,” saidMark Schmit, SHRM’s director ofresearch. “This is the smart approachbecause a health-care plan design affectsthe entire organization.”

Legislative StatusThe House voted Feb. 18 on four

amendments that would prohibit theuse of federal funds to implement theAffordable Care Act. Despite passage inthe House, the measure is unlikely topass in the Senate and President Obamahas said he would veto the measure if itreaches his desk.

Meanwhile, a Florida district court onJan. 31, 2011, struck down the act asunconstitutional (Florida v. U.S.Department of Health and HumanServices, Case No.: 3:10-cv-91-RV/EMT (N.D. Fla. 2011)). The courtagreed with a Virginia district court(Virginia v. Sebelius, 728 F. Supp. 2d768 (E.D. Va. 2010)) that the law’sindividual mandate is unconstitutional,but it concluded that the entire lawmust fall rather than following theVirginia court’s decision to sever theindividual mandate provision from therest of the law.

Meanwhile, two other district courtshave upheld the constitutionality of thelaw (Liberty Univ. v. Geithner, 2010WL 4860299 (W.D. Va. 2010) andThomas More Law Center v. Obama,720 F. Supp. 2d 882 (E.D. Mich. 2010)).

While the outcome remains unclear,employers are advised to implementhealth care reform provisions that are ineffect, starting with those with near-term compliance deadlines. Thisincludes the mandate for coverage of

VIsIons

children to age 26 and the elimination of certain annual and lifetime limitsand coverage for non-prescribed over-the-counter drugs through flexiblespending accounts.

Reference: www.shrm.org/surveys

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New Disclosures for In-Office ImagingAn amendment to the “in-office ancillary services” exception to federal

physician self-referral prohibitions (the Stark Law) affects all medical prac-tices that refer patients for magnetic resonance imaging (MRI), computedtomography (CT) and positron emission tomography (PET) to the extentsuch services are rendered in the referring physician’s office, accordingattorneys at Seyfarth Shaw, a global law firm.

Under a new federal law and revised Medicare and Medicaid rules effective Jan. 1 this year, physicians must now give patients receiving imaging referrals a written list of at least five alternate suppliers of such

services within a 25-mileradius of the physician’soffice location.

If there are fewer than fivealternate suppliers within a25-mile radius, the disclosuremust list all available suppli-ers, and if there are none,advise the patient of theoption to receive referredservices elsewhere. Hospitalsmay be listed as alternateproviders of the service, butthey do not count towardthe five required listings.

Reference:www.seyfarth.com

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Agency Begins GINA Enforcement The Equal Employment Opportunity Commission issued final regulations

for enforcement of Title II of the Genetic Information Non-discriminationAct (GINA) effective Jan. 10, 2011.

Title II prohibits employment discrimination based on genetic informa-tion and restricts the acquisition and disclosure of genetic tests and familymedical history. The regulation includes this footnote: “GINA is notintended to limit the collection of family medical history by health careprofessionals for diagnostic or treatment purposes.”

In addition, under the regulations, an employer may request family med-ical information to substantiate the need for regulated family or medicalleave. The regulations also allow family medical history questions as part ofa wellness assessment as long as the responses are voluntary.

The GINA prohibition on acquisition of genetic information, includingfamily medical history, applies to medical examinations related to employ-ment. For example, an employer must tell health care providers NOT tocollect genetic information as part of an examination intended to deter-mine the ability to perform a job.

Reference: www.federalregister.gov/articles/2010/11/09/2010-28011/ regulations-under-the-genetic-information-nondiscrimination-act-of-2008.

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Employers Expect HealthReform to Increase BenefitCosts, Survey Shows

A majority of employers believe thePatient Protection and Affordable Care Actwill increase their benefit costs and saychanges are needed in the law to improvequality, reduce expenses and reward healthsystem performance, according to surveyfindings from the Midwest Business Groupon Health (MBGH).

While many employers are already vol-untarily expanding coverage of preventiveservices to better manage chronic diseaseand associated absence, nearly 60 percentof respondents said they would expandwellness programs and use incentivesallowed under the law.

Also among the findings:• Of the 65 percent of respondents who

reported they have done some modelingon how health reform will impact benefitcosts, 25 percent forecast increases of 2to 5 percent and 15 percent estimatedincreases of 6 to 10 percent.

• 86 percent believe it is unlikely reformswill reduce the rate of health care costincrease and 74 percent believe it’s likelyhealth reform will boost costs even morethan if the legislation was not passed.

Commenting on the findings, AndrewWebber, president and CEO of the NationalBusiness Coalition on Health said:

“The survey results reflect employer frus-tration that cost containment, as their pri-ority goal for health care reform legisla-tion, is not, at present, being realized.While there appears to be strong supportfor the legislative provisions related to pay-ment reform, value-based insurancedesign, medical homes and accountablecare organizations, I think employers aresignaling the Obama Administration thatthese delivery reform and value-based pur-chasing strategies need to be fast-tracked.Cost containment cannot wait.”

Larry Boress, MBGH president and CEO,said:

“It’s clear that keeping workers healthyis a key focus. In fact, employers arealready implementing strategic healthmanagement approaches and these arequickly evolving into viable cost-reductionstrategies.”

The online survey, co-sponsored by theNational Business Coalition on Health(NBCH), Business-Insurance and WorkforceManagement, was conducted from lateNovember to mid-December 2010. Amongthe 430 respondents, 43 percent repre-sented employers with more than 500employees. Visit http://www.nbch.org/Newsfor a summary of the findings.

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Beryllium AlertThe National Institute for

Occupational Safety and Health(NIOSH) has published a berylliumalert, Preventing Sensitization and Diseasefrom Beryllium Exposure, warning thatcases of beryllium sensitization andchronic beryllium disease have beenreported from exposures below the cur-rent OSHA Permissible Exposure Limitof 2.0 micrograms per cubic meter of airand the NIOSH recommended exposurelimit (REL) of 0.5 micrograms per cubicmeter. A safe exposure limit for beryl-lium has not been determined, it says.

Bullying in the WorkplaceBills have been introduced in both

houses of the Washington state legisla-ture with the intention of providing alegal remedy for employees and legalincentives for employers to addressworkplace bullying. The proposed legis-lation would add a new section to theWashington Law AgainstDiscrimination (RCW 49.60) to makeit an “unfair practice” to subject anemployee to an abusive work environ-ment. The state Human RightsCommission reports that approximatelyone in five employees “directly experi-ence health-endangering workplace bul-lying, abuse and harassment.”

California Turns Up HeatA new state law makes it easier for

the California Division of OccupationalSafety and Health to classify workplacesafety violations as “serious” for purposesof issuing citations and proposed penal-ties to employers. Assembly Bill 2774broadens the definition of “serious vio-lation” and establishes specific rebut-table presumption procedures to helpimprove enforcement efforts.

Employer OutreachNIOSH and the Retail Industry

Leaders Association have agreed towork together on outreach, communica-tion and professional development inoccupational safety and health to retailcompanies and other stakeholders.Meanwhile, the National OccupationalResearch Agenda Manufacturing SectorCouncil is seeking partners to collabo-rate on topic areas including contactwith objects and equipment, falls, mus-culoskeletal disorders, hearing loss, can-cer, health disparities, small businessesand catastrophic incidents. Visitww.cdc.gov/niosh.

Labor DepartmentRequests OSHA Budget Increase

The U.S. Labor Department’s FiscalYear 2012 budget request totals $12.8billion in discretionary funding to helpAmericans find and keep jobs. TheDOL requested $583 million for theOccupational Safety and Health

Administration (OSHA), an increase of$24.7 million compared to FY 2011,including an additional $6.4 million toimprove regulatory standards. Of thatamount, $2.4 million is earmarked forthe agency’s Injury and IllnessPrevention Program rule, its top regula-tory priority, according to DavidMichaels, assistant secretary for labor.The program would establish policy forhow companies handle workplace safetyand health protection practices. Theagency also is working on a combustibledust standard.

The budget request calls for:• a $7.7 million increase for OSHA

enforcement, which would cover 25 additional full-time complianceofficers;

• an increase of nearly $6 million forwhistleblower protection programs;

• $384 million for the Mine Safety andHealth Administration, a nearly $27million increase over the FY 2010enacted level;

• a $9 million allocation to strengthenworker rights and protections inpartner trading countries through“increased investments in theInternational Labor Affairs Bureau’sBetter Work programs.

Refer to www.dol.gov/budget.

Life and Health ValuesNIOSH is seeking comments on its

draft Current Intelligence Bulletin,Derivation of Immediately Dangerous toLife and Health (IDLH) Values. SinceIDLH values were first established in1974, NIOSH has continued to reviewscientific data to improve the protocolused to develop guidelines for acuteexposures. Visit www.cdc.gov/niosh/docket/review/docket156.

Medical MarijuanaLawsuit

The American Civil Liberties Unionsaid it will appeal a federal court deci-sion to dismiss a lawsuit it filed againstWalmart for firing an employee forusing medical marijuana in accordancewith Michigan state law. A federal courtjudge found the law does not require

VIsIons

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businesses to make accommodations foremployees who use medical marijuanato relieve symptoms. The employee,who has an inoperable brain tumor andcancer, said he never came to workwhile under the influence. He was firedfrom his job at a Walmart store inBattle Creek, MI, after he tested posi-tive for the drug.

Nanotechnology StudyThe U.S. Environmental Protection

Agency (EPA) has awarded $5.5 millionto three consortia to support researchon nanotechnology. Scientific informa-tion developed from the research will beused to help guide the EPA and otheragencies in decisions about the safety ofnew materials and products that aremade using nanotechnology.

NLRB Chairman Issues Statement

After a House Committee hearing onEmerging Trends at the National LaborRelations Board, NLRB ChairmanWilma Liebman issued this statement:“The most significant ‘emerging trend’at the NLRB is that the agency is com-ing back to life after a long period ofdormancy. After more than two yearswithout a quorum due to chronic vacan-cies, the board now has four membersand has been tackling many of the diffi-cult cases that languished for years. Weare actively seeking input from practi-tioners and the public by inviting briefsfor important cases that are underreview, and by using the process of fed-eral rulemaking to seek comments onone potential rule change intended toinform American employees of theirstatutory workplace rights.”

Vaccination ProposalsFlu shots should be mandatory for

American health care workers and acondition of employment for them,according to an Association forProfessionals in Infection Control andEpidemiology (APIC) position paper.APIC said the Centers for DiseaseControl and Prevention (CDC) andother national health care organizationsreport that voluntary vaccination has“failed to increase immunization rates toacceptable levels required to substan-tially reduce health care acquiredinfluenza.” Mandatory vaccination of

health care personnel is one of the mostimportant strategies to decreaseinfluenza transmission to or from high-risk people, according to APIC.

Meanwhile, the Department ofHealth and Human Services hasunveiled a new National Vaccine Planto establish priority areas for new vac-cines and vaccine enhancement,develop evidence-based surveillancestrategies for assessing the safety andefficacy of vaccines, create awareness ofvaccine-preventable diseases andimprove coordination of all aspects offederal vaccine and immunization activ-ities, according to the National VaccineProgram Office.

OSHA Actions

Hearing Protection: A proposalto change OSHA’s interpretation of“feasible administrative or engineeringcontrols” in its hearing protection stan-dard elicited complaints from the busi-ness community at a House Oversightand Government Reform Committeehearing. Calling it a “particularly strik-

ing example of overreach,” JayTimmons, president and chief executiveofficer of the National Association ofManufacturers, testified that the pro-posal would reverse decades of agencyprecedent that allows employers to pro-vide personal protective equipment suchas ear plugs and ear muffs instead ofmore costly administrative or engineer-ing controls such as redesigning facili-ties and buying new equipment.

Injury Reporting: Employers sub-ject to OSHA recordkeeping require-ments were required to post annualSummary of Work-Related Injuries andIllnesses (OSHA Form 300A) no laterthan Feb. 1, based on data recorded dur-ing 2010. The annual summary must beposted in a conspicuous place throughApril 30.

Personal ProtectiveEquipment: OSHA released newEnforcement Guidance for PersonalProtective Equipment in General Industrythat became effective Feb. 10. Itreplaces a 1995 directive and reflectstwo significant changes: A 2007 rulerequiring employers in general industry,shipyard employment, long shoring,marine terminals and construction topay for most types of required PPE and a2009 rule updating PPE standards tomake them more consistent with con-sensus standards. Visit www.osha.gov/SLTC/personalprotectiveequipment.

Proposals Back to DrawingBoard: The agency temporarily haltedreview by the Office of Managementand Budget of its proposal to restore acolumn for work-related musculoskeletaldisorders on employer injury and illnesslogs. It also withdrew a proposed revi-sion to its noise standard that wouldclarify the term “feasible administrativeor engineering controls.” The agencysaid it needs more time to solicit inputfrom small business operators on poten-tial impacts.

Popcorn Processing Targeted:OSHA has revised its NationalEmphasis Program on MicrowavePopcorn Processing Plants in an effortto further reduce worker exposure todiacetyl, a chemical used to enhanceflavor, and other the hazards.

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Frank H. LeonePresident and CEO

Since 1985

Karen J. O’HaraSenior Vice President

Since 1990

Roy K. GerberSenior Principal

Since 1998

Donna Lee GardnerSenior Principal

Since 1997

RYAN Associates’ Consulting Services650 OCCUPATIONAL HEALTH-SPECIFIC ENGAGEMENTS SINCE 1985

1-800-666-7926, X16 • WWW.NAOHP.COM

I N C H A L L E N G I N G T I M E S

experience reigns

Curriculum planners held twofocus groups sessions and con-ducted one-on-one calls recently

with NAOHP members to help fine-tune plans for RYAN Associates’ 25thAnnual National Conference, sched-uled Oct. 17-19 in Atlanta.

Respondents included members whoattended the 2010 conference and for-mer faculty members.

It was generally agreed the conferenceshould have a business value-orientedtheme, e.g., “Helping AmericanBusiness Succeed” or “Making theBusiness Case for Occupational Health.”

Other general suggestions included:• Individual carve-out sessions for clini-

cians, experienced program adminis-trators and individuals new to thefield of occupational health;

• “Jam sessions” and numerous othernetworking opportunities;

• Highlighting the Silver Anniversaryby featuring panel and roundtablediscussions with experienced faculty;

• Emphasis on case studies, model pro-grams and implementation tools;

• Achieving consistency in the man-agement of multiple sites;

• Insights to cultivate payer relations.

Specific proposed topics included:• Product line diversification and

“non-traditional” service integration.

• Business management/leadershiptechniques for clinicians;

• Special topics relevant to either hospital-affiliated or non-hospital-affiliated programs;

• Billing, coding and documentationpractices to improve reimbursement;

• Patient satisfaction and operationalbenchmarking activities;

• Georgia-specific workers’ compensa-tion and provider summit;

• Legal and regulatory updates;

• Information system functionality and privacy protection;

• Survival skills for dealing with eco-nomic realities, belt-tightening andlean staffing;

• Anticipated national health carereform impacts;

• Managing chronic pain and disability- the most expensive cases.

The conference curriculum will beposted at www.naohp.com in March.

RYAN Associates’ National Conference Planning

Product Diversity Themeat Nashville Seminar

RYAN Associates’ spring seminar,Profiting from Product Line Diversity,is intended to help occupationalhealth professionals respond quicklyand appropriately to local marketdemands and national trends:April 14: Delivering an Exceptional

Onsite ProgramApril 15: Integrating Urgent Care

and Occupational Health ServicesThe seminar will feature faculty

from hospital-affiliated programsand independent freestanding clinicswith successful onsite and/orblended clinic operations.

The venue is the Loews VanderbiltHotel in Nashville, adjacent to thelovely Vanderbilt University campusand close to the city’s famed musicscene. A limited number of vendorswith products relevant to the deliv-ery of occupational health, onsiteand urgent care services will be onhand. The seminar will feature lec-tures, case studies, facilitated round-table discussions and multiple net-working opportunities.

To register, visit www.naohp or call800-666-7926, ext. 0.

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VIsIons

To list your event, email information to Karen O’Hara,VISIONS Editor: kohara@naohp.com

MAR

APR

March 26-29American Occupational HealthConference; annual meetingsponsored by the AmericanCollege of Occupational andEnvironmental Medicine; Grand Hyatt, Washington, D.C.;www.acoem.org.

March 28-30 Management and LeadershipSkills for Environmental Healthand Safety Professionals; sponsored by Harvard School of Public Health; Boston, MA;https://ccpe.sph.harvard.edu/programs. MAY

May 1-5Risk and Insurance ManagementSociety annual conference;Vancouver, Canada;www.rims.org/annualconference.

May 10-132011 National Urgent CareConvention; sponsored by UrgentCare Association of America;Chicago; www.ucaoa.org.

May 14-19Innovate. Integrate. Inspire:annual American IndustrialHygiene Association conferenceand exposition; sponsored byAIHA® and ACGIH®; Portland, OR;www.aihce2011.org.

May 24-26Drug and Alcohol TestingIndustry Association annual conference; sponsored by DATIA;Doral Resort & Spa, FL:www.Datia.org/conference2011.

April 7Respirator Fit Testing (spirome-try refresher April 8); sponsoredby M.C. Townsend Associates,LLC; Pittsburgh, PA;www.mctownsend.com.

April 13-15Occupational Health and theRenewable Energy Industry;sponsored by Mountain & PlainsEducation and Research Center;Denver, CO;http://maperc.ucdenver.edu.

April 14-15Profiting from Product LineDiversity: Delivering anExceptional Onsite Program andIntegrating Urgent Care andOccupational Health Services;sponsored by RYAN Associates;Loews Vanderbilt Hotel,Nashville, TN; 800-666-7926;www.naohp.com.

April 29-May 5American Association ofOccupational Health Nursesannual conference; Atlanta, GA;www.aaohn.org.

JUNJune 6-8NIOSH-Approved SpirometryCourse, followed by CAOHC-approved Hearing ConservationCourse; sponsored by M.C.Townsend Associates, LLC;Pittsburgh, PA;www.mctownsend.com.

June 12-15 Safety 2011: ASSE PDC & Expo;sponsored by American Societyof Safety Engineers; McCormickPlace Convention Center,Chicago, ILwww.asse.org/education/pdc11.

ASSOCIATIONS

Urgent Care Association of America(UCAOA) UCAOA serves over 9,000 urgent care centers.We provide education and information inclinical care and practice management, andpublish the Journal of Urgent Care Medicine.Our two national conferences draw hundredsof urgent care leaders together each year.Lou Ellen Horwitz • Executive DirectorPhone: (813) 657-0508lhorwitz@ucaoa.orgwww.ucaoa.org

BACKGROUND SCREENING SERVICES

Acxiom You can’t afford to take unnecessary risks.That’s where Acxiom can help. We providethe highest hit rates and most comprehensivecompliance support available–all from anunparalleled, single-source solution. It’s a customer-centric approach to backgroundscreening, giving you the most accurate information available to protect your company and its brand.Michael Briggs • Sales LeaderPhone: (216) 685-7678 • (800) 853-3228Fax: (216) 370-5656michael.briggs@acxiom.comwww.acxiombackgroundscreening.com

CONSULTANTS

Advanced Plan for HealthAdvanced Plan for Health has a plan and aprocess to reduce the rising costs of healthcare. By partnering with APH, you can providecustomized plans to help employees of thecompanies, school systems and governmentoffices in your market. You can show theorganizations how to improve their healthplan, finances and employee productivity.Rich Williams Phone: (888) 600-7566 Fax: (972) 741-0400 richwilliams@aph-online.comwww.aph-online.com

Bill Dunbar and Associates BDA provides revenue growth strategies toclinics and hospitals throughout the U.S.BDA’s team of professionals and certifiedcoders increase the reimbursement to itsclients by improving documentation, coding,and billing. BDA offers a comprehensive, cus-tomized, budget-neutral program designed tofocus on improving compliance along withnet revenue per patient encounter.Terri Scales Phone: (800) 783-8014Fax: (317) 247-0499 ts@billdunbar.com • www.billdunbar.com

Medical Doctor Associates Searching for Occupational Medicine Staffingor Placement? Need exceptional service andpeace of mind? MDA is the only staffingagency with a dedicated Occ Med team ANDwe provide the best coverage in the industry:occurrence form. Call us today.Joe WoddailPhone: (800) 780-3500 x2161Fax: (770) 248-6701woddailj@mdainc.comwww.mdainc.com

Reed Group, Ltd.The ACOEM Utilization ManagementKnowledgebase (UMK) is a state-of-the-art solution providing practice guidelines infor-mation to those involved in patient care, uti-lization management and other facets of theworkers’ compensation delivery system. TheAmerican College of Occupational andEnvironmental Medicine has selected ReedGroup and The Medical Disability Advisor asits delivery organization for this easy-to-useresource. The UMK features treatment modelsbased on clinical considerations and four lev-els of care. Other features include ClinicalVignette – a description of a typical treatmentencounter, and Clinical Pathway – an abbrevi-ated description of evaluation, management,diagnostic and treatment planning associatedwith a given case. The UMK is integrated withthe MDA for a total return-to-work solution. Ginny Landes Phone: (303) 407-0692 Fax: (303) 404-6616 glandes@reedgroup.com www.reedgroup.com

Refer aVendor— Earn $100

Vendor, individualand institutionalmembers of the

NAOHP will receive a$100 commission forevery referral theymake that results in anew vendor member-ship. The commissionwill be paid directly tothe referring individualor their organization.There is no limit to thenumber of referrals. In other words, if fivereferrals result in fivenew memberships, thereferring party willreceive $500.

If you know of a vendor who would benefit from joining the NAOHP VendorProgram, please contactRachel Stengel at 800-666-7926 x12.

The following organizations and consultants participate in the vendor program of the NAOHP,including many who offer discounts to members. Please refer to the vendor program sectionof our website at: http://www.naohp.com/menu/naohp/vendor/ for more information.

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RYAN AssociatesServices include feasibility studies,financial analysis, joint venture devel-opment, focus, groups, employer sur-veys, mature program audits, MISanalysis, operational efficiencies, prac-tice acquisition, staffing leadership,conflict resolution and professionalplacement services.Roy GerberPhone: (800) 666-7926x16Fax: (805) 512-9534rgerber@naohp.comwww.naohp.com

ELECTRONIC CLAIMMANAGEMENTSERVICES

StoneRiver P2P LinkP2P Link provides electronic connectiv-ity between workers’ compensationpayers and medical providers. Since1999, P2P Link has been deliveringmedical bills and supporting documen-tation electronically. P2P Link facilitates faster payments to medical providers while reducingadministrative costs.Jewels MercklingPhone: (901) 653-2619julie.merckling@stoneriver.comwww.stoneriver.com/solutions/p2p-link

Unified Health Services, LLCUnified Health Services provides com-plete electronic work comp revenuecycle management services from“patient registration to cash applica-tion” for medical groups, clinics, andhospitals across the country. Thisincludes verification and treatmentauthorization systems, electronic

billing, collections, and EOB/denialmanagement. Provider reimburse-ments are guaranteed.Don KilgorePhone: (888) 510-2667Fax: (901) 255-6797dkilgore@uhsweb.comwww.uhsweb.com

WorkCompEDI, Inc.WorkComp EDI is a leading supplier of workers’ compensation EDI clear-inghouse services, bringing togetherPayors, Providers, and Vendors to promote the open exchange of EDI for accelerating revenue cycles, lower-ing costs and increasing operationalefficiencies. Marc MenendezPhone: (800)297-6906Fax: (888) 454-2681MMenendez@WorkCompEDI.comwww.workcompedi.com

LABORATORIES &TESTING FACILITIES

Clinical Reference Laboratory Clinical Reference Laboratory is a pri-vately held reference laboratory withmore than 20 years experience part-nering with corporations in establish-ing employee substance abuse pro-grams and wellness programs. In addi-tion, CRL offers leading-edge testingservices in the areas of Insurance,Clinic Trials and Molecular Diagnostics.At CRL we consistently deliver rapidturnaround times while maintainingthe quality our clients expect.Dan WittmanPhone: (800) 445-6917Fax: (913) 492-0208wittmand@crlcorp.comwww.crlcorp.com

eScreen, Inc. eScreen is committed to delivering innovative products and services whichautomate the employee screeningprocess. eScreen has deployed propri-etary rapid testing technology in over1,500 occupational health clinicsnationwide. This technology createsthe only paperless, web-based, nation-wide network of collection sites foremployers seeking faster drug testresults.Robert ThompsonPhone: (800) 881-0722Fax: (913) 327-8606 marketing@escreen.comwww.escreen.com

MedDirectMedDirect provides drug testing products for point-of-care testing, lab confirmation services and DOTturnkey programs.Don EwingPhone: (479) 649-8614Fax: (479) 648-3246dewing@gomeddirect.comwww.gomeddirect.com

MedTox Scientific, Inc.MEDTOX is committed to providingthe best service/testing quality in theindustry. MEDTOX is a SAMHSA certi-fied lab and manufactures our owninstant drug testing products–the PRO-FILE® line. Our expertise also includeswellness testing, biological monitor-ing, exposure testing and many moreservices needed by the occupationalhealth industry.Jim PedersonPhone: (651) 286-6277Fax: (651) 286-6295jpederson@medtox.comwww.medtox.com

National Jewish HealthNational Jewish Health, world leaderin diagnosis, treatment and preventionof diseases due to workplace and envi-ronmental exposures offers practical,cost effective solutions for workplacehealth and safety. We specialize inberyllium sensitization testing, diagnosis and treatment, exposureassessment, industrial hygiene consultation, medical surveillance and respiratory protection. Visit www.NationalJewish.org. Other metal sensitivity testing is available. Wendy NeubergerPhone: (303) 398-1367800.550.6227 opt. 6neubergerw@njhealth.orgwww.njlabs.org

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Vendor program, cont.

Oxford ImmunotecTB Screening Just Got Easier withOxford Diagnostic Laboratories, aNational TB Testing Service dedicatedto the T-SPOT.TB test. The T-SPOT.TBtest is an accurate and cost-effectivesolution compared to other methodsof TB screening. Blood specimens areaccepted Monday through Saturdayand results are reported within 36-48 hours.Noelle SneiderPhone: (508) 481-4648Fax: (508) 481-4672nsneider@oxfordimmunotec.comwww.tbtestingservices.com

Quest Diagnostics Inc.Quest Diagnostics is the nation’s lead-ing provider of diagnostic testing,information and services. OurEmployer Solutions Division provides a comprehensive assortment of pro-grams and services to manage yourpre-employment employee drug test-ing, background checks, health andwellness services and OSHA requirements.Aaron AtkinsonPhone: (913) 577-1646Fax: (913) 859-6949aaron.j.atkinson@questdiagnostics.comwww.employersolutions.com

MEDICAL EQUIPMENT,PHARMACEUTICALS,SUPPLIES AND SERVICES

Abaxis®Abaxis® provides the portable PiccoloXpress™ Chemistry Analyzer. The analyzer provides on-the-spot multi chemistry panel results with compara-ble performance to larger systems inabout 12 minutes using 100uL ofwhole blood, serum, or plasma. TheXpress features operator touchscreens, onboard iQC, self calibration,data storage and LIS/EMR transfercapabilities.Joanna AthwalPhone: (510) 675-6619 Fax: (736) 262-6973joannaathwal@abaxis.comwww.abaxis.com/index.asp

AlignMedAlignMed introduces the functional and dynamic S3 Brace (Spine andScapula Stabilizer). This rehabilitationtool improves shoulder and spine func-tion by optimizing spinal and shoulderalignment, scapula stabilization and

proprioceptive retraining. The S3 isperfect for pre- and post- operativerehabilitation and compliments physical therapy. Paul JacksonPhone: (800) 916-2544 Fax: (949) 251-5121pjackson@alignmed.comwww.alignmed.com

Alpha Pro Solutions, Inc.Internationally recognized leader ofDrug Free Workplace and handhygiene training and consulting.Occupational Health clinics make greatre-sellers to employers (DERs, supervi-sor signs and symptoms, employeeawareness). Drug Collector, BAT andInstructor training via WEB andClassroom. Breathalyzer and screeningdevices. Instructor tools: WEB,PowerPoint, Manuals, Tests, Videos. Sue ClarkPhone: (800) 277-1997 x700Fax: (727) 688-2727sue@alphaprosolutions.comwww.alphaprosolutions.com

A-S Medication Solutions LLCASM, official Allscripts partner, intro-duces PedigreeRx Easy Scripts (PRX), aweb-based medication dispensingsolution. Allowing physicians to elec-tronically dispense medications at thepoint-of-care with unique ability tointegrate with EHR or be used stand-alone. PRX will improve patient care,safety and convenience, while gener-ating additional revenue streams forthe practice.Lauren McElroyPhone: (888) 990-6510info@a-smeds.comwww.a-smeds.com

Automated Health CareSolutionsAHCS is a physician-owned companythat has a fully automated in-office rx-dispensing system for workers’ com-pensation patients. This program is avalue-added service for your workers’compensation patients. It helpsincrease patient compliance with med-ication use and creates an ancillaryservice for the practice. Shaun Jacob, MBAPhone: (312) 823-4080Fax: (786) 594-4645sjacob@ahcs.com

Dispensing SolutionsDispensing Solutions offers a conven-ient, proven method for supplyingyour patients with the medications

they need at the time of their officevisit. For nearly 20 years, DispensingSolutions has been a trusted supplierof pre-packaged medications to physi-cian offices and clinics throughout theUnited States. Bernie TalleyPhone: (800) 999-9378Fax: (800) 874-3784 btalley@dispensingsolutions.com www.dispensingsolutions.com

Keltman Pharmaceuticals, Inc. Keltman is a medical practice serviceprovider that focuses on bringinginnovative practice solutions toenhance patient care, creating alterna-tive revenue sources for physicians.Keltman’s core service is a customiz-able point of care dispensing system.This program allows physicians to setup an in-office dispensing systembased on a formulary of pre-packagedmedications selected by the physician.Wyatt WaltmanPhone: (601) 936-7533Fax: (601) 936-7787wwaltman@keltman.comwww.keltman.com

Lake Erie Medical & SurgicalSupply, Inc./QCP For 24 years Lake Erie Medical hasserved as a full-line medical supply,medication, orthopedic and equip-ment company. Representing morethan 1,000 manufacturers, includingGeneral Motors, Ford and Daimler-Chrysler, our bio-medical inspectionand repair department allows us tooffer cradle-to-grave service for yourmedical equipment and instruments. Michael HolmesPhone: (734) 847-3847Fax: (734) 847-7921Mikeh@LakeErieMedical.com www.LakeErieMedical.com

PD-Rx PD-Rx offers NAOHP members a com-plete line of prepackaged medicationsfor all Point of Care and Urgent CareCenters. So if it’s Orals Medications,Unit Dose, Unit of Use, Injectables, IV,Creams, and Ointments or SurgicalSupplies that you need, let PD-Rx fillyour orders. 100% Pedigreed. Jack McCallPhone: (800) 299-7379 Fax: (405) 942-5471jlm@pdrx.comwww.pdrx.com

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U.S. Preventive MedicineUS Preventive Medicine offers ThePrevention Plan(tm), a suite of com-prehensive health management prod-ucts to improve the health, productiv-ity and quality of life for members,while reducing health care costs foremployers, insurers and governmententities. Health systems across thecountry are realizing the value of ThePrevention Plan.Richard Maguire-GonzalezSr. Vice President, NetworkDevelopmentPhone: (866) 665-0096rgonzalez@USPreventiveMedicine.comwww.USPreventiveMedicine.com orwww.ThePreventionPlan.com

PROVIDERS

Methodist Occupational Health CentersMethodist Occupational HealthCenters (MOHC) is an Indiana basedprovider of clinic based occupationalhealthcare and a national provider ofworkplace health services for employ-ers looking to reduce overall employeehealthcare costs. In addition, MOHCIprovides revenue cycle services nation-ally to other occupational health programs and health systems.Thomas BrinkPhone: (317) 216-2526 Fax: (317) 216-2839tbrink@clarian.orgwww.mohci.com

New England Baptist HospitalOccupational Medicine CenterNew England’s largest hospital based occupational health network offers a full continuum of care. Areas ofexpertise include biotechnology,orthopedics, drug and alcohol testing,immunizations, medical surveillanceand physical examinations.Irene AndersonPhone: (617) 754-6786 Fax: (617) 754-6453Ianderso@caregroup.harvard.edu

PUBLICATIONS

Center for Drug TestInformationWe are here to help you find theanswers to your questions about alcohol and drug testing and the StateLaws that apply. We provide specificstate information and court cases youcan use to protect your organizationand save money by knowing yourstate’s incentives and workers’ compensation rules.Keith DevinePhone: (877) 423-8422Fax: (415) 383-5031info@centerfordrugtestinformation.comwww.centerfordrugtestinformation.com

SOFTWARE PROVIDERS

Integritas, Inc. Agility EHR 10 is both CCHITCertified® 2011 Ambulatory EHR, andcertified as an ONC-ATCB 2011/2012Complete EHR, enabling government

incentives for eligible providers.Designed to meet specific needs ofhigh volume Occ Med/Urgent Careclinics, charting is fast and thorough,coding is automated, customer sup-port is notoriously outstanding. Genevieve MusonPhone: (800) 458-2486www.integritas.com 2011sales@integritas.com

MeditraxMediTrax™ is a user-friendly softwarethat meets real-world information management needs. Features includepoint-and-click appointment schedul-ing, workflow-driven-data entry, “one-minute” patient registration andcheckout, voice-recognition supportfor clinical dictation, automated ICD9and CPT4 coding, integrated workers’comp and OSHA reporting, testing-equipment interfaces, and occupation-specific surveillance programs. Joe Fanucchi, MDPhone: (925) 820-7758Fax: (925) 820-7650drjoe@meditrax.com www.meditrax.com

Practice VelocityWith over 600 clinics using our soft-ware solutions, Practice Velocity offersthe VelociDoc™—tablet PC EMR forurgent care and occupational medi-cine. Integrated practice managementsoftware automates the entire rev-enue cycle with corporate protocols,automated code entry, and automatedcorporate invoicing.David Stern, MDPhone: (815) 544-7480Fax: (815) 544-7485info@practicevelocity.comwww.practicevelocity.com

PureSafety’s OccupationalHealth Manager® (OHM®) &SYSTOC®

PureSafety’s powerful, yet easy-to-usesoftware helps you manage all aspectsof occupational health and safety witha full suite of solutions for bothemployers and providers – powered byindustry-leading OHM and SYSTOCsoftware platforms. Now you have thepower of the industry’s best tools formedical surveillance; case manage-ment; billing; flexible reporting andmuch more at your fingertips – from asingle company.Kelley Maier, VP, MarketingPhone: (888) 202-3016Fax: (615) 367-3887marketing@puresafety.comwww.puresafety.com

Medical Director/ Staff Physicians

• Northwest (Medical Director)• Southwest Ohio (Medical Director)• Georgia (Medical Director)• South Carolina (Medical Director)• D.C. Area (Medical Director)• Chicagoland (Medical Director)• Central Texas (Staff Physician)• Northern California-Monterey Area (Staff Physician)• Southern Oregon (Medical Director)

• Northern California (Medical Director)

For details, visit www.naohp.com/menu/pro-placement.

The NAOHP/RYAN Associates Professional Placement Service is seeking qualified candidates for the following positions:

226 East Canon PerdidoSuite M

Santa Barbara, CA 93101

1-800-666-7926www.naohp.com

PresidentJewels Merckling, Vice President,Enterprise SalesIntegritas, Inc.Kansas City, MO816-399-3951Jewelsm1210@integritas.com

Northeast – DE, MD, New England states, NJ, NY, PA, Washington D.C., WVDr. Steven CrawfordCorporate Medical DirectorMeridian Occupational HealthWest Long Branch, NJ 732-263-7950scrawford@meridianhealth.com

Southeast – AL, FL, GA, MS, NC, SC, TN, VALeonard Bevill, CEOMacon Occupational MedicineMacon, GA478-751-2925; lbevill@maconoccmedicine.org

Great Lakes - KY, MI, OH, WIKaren Bergen, R.N., AdministratorMarshfield Clinic Marshfield, WI715-847-3465kosidowski-bergen.karen@marshfieldclinic.org

Midwest - IL, INTom Brink, President and CEOMethodist Occupational Health CentersIndianapolis, IN317-216-2520; tbrink@clarian.org

Heartland – AR, IA, KS, LA, MN, MO, MT, NE, ND, OK, SD, TXMike Schmidt, Director of OperationsSt. Luke’s Occupational Health ServicesSioux City, IA 712-279-3470; schmidMS@stlukes.org

West – AK, AZ, CA, CO, HI, ID, NM, NV, OR, UT, WA, WYDr. John Braddock, CEO & Medical DirectorCascade Occupational MedicineLake Oswego, OR503-635-1960; braddockj@cascadeoccmed.com

AT LARGEMichelle McGuire, Software Solutions SpecialistOccupational Health Research/SystocLawrence, Kansas207-474-8432; mcguire@systoc.com

Troy Overholt, DirectorSt. Luke’s Work Well SolutionsSt. Luke’s HospitalCedar Rapids, IA319-369-8749; OverholTL@crstlukes.com

NAOHP Regional BoardRepresentatives and

Territories

Board Roster