The News You Need for May 7

Case management and cannabis are what we're all about today at WorkersCompensation.com

Harrisburg, PA (WorkersCompensation.com) -- Last week, the Supreme Court of Pennsylvania granted a Petition for Allowance of Appeal in Schmidt v. Schmidt, Kirifides and Rassias, PC, 2024 WL 1873090 (Pa. 04/30/24). When the case comes before the court, the big question it will address is whether "medical services" and "medicines and supplies" under the commonwealth's Workers' Compensation Act include cannabinoid oil.

In the case that spurred the petition, Schmidt v. Schmidt, Kirifides & Rassias , PC, 305 A.3d 1137 (Pa. Commw. Ct. 2023), the Common Court of Pennsylvania held that the workers' compensation judge was correct to find that CBD oil was both a "medicine" and a "supply" compensable under the act.

How did the court get there?

The case involved an attorney, who sustained a work injury when, in a squatting posture, he loaded files into a trial bag for work, tipped the trial bag onto its wheels, had back pain, and fell over on his side. The attorney's work injury treatment was limited to pain management, for which he was prescribed oxycodone, OxyContin, Soma, Ativan, Zoloft, and CBD oil. The CBD oil was prescribed in lieu of increasing the attorney's dosages of pain medication.

The WCJ determined that the employer was liable to pay for the cost of the CBD oil, which had no THC in it, because it was a medical supply and part of the attorney's reasonable and necessary medical treatment.

On appeal, the Workers' Compensation Appeals Board disagreed, prompting the attorney to take the case to court.

Under Pennsylvania workers' compensation law, employers must provide payment for "reasonable surgical and medical services," which includes "medicines and supplies, as and when needed."

In upholding the WCJ, the Commonwealth Court agreed that the CBD oil met the act's standard for "medicines and supplies" because:

+ A doctor prescribed the CBD oil to the attorney to treat his pain.

+ The CBD oil benefited the attorney's well-being by reducing his pain, eliminating his need to increase the use of highly addictive opioid medications, and forestalling "expensive and risky" surgery.

In the court's view, this was in line with dictionary definitions of "medicine" ("a substance or preparation used in treating disease[;] [ ] something that affects well-being; ... [ ] a substance (such as a drug or potion) used to treat something other than disease”) and "medical supplies" ([a]ny item that is essential for?treating?illness or injury”).

But isn't cannabis illegal under federal law?

The employer didn't build its case well enough to satisfy the court on this argument, instead relying on "literature from the FDA's website providing consumer information about products containing cannabinoids."

The court went on to explain that the fact that some firms marketing CBD products may violate federal law and that selling approved products with unsubstantiated therapeutic claims violates federal did not make the attorney's use or the employer's reimbursement for CBD oil illegal.

"There was no record evidence that the CBD oil [the employee] used is illegal under federal law," the court wrote.

The court looked to Appel v. GWC Warrant Corp., 291 A.3d 927 (Pa. Commw. Ct. 2023), which held that since an employer was not "prescribing marijuana" but was just reimbursing a claimant for his lawful use thereof, the employer was not in violation of federal law.

"Certainly, if employers?must?reimburse employees for their use of a drug Congress has declared?illegal, the fact that the FDA has merely declared that some firms’?marketing?of CBD oil illegal cannot be an impediment to employers reimbursing employees when their use of CBD oil is legal and reasonable and necessary treatment of their work-related injury," the court wrote.

Thus, the court reversed the board's decision.

Will the Pennsylvania Supreme Court agree? Stay tuned.

Case Management Focus: It’s National Nurses Week — Celebrating Nurses!

Anne Llewellyn MS, BCPA, RN, CMGT-BC, CRRN, BCPA, FCM

Sarasota, FL (WorkersCompensation.com) -- The American Nurses Association celebrates National Nurses Week 2024, May 6 - May 12, and throughout May. This year's theme, "Nurses Make the Difference," honors the incredible nurses who embody the spirit of compassion and care in every healthcare setting. In this post, I wanted share highlights of my journey as a nurse. I hope this post prompts you to share your story and celebrate your successes.

Here is my story.

• I began my career as a Practical Nurse on the recommendation from my cousin because I did not want to be a secretary. She said try to be a practical nurse. The course is only one year and if you don’t like it you only put in one year.
• I checked out the program, filled in the application and started the program in September 1972. I graduated from St. Mary's School of Practical Nursing in 1973. It was a brutal program, but with hard work, determination, and perseverance, I graduated and passed my State Board and became a Licensed Practical Nurse.
• My first job was in a 64-bed male unit at the hospital where I trained. Most of the patients were blue-collar workers. Many were alcoholics or older men with multiple chronic illnesses. In 1973, LPNs were in charge, passed medications and did the treatments the patients needed. Looking back, I am not sure all we did was within our scope of practice, but this was the era we lived. We had nurses' aides we worked with, who taught, supported, and alerted us when someone was in trouble. It was trial by fire, but we did good work, and I loved what I was doing.
• Responding to rumors that nurses who were not RNs by 1980 could not work in hospitals, I returned to school to get my RN in 1976. I chose an associate degree program in Center City, Philadelphia again. I filled out the application and was accepted. The course began in 1976. My background and experience as an LPN were critical to my success. I graduated and passed my State Boards in September 1978. I worked at the hospital connected to the Nursing School at Hahnemann University. I worked there till I left Philadelphia to move to Florida in 1988. I was a critical care nurse and worked in the Emergency Department and the Respiratory Intensive Care Unit. Doing those year, we saw patients who were critically injured and were on ventilators for months. During that time we learned how important our jobs were to the patients, family and the residents and attendings we worked with. They trusted us and came when we called as they knew we were on top of our patients. I also learned how resilient people were and also the importance of teamwork.
• In addition to my clinical experiences, I worked as a risk manager, traveling to four hospitals in the Philadelphia area where I reviewed incident reports and investigated medical errors and documented what happened in case of a lawsuit. This experience gave me a view of the big picture of how hospitals functioned, how mistakes occurred, and the importance of advocating for the patient and the family while trying to decrease liability for the hospital.
• I learned that most people who experienced a medical error in the hospital mainly wanted the error to be admitted, an apology for those harmed, and a plan to make sure the error would not happen again. If this was not done, usually a lawsuit occurred.
• In 1988, I moved to Florida after my husband, and I were married as he was working. To get there, I joined a traveling nurse company that helped me get a job and housing while I planned a wedding, left my job as a Risk Manager and sold my condo in preparations for the move.
• Traveling Nursing was a great experience that I wished I had tried earlier. I met many nurses who were travelers and worked across the country and loved it. As I had emergency department experience, I got a job in a community hospital in Fort Lauderdale in the ED. It was a less hectic pace than I was used to, and it took me time to adjust. I worked there from 1988 -1996 as a full time employee and then as a part timer. I made a new set of friends/colleagues and am still friends with many of them 36 years later.
• In 1990, on a tip from a friend, I investigated the role of Nurse Case Manager. Not knowing what a case manager did, I interviewed for a job with Intracorp. The woman who interviewed me (who later became my manager) explained that case management was "good nursing." My job as a catastrophic nurse case manager would be to ensure the patients got what they needed in the least restrictive setting, in a timely manner, for the most cost-effective price. I would also report to the insurance company who covered the patient why things were being done and what resources would be needed to help a person who had a catastrophic illness or injury to heal and regain their baseline or adjust to their new normal. I would also advocate for the patients and their families to understand what was happening and help to coordinate care and transition them to the next level of care. The role sounded interesting, so I took the job. I stayed in the ED to keep my clinical skills by working weekends. This helped my husband and I save for our new home.
• Case Management closed the circle of nursing for me. It allowed me to see how people recover and live with the repercussions of their injury or illness. As a nurse case manager, I educated, empowered, and advocated for those people to get the medical care and resources they needed. They also empowered me to be a good nurse.
• In 2010, I moved into journalism when I went to work for Dorland Health as the editor-in-chief for Case In Point, a case management publication. This job opened new doors and allowed me to share my views and highlight professionals developing best practices in their roles as case managers. I had great managers and mentors who pushed me past what I thought I was able to do. The role gave me a voice as a nurse case management leader, educator, and mentor that served me well personally and professionally.
• In 2014, I got to see healthcare from the patient's perspective when I was diagnosed with a central nervous system brain tumor. I can say the diagnosis rocked me to the core. It took away my job and almost took my life. But it gave me insight into what it is like to be a patient. As a nurse, I knew the healthcare industry from the industry's point of view, but as a cancer patient, I learned how challenging the healthcare system was for the people who use it – the patient and their families. With an excellent healthcare team, I survived, and after healing, I used my writing and case management skills to start a new career as a Nurse Advocate. This role gave me a purpose and allowed me to help patients and families navigate the complex healthcare system. I started my blog, Nurse Advocate, to share my experiences to help improve the system and support all stakeholders in humanizing healthcare.

Becoming a nurse was the best career decision I could have made. I have had a great career, and I thank all who supported me and allowed me to grow professionally and personally. ?During National Nurses Week, I hope you share your story about why you became a nurse and your career. This is our week, so make sure you celebrate your successes!

How AI can Help Streamline the Medicare Set-Aside Process

Kim Wiswell

Medicare Set-Aside Arrangements (MSAs) are an important part of workers’ compensation programs and assist in earmarking settlement funds to cover future medical expenses stemming from workplace injury claims. However, providing an easy process for adjusters to refer MSAs, as well as managing operations to create these complex reports for the workers’ comp insurance industry efficiently has long been a challenge, especially when dealing with manual documentation and complex compliance requirements.

Let’s explore how the integration of AI and automation can effectively address these hurdles and make the MSA process more efficient.

Two Significant Challenges to Traditional MSA Processes Manual Documentation

The conventional MSA application process relies heavily on manual documentation. This involves the painstaking tracking of medical records, treatment history, and payment reports. This tedious approach is not only time-consuming, but also prone to inaccuracies, often requiring significant human resources. In addition, manual documentation increases the risk of missing critical information, leading to delays and potential compliance issues. Claims assistants or adjusters often spend a significant amount of time on MSA requests, ranging from an average of two to ten hours per referral, depending on factors like claim complexity, age, and the volume of medical records involved. Extended follow-up correspondence for clarification of body parts accepted under the claim or missing records can further extend this time.

Complex Regulatory Landscape

Another significant challenge is the navigation of the complex regulatory landscape of Medicare compliance. To be successful, the MSA application process requires meticulous attention to detail and expertise in interpreting Medicare's guidelines and regulations. Compliance errors can lead to penalties, delays in MSA approval by CMS, and heightened administrative burdens for all involved stakeholders.

Addressing These Challenges: Harnessing AI for Enhanced MSA Operations

AI-powered solutions can address both of these obstacles. By automating the documentation process, AI significantly reduces the manual effort needed to produce MSA determinations. Advanced algorithms can quickly analyze medical records, treatment histories, and billing information to generate comprehensive MSA documentation accurately. By automating repetitive tasks, AI reduces the likelihood of errors, accelerates processing times, and frees up resources for more strategic activities. In addition, AI technologies offer sophisticated compliance management capabilities, which allows all parties to navigate Medicare regulations with ease. AI-powered platforms continuously monitor changes in Medicare policies, ensuring MSA documentation remains up-to-date and compliant.

Additionally, AI algorithms can identify potential compliance issues proactively, allowing stakeholders to address them promptly and mitigate risks effectively. Integrating AI technologies into MSA operations can significantly impact MSA workflows. By automating the information and documentation collection and simplifying compliance management, AI streamlines both the MSA referral process, as well as internal operations, improving efficiency, and ensuring adherence to Medicare regulations. As the complexity of modern healthcare continues to evolve, leveraging AI becomes increasingly important for optimizing MSA processes and achieving better outcomes for all involved.