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Dr. Paul Volkman: The People’s Pusher

Tuesday, February 21st, 2012

Dr. Paul Volkman specialized in mitigation of pain. Did he ever. From 2003 to 2005 he was the most prolific prescriber of Oxycodone and related opioids in the entire country. He was recently sentenced to four life terms in prison for the deaths of four patients. There were eight additional overdose deaths associated with his practice, but these lacked enough evidence to prosecute. Patients came from hundreds of miles away and were charged $125 to $200 in cash for visits to see a doctor. Volkman’s distribution system had a devastating effect on southern Ohio, where he based his practice.

Prosecutors said Volkman rarely, if ever, counseled patients on alternate treatments for pain, such as physical therapy, surgery or addiction counseling. Volkman denied the allegations and said he always acted in good faith. A month before his conviction, he dismissed his attorneys and defended himself. His skills as an attorney appear to be totally in sync with his skills as a physician.

Street Creds and Credentials
Volkman went to work at the Tri-State Health Care and Pain Management clinic in southern Ohio in 2003. The clinic was operated by Denise Huffman and her daughter Alice Huffman Ball, who have pled guilty to one count of operating Tri-State as a business whose primary goal was the illegal distribution of prescription drugs. Denise has been sentenced to 12 plus years in prison; her daughter is serving five years. Both testified against Volkman, as did a horde of witnesses including pharmacists, police investigators, clinic employees and patients who received pills from Volkman.

What is striking about this case is the harsh sentencing. Four life terms is the kind of sentence you rarely see applied to white collar criminals; Volkman was sentenced as if he were a run-of-the-mill (pun intended) drug kingpin, which, minor differences aside, he was.

Through the wonders of the internet, we learn that Volkman had a three star rating from his patients and earned his medical degree at the University of Chicago Pritzger School of Medicine in 1974, followed by a residency at Duke Medical Center. After that, well, something went terribly wrong. Nonetheless, with his impressive creds, he’s sure to be a very popular man for the rest of his highly circumscribed life.

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North Carolina Workers Compensation Medical Fee Disputes

Tuesday, February 21st, 2012
The procedure for Workers Comp medical provider fee disputes has changed.  You can find the link here or the new rules are published below.   You will need  PDF reader to view the document.  You can also print this blog post.  I tried to make the new rules as readable as possible.  Some web browsers may change or scramble it.


My main concern is the 20 day deadline for the 26I response by a carrier, TPA, or employer.  Is the 20 days from receipt or when the dispute was mailed by the provider?




Procedure for Medical Provider Fee Dispute Resolution Pursuant to N.C. GEN. STAT. §97-26(i)


1. Direct Inquiry
A Medical Provider may submit an Industrial Commission Form 26I: Medical Provider Dispute Resolution Questionnaire directly to the employer or carrier believed to be liable for unpaid medical fees.


    a. The Medical Provider will be responsible for obtaining directly from the injured employee information regarding the identity of the employer liable for the injury.


    b. The Medical Provider may obtain contact information for an employer, or for the workers’ compensation insurance carrier for a particular employer on a particular injury date, by means of the Workers’ Compensation Name Search System on the Industrial Commission website.


    c. If the Medical Provider is unable to obtain the necessary employer or carrier contact information through the Workers’ Compensation Name Search System, the Medical Provider may contact the Medical Fees Section of the Industrial Commission for assistance in obtaining that carrier contact information.
       i. The assistance provided by the Medical Fees Section will be
limited to providing employer contact information and to assisting
the Medical Provider in identifying the workers’ compensation
insurance carrier associated with a particular employer on a particular date.
       ii. The Medical Fees Section will not share with the Medical Provider
any information related to any specific claim before the Industrial
Commission.
       iii. The Medical Fees Section will not directly facilitate or otherwise
be involved in any communication between the Medical Provider and any employer or workers’ compensation insurance carrier at this stage in the process.


2. Informal Dispute Resolution Process
If the employer or carrier does not respond to the Form 26I Questionnaire within 20 days, or responds by denying liability for the unpaid medical fees, the Medical Provider may submit a written request for assistance to the Medical Fees Section of the Industrial Commission. The written request for assistance must be accompanied by a copy of the Form 26I Questionnaire submitted by the Medical Provider, including all accompanying materials, and any response received by the Medical Provider from the employer or carrier contacted. Upon receipt of the written request for assistance meeting the above requirements, the Medical Fees Section will initiate an informal dispute resolution process between the Medical Provider and the employer or carrier identified on the Form 26I Questionnaire.


3. Limited Intervention
If informal dispute resolution does not resolve the dispute to the Medical Provider’s satisfaction, the Medical Provider may request limited intervention in an existing claim before the Industrial Commission by filing a formal Motion to Intervene with the Executive Secretary’s Office. The motion will be granted only if (a) a claim related to the medical fees in dispute has been filed before the Industrial Commission, and (b) liability for the underlying injury in the claim has not been denied or has been adjudicated in the employee’s favor.


The Motion to Intervene must include the following:
a. IC file number, if known.
b. Employee’s name, address, and SSN (last four digits only).
c. Date of injury and a brief description of the workplace injury, including the body parts known to be affected.
d. Itemized list of the medical fees in dispute, including CPT codes relating specific charges to the Workers’ Compensation Medical Fee Schedule, and explanations directly relating each charge to the employee’s workplace injury.
e. Copy of the Form 26I Medical Provider Dispute Resolution Questionnaire submitted by the Medical Provider, including all accompanying materials, and any response received back by the Medical Provider from the employer or carrier contacted.
f. Copy of the written request for assistance submitted to the Medical Fees Section.
g. Copy of the written summary by the Medical Fees Section of the informal resolution process and outcome.
h. Sworn affidavit by the Medical Provider that:
   i. The Medical Provider has treated the employee,
   ii. The medical fees itemized by the Medical Provider are current and unpaid, and
   iii. The Medical Provider reasonably believes that the employer or carrier named on the Form 26I Questionnaire is obligated to pay the fees under the Workers’ Compensation Act.
i. Certification of service upon both the employee and the employer or carrier named on the Form 26I Questionnaire.


4. Request for Review by the Full Commission of a Denial by the Executive Secretary
If the Medical Provider’s request to intervene is denied by the Executive Secretary, the Medical Provider may request the Full Commission’s administrative review of the Executive Secretary’s Order, by filing such written request with the Dockets Section within 10 days of receipt of the Executive Secretary’s Order denying the intervention. The request for review by the Full Commission must be served on all parties and must be accompanied by a statement of facts necessary to an understanding of the issue; a statement of the relief sought; copies of the motion to intervene with all attachments as required by Section 3 of this procedure which were submitted for consideration by the Executive Secretary; and a copy of the Order denying the motion to intervene.
Within 10 days after service of the request for review by the Full Commission, any other party to the case may file a response with supporting affidavits or related portions of the file that were not submitted with the request for review by the Full Commission.


A determination will be made by the Full Commission on the basis of the request for review, any response, and any supporting documents. No briefs or oral argument will be received or allowed unless ordered by the Industrial Commission upon its own motion.


5. Discovery and File Requests
If the Medical Provider is allowed to intervene, the Medical Provider shall have limited access only to those elements of the claim file related to the medical fee dispute, in accordance with the non-public nature of the claim file under N.C. GEN. STAT. § 97-92(b). Requests for information from the Industrial Commission file related to the medical fee dispute must be in writing and directed to the Claims Section of the Industrial Commission and accompanied by the Executive Secretary’s Order allowing the Medical Provider to intervene. Discovery, as to the matters related to the medical fee dispute, may be conducted by the Medical Provider once the Medical Provider has been allowed to intervene.


6. Request for Hearing
An intervening Medical Provider may request a hearing before the Industrial Commission on the fee dispute by filing an Industrial Commission Form 33I: Intervenor’s Request that Claim be Assigned for Hearing along with a $200.00 filing fee. The Form 33I will be handled in the same manner as a Form 33 Request for Hearing, including referral to mediation through the Mediation Section.


Upon resolution of the fee dispute, whether by agreement of the parties or decision of the Industrial Commission, the Medical Provider will be dismissed from the claim. Thereafter, the only standing the Medical Provider will retain in the claim following an Order

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Fatigue Risk Same As Alcohol Risk – Shocker

Monday, February 20th, 2012

There were many questions, comments, and web traffic on this blog from the post last week on Fatigue Risk Management. I thought research on Google would aid me in finding some other material.

I came across an interesting study on the effects of fatigue as compared to alcohol consumption. I thought there would only be an inference that fatigue and alcohol consumption would be related from a Risk Management viewpoint. I was shocked to find a study that was actually able to equate a period of time with a level of alcohol consumption. See the study here.
This should be an eye-opener for Risk Managers from all types of industry and governmental organizations. The study was performed in Australia in 1997. The website lists different conclusions on relating fatigue vs. alcohol risks. The main conclusion was there is no difference in motor skills between someone with a Blood Alcohol Content (BAC) of .1% and sleep deprivation for 24 hours.

I am assuming they did not use .08% as a marker as the overall BAC for a DUI was .1% at the time. There is a chart on the page that would show a .08% alcohol equivalent at 20 – 21 hours without sleep. As mentioned my last post on this subject, there can be a cumulative effect for sleep deprivation where even shorter amounts of deprivation in succession would add up to result in the same effect. The last post also pointed out that there are other things that enhance fatigue as an additive effect to lack of sleep.
I think this area will have a revival of sorts as Risk Managers look to reduce Workers Comp accidents in the future. I doubt any Safety Departments or Risk Managers would let someone work on a job with a .08% alcohol level = 20 hours without sleep.

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Health Wonks, drug epidemic, ACA mandate, exploding hog farms & more

Thursday, February 16th, 2012

Health Wonk Review – Jason Shafrin has posted the Health Wonk Review: More than Birth Control Pills edition at Healthcare Economist. And there is indeed much more than birth control in this issue: politics, health care reform, the Affordable Care Act, and a grab bag of other timely topics. Check it out!

CDC calls prescription drug problem “epidemic” – The CDC weighs in on the prescription drug abuse problem, calling it “epidemic” and “the fastest growing drug problem in the United States.” Risk & Insurance offers a concise summary. And on the same theme is a story about how New Jersey has implemented a Prescription Drug Monitoring Program. “In unveiling the program last month, state officials related that one patient obtained more than 2,500 doses of oxycodone and methadone in a four-week period. The patient presented what are now believed to be forged prescriptions to three pharmacies on 14 separate occasions, spread out his visits among the pharmacies, and paid sometimes with cash and sometimes by insurance.”

Affordable Care Act: What if… – What if the Supreme Court overturns the mandate? At Managed Care Matters, Joe Paduda looks at what the repeal of the mandate would mean for workers comp.

Marijuana & impairment Roberto Ceniceros recently discussed the issue of marijuana use and impairment. He cites a recent Louisiana appeals-court ruling that upheld benefits for an injured worker who showed positive in a post-injury test for consumption of marijuana and a prescription drug.

Emerging Risks: Exploding Hog Farms – Hog farmers take note: the Minnesota Daily covers reports of a mysterious foam that has caused Midwest swine barns to unexpectedly explode. The foam can build up to heights of four feet on manure pits. “The foam traps gases like methane and when a spark ignites it causes an explosion. About a half dozen barns in the Midwest have exploded since the foam was discovered in 2009. / In mid-September 2011, a barn in Iowa was added to the growing number of barns taken down by the foam. In the explosion, 1,500 pigs were lost, and one worker was injured.”

Contractors in conflict zones – At Risk Management Monitor, Jared Wade discusses contractor deaths in Afghanistan as reported in a recent New York Times article. He notes that, “In 2011, for the first time, there were more civilian contractors working for U.S. companies that died in Afghanistan than there were U.S. soldiers.” He follows up with excerpts and links to a prior Risk Management story on working in the world’s most dangerous locations

Economy & Insurance – Global financial woes will not derail the economy, according to Robert Hartwig, President and Economist at the Insurance Information Institute, who has been a reliable forecaster and source of information on both the overall economy and the impact on the insurance industry. He sees opportunities for insurers beyond waiting for rate increases. Read more in Chad Hemenway’s story at Propertycasualty360: Hartwig: U.S. Insurers Should Look at ‘New Trajectory of Growth’

Aging & Construction Work – The Center for Construction Research and Training analyzed 100,000 workers comp construction industry claims for the
state of Colorado to understand the relationship between the claimant
age and costs by the causes and natures of injuries and illnesses. Consistent with other aging studies, the report says “Older construction workers filed a small percentage of the total workers’ compensation claims; however, when they did file a claim the associated costs were greater.” Review the key findings: The Role of Age on the Cause, Type, Nature and Cost of Construction Injuries (PDF)

News briefs

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Fatigue Risk Management – Cutting Edge (Or Is It?)

Wednesday, February 15th, 2012
One of the best studies I have seen in quite some time on workplace Risk Management was a recently published analysis on Fatigue Risk Management (FRM) – see this article. It is from the American College of Occupational and Environmental Medicine.

The subject is not cutting edge. Every Risk Manager know that as fatigue rises, so does the accident rate. The key points of the study are:

• Fatigue is related to duration of sleep and timing (circadian rhythm) of sleep.
• Inadequate sleep is correlated with a variety of adverse medical outcomes.
• Various shift work schedules can affect both the duration and the timing of sleep.
• Inadequate duration of sleep is correlated with injury rate.

The study goes on to point out the differences between fatigue and sleepiness. When the term fatigue is used, many think of it as the same as sleepiness, but these are actually two different (although related) states. Sleepiness is the tendency to fall asleep; fatigue is the body’s response to sleep loss or to prolonged physical or mental exertion.
Fatigue may be reduced by sedentary activity or rest without sleeping,whereas subjective sleepiness and the propensity for sleep are often exacerbated by sedentary activity or rest.1 Sleep propensity can be accompanied by decreased alertness which then leads to decreased attention to detail, impaired judgment,
and slowed response time. This can affect productivity, safety, and overall health

Table 1 lists several factors that can lead to fatigue and increased sleep propensity and that affect the resultant degree of impairment. Fatigue and decreased alertness resulting from insufficient or poor quality sleep can have several safety-related consequences, including slowed reaction time, reduced vigilance, reduced decision-making ability, poor judgment, distraction during complex tasks, and loss of awareness in critical situations.

Sleep deprivation has long been recognized as an unmet public health challenge. Many individuals believe they adapt to chronic sleep loss or that recovery requires only a single extended sleep episode, but studies have shown that this is not the case.  

Table 5 near the end of the study has a great checklist for fatigue.  I think we will all see fatigue become a very hot risk management and claims item over the next few years.

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