Digging into the facts MK Consulting, Inc. was recently asked to look at a case in which a man was reportedly struck on the left side of the chest.  The claim reported that he fell and injured his left knee and chest.   Buried in the same records, however, was a costly dental restoration plan. Based on the facts, I wondered how the claimant could justify such a thing.  So, I started with the Emergency Department   ED records. I reviewed everything and cross referenced the alleged event facts and ALL the objective data.  I looked at pieces of information tucked in the ER nurse’s triage notes, what the EMS documented the treating physician’s exam and  the discharge orders. In other words, I looked at everything. I really focused on the subjective complaints and reported information   Actually, I reviewed everything three times! Guess what?! NO oral trauma was documented. There was NO subjective complaint regarding oral, dental, teeth, gum pain/trauma, etc.  In fact, the claimant self-reported NO head trauma.  Furthermore, there was an entry documenting “no oral trauma.” None of the hallmarks of oral trauma were there:  No blood, no laceration, no missing or cracked teeth.  NO oral pain. Instead, the exam stated, “Oral musoca, pink and moist.” So I am thinking, why did the carrier send this file?  I kept digging.  Because nothing is really obvious, is it? I discovered that the records reported that the claimant received chiropractic care about three days after the incident date. But there was no mention of facial or oral trauma in the chiropractic notes.  Odd, inasmuch as the description of the event and ALL injuries was very detailed. More review…this time the dental records.  The injured man was seen by the dentist the day of the alleged incident. More mystery, as there was no documented problems.  I concluded that he must have been seen before the accident as well. Next, I pulled out the dental billing statement. NO billed return visit until four weeks after the alleged accident.  I then went back to the handwritten dental documentation. The corresponding notes clearly   documented NEW findings involving MULTIPLE teeth:   A fractured bridge, damaged  crown, cracked/loose teeth and a FRESH laceration around the gum with an associated a tooth fracture. These findings were significant.  HUGE RED FLAG! A person would likely not wait four weeks to seek dental evaluation or treatment. And while some of the findings might be a mixed bag of acute and non-acute, the findings clearly did not fit the alleged mechanism of injury and the self-report of no facial/head trauma. Final recommendations?  I recommended that BEFORE payment consideration be made, the carrier request additional documentation that supported the initial MOI and lack...