10 red flags when reviewing records for minor motor vehicle accidents
For motorists, the National Highway Traffic Safety Administration has good news and bad news.
According to a March 2016 report, there were 219 fewer fatalities from motor vehicle crashes in 2014 than in 2013 – part of an ongoing decline in the number of motor vehicle-related deaths across the country since 2006.
But the number of people injured during a car crash is on a slight uptick. In 2014, 2.34 million people sustained injuries in a motor vehicle accident. In 2013, the number totaled 2.31 million.
While the increase in injuries is considered “statistically insignificant,” the boost represents thousands of patients, countless insurance claims and a bevy of complaints about sore necks and bad backs.
Of course, many injuries from automobile collisions are severe. But, when the accident is a “minor impact collision,” studies have shown that occupants are unlikely to suffer longstanding injuries. The treatment and length of the open or unresolved claim, however, can be protracted and may involve plaintiff counsel.
Bruises, after all, heal quickly. Psychologic factors, in fact, might be the reason behind most complaints of chronic pain after a minor collision, according to a report about the biomechanics of minor automobile accidents. In fact, researchers have found that claimants complaining of whiplash get better more quickly if they don’t have access to compensation for their pain and suffering.
As you review records from a minor crash, there are plenty of red flags that could signal big problems.
Here are 10 red flags to look out for:
No damage, significant injuries: The vehicle suffered very little damage, but the patient complains of significant injuries – or offers multiple variations of physical complaints.
Extended care without assessment: The patient seeks extended periods of chiropractic care, physical therapy, acupuncture and pain center treatments before seeking help from an orthopedist, an evaluation from a neurologist or an assessment from another medical specialist.
Lack of improvement is a big RED Flag.
Ongoing treatment, no specialist: The patient undergoes ongoing treatment from a family practitioner or primary care physician, but does not seek treatment from a specialist.
MRIs, CT scans: The patient undergoes high-level diagnostics immediately. Remember: An MRI, a CT scan and similar tests should be done to confirm or rule out a condition – not as part of a fishing expedition.
Prior problems: If a patient undergoes surgery or is hospitalized after a minor collision, it may be an indicator of prior health issues or problems or conditions that pre-date the accident.
Compare, contrast: Compare the billing statements against the narrative records. Missing records are a red flag.
Examination required: Review carefully the mechanism of injury throughout the medical records. Any ongoing changes and embellishments are a red flag.
Unusual injuries: Shoulders and wrists are usually not injured in a minor collision. If there was no head trauma, any alleged neurological, cognitive and learning losses should be thoroughly investigated.
Lack of advanced treatments: If injections, discograms and other more advanced treatments and diagnostics weren’t ordered, it’s likely the injuries were minor. Doctors try to avoid these tests and treatments as they carry potential risks and complications. Additionally, advanced treatments should be supported by diagnostics and objective findings.
Degenerative findings: If radiologic studies found significant degenerative issues, these evolved before the motor vehicle accident because of old age or other factors. Exacerbation or aggravation can occur, but there should be a return to the medical baseline.
As you review a case or claim from a minor motor vehicle collision, be sure to follow the providers through the entire medical records. Know who they are and how they participated in the care. Track the dates of the diagnostics and understand whether they were ordered pre date of loss or injury.
And, as the nation faces an epidemic of opioid addiction, keep an eye on prescriptions. Review medication lists from all providers, especially records from the hospital emergency department and outside pharmacies. Was the patient already taking medications that might indicate existing problems? Is an opioid addiction in play?
Medical records can reveal plenty about the severity of a person’s injuries after a car crash. And, if the vehicle received only minor or minimal damage, a trained eye can uncover the discrepancies that would rule out a major injury.
Red flags and savings can usually be found in all cases if you just know where and how to look!
Helping older workers stay in the workforce
The Great Recession was a big hit for our nation’s older workers. They lost jobs and retirement savings, forcing them to delay retirement and stay in the workforce longer.
For baby boomers and older Gen Xers, who hoped to be logging retirement time about now, that’s not great news. But, for many reasons, it’s a good thing for employers.
Older workers bring with them expertise, long-term knowledge and institutional history that can be a boon for today’s workplaces. And, just because their hair is graying, it doesn’t mean they’re slowing down. In fact, one study from North Carolina State University found that older computer programmers actually know as much – and even more – than their younger co-workers.
Still, aging workers bring their own set of issues thanks, in large part, to one simple fact: They’re getting older. The graying workforce is forcing employers to make changes related to workers’ compensation and other insurance claims, but it’s slow going. In a survey by the Society for Human Resource Management, 36 percent of respondents said their workplace is just beginning to look at policies and practices related to older workers.
We cover the issue much more in a recent article in Property Casualty 360, but here are four things to keep in mind as your workforce gets older.
- The risk of heart disease, diabetes and other chronic diseases increase as we age. So do medical bills. In fact, the American Diabetes Association found that medical costs are double the amount for people with diabetes.
- The majority of baby boomers are either overweight or obese, leading to higher risk for conditions such as hypertension, vascular disease and arthritis. Obesity also can restrict a person’s abilities at work.
- More time is required for bone and wound healing. In fact, aging skin can take up to four times as long to fix itself.
- Joint range of motion declines with age.
As you celebrate the successes and wins of your older workers, it’s critical for employers to ensure they set them up for success.
As the costs of claim expenses and indemnity pay outs increase, many companies are becoming more sophisticated in their data analysis.
Here are nine tips for capturing and using data for predictive analysis:
- Claims systems capture large amounts of data. They include the names of providers, dollars spent, indemnity costs, types of injuries, body parts, comorbidities, lost time, geographic location, prescription drug use, costs associated with outside counsel, independent adjusters, case managers and various vendors.
- Age, comorbidities and medications can be analyzed for predictive modeling. Example: Age, obesity and diabetes all, either singularly or collectively, increase medical care costs and the time off work required for recovery and rehab. By using this information in various ways, insurance companies and payer sources can create in-depth risk analytics and claim trends.
- Through data collection, patterns in payments, providers, employers, injuries and more can be found. This can lead to more successful risk models and predictive analysis.
- Information can be analyzed to help identify emerging trends that can impact the carrier at various points along the claims continuum. This information also can be used to create other risk or claims products to assist the payer source or employer; address safety or return to work issues; or implement different claims or underwriting practices.
- Analysis of providers and hospital data can identify treatment trends, patient outcomes, length of treatment and care, dollar expenditure and other issues. This information can be obtained through claims paying or bill audit software.
- Outside sources, including review companies and nurses, also can obtain helpful data for analysis.
- Trends in hospital charges and the use of services by patients or claimants can be captured and analyzed. Comparison of hospital information in a geographic location can be invaluable to a payer source.
- Much of this data is used to analyze risk and claims trends, which, in turn, gives a more accurate risk profile. By providing hard data, underwriting should be improved. This information is then shared with the insured, which can help explain or justify underwriting decisions.
- Possible trends that can be captured to help identify various types of fraud.
At MKC Medical Management, we help claims adjusters and attorneys understand complex medical records and information.
Here are studies, reports and stories that caught our eye in the last month.
Return to Work: The workers’ compensation industry must focus on encouraging a timely return to work, helping employers keep a trained workforce and improving the quality of life and financial stability for people who are injured on the job, agreed most industry leaders at the third National Conversation on the Future of Workers’ Compensation. These “foundational principles” for workers’ compensation are critical as the industry faces criticism from the U.S. Department of Labor and OSHA.
Medical Fee Schedule Recommendations: The Workers Compensation Research Institute recently released a new study to help policymakers adopt, reform or update the medical fee schedule in their state workers’ compensation system. Designing Workers’ Compensation Medical Fee Schedules 2016 shows how 43 states with workers’ compensation physician fee schedules and the District of Columbia made fee schedule design decisions, which have become the focus of policy debates.
Opioids and Dialysis: A presentation during American Society of Nephrology’s Kidney Week linked opioid prescription with a higher mortality risk for dialysis patients. Those patients also were at a higher risk of discontinuing dialysis and hospitalization.
More Marijuana?: Now that weed is legalized in California, an article in the Insurance Journal explores the question of whether the new law will increase demand for it from injured workers. The insurance industry is encouraged to start thinking ahead.
Use or Abuse: Doctors are on the frontlines of the war against opioid addiction, but working as one of these “medical gatekeepers” is becoming more and more complicated. Steven Reidbord, a psychiatrist, covers the topic on MedPage Today.
For more great information and topics, check out our blog on MKC Medical Management.
I’ve worked with a lot of legal nurse consultants since launching MKC Medical Management in 1997. And, from experience, I know what qualities make for the best ones.
This fall, I had the chance to dive deep into that topic as I wrote a piece about how to hire a great LNC. For more information, see my article in Attorney at Law Magazine.
Here are seven tips for hiring a great LNC:
Know what you want: Have specific goals in mind and make sure the LNC meets them. Find out if somebody else will review the final product before it’s sent to you.
Ensure the LNC understands the case: The LNC must understand not only who is at fault, but the standard of care and any other relevant legal issues.
Expect a translation of medical terms: If the reader has to use Google or a medical dictionary to get through the report, then the LNC has failed.
Demand attention to detail: If the LNC repeatedly misspells words, gets dates wrongs and makes other mistakes, then you need to question whether she has what it takes to be a consultant.
Make sure medical information is properly reported: The LNC’s analysis should demonstrate a knowledge of the disputed facts versus the undisputed facts, along with any expert opinions. Any information that speaks to your specific issue or questions should be included.
Look for a basic understanding of biomechanics: Nurses are not biomechanical engineers, but they need to have an understanding of how an accident affects the body.
Meet in person or by telephone: An LNC must be able to think like the opposing counsel and determine why a provider did what they did. A lot of information about the nurse’s skills and expertise can be gleaned from talking through issues in person or by telephone.
Not every registered nurse makes for a good LNC. It’s critical they understand both a claim’s legal nuances and are able to explain them clearly in writing. But, when you do land on a great one, they can help you build your case – and win.
Here are studies, reports and stories that caught our eye in the last month.
Medical marijuana and the workplace: An article in WC Workers’ Compensation magazine covers the clinical and legislative significance of medical marijuana. As more states approve the use of medical marijuana, employers must consider how to handle claims when medical marijuana is prescribed for work-related injuries and policies related to work duties for those using medical marijuana, the article says.
Liability Medicare Set-Asides on the horizon: An article in Claims Management says that the Centers for Medicare and Medicaid Services could review Liability Medicare Set-Asides. The article updates the latest movement on the issue and recommends current best practices for liability claims with Medicare beneficiaries.
New study on Alzheimer’s disease: In a report from JAMA Psychiatry, higher brain amyloid burden, an early indicator of Alzheimer’s disease, was associated with more frequent feelings of isolation, being left out and lacking companionship. These feelings could be associated with early brain changes in preclinical Alzheimer’s disease before the onset of mild cognitive impairment.
Help for those healing: As many as 70 percent of patients with cancer report increased anxiety, depression, fatigue and a poorer quality of life after chemotherapy. A study in the Journal of Clinical Oncology found improvements when patients took part in a web-based cognitive rehabilitation program.
Kids at risk: An analysis in JAMA Pediatrics found that pediatric hospitalizations for opioid poisonings increased almost two-fold from 1997 to 2012. Older adolescents had the highest hospitalization rates, but the largest percentage increase was among toddlers and preschoolers. Public health interventions, policy initiatives and consumer-product regulations are required to curb children’s exposure and misuse of the drugs.
Emergency room visits are on the rise. One study from the American College of Emergency Physicians found that 28 percent of ER doctors polled have reported a spike in the number of cases since the Affordable Care Act took effect. Another 47 percent have seen at least a slight increase.
The costs are on the upswing too, especially for personal injury claims, as
hospitals attempt to recoup money thanks to changes in the health care system and other factors. In fact, charges can vary wildly – from $4 to care for a sprained ankle to $24,000, according to one study. There is no associated fee schedule with property and casualty claims. This, by default, allows providers to set their own fees with the expectation of full reimbursement.
Still, the ER is the first place many go for medical care. And those ER records provide a critical, but complex window into a patient’s health and injuries, establishing a medical baseline at the time of the incident. To the untrained eye, the codes, test results and billing practices can be a confusing garble of medical terms and figures. But, when insurance claims are analyzed by MEDICAL consultants they provide vital clues into a patient’s actual injuries, the inciting event and billing practices.
Did the injured person actually suffer serious injuries or is there some inconsistencies in their reporting? Are the provider charges verifiable with the medical record? Were the ordered and completed test indicated for the injuries and reported conditions? In my mind, appropriate care is appropriate care regardless of payer source. Unfortunately, this is not always true. In ERs, doctors practice “defensive medicine” to avoid malpractice claims, which can drive up health care costs. Liability claims also are the only kind of claim to not have an applicable fee schedule. Other types, such as workers’ compensation, Medicare and private insurance claims, pay out at a specific level. With liability, there are no specific allowed fees for a test or procedure.
The ER records are where you analyze and begin to build your case. An accurate reading and understanding will provide the objective findings to understand how the injured person fared after that slip and fall or car accident, and contrast those findings against subjective complaints and reported history.
If you’re analyzing them, here’s what you need to know:
Basic ER documentation: Be sure you have all of the paperwork. In the ER, that includes the RN triage sheet, the ER physician documentation, diagnostics studies and testing, bedside nursing notes, consultation reports, order sheets and consent. Look at what was ordered? Is it consistent with the working diagnosis? Was the physician confirming a suspicion or ruling something out. These details matter because they help us grasp the records and course of events and help lay a foundation of understanding.
Patient arrival: How did they get to the hospital? Did they go by ambulance immediately? Or did they wait a few days and drive themselves to the ER? What was their recorded status upon arrival? What was the patient’s position on the Triage Acuity Scale, which ranks the severity of a person’s injury? If they arrived by ambulance, what information did EMS provide?
Symptoms and chief complaint: Carefully review the physical examination. Compare the nurse’s triage against the physician’s examination and notes. Look for inconsistencies. Does their chief complaint match the objective findings? Do the complaints escalate? Are there new ones? The initial complaints are always the most accurate. Review those first complaints against the reports from EMS.
Bills: Check the charges to make sure the services included in the bill are in the medical documentation. Ask questions. Was it medically appropriate to order a CT scan? Was the skill level the hospital charged appropriate for the injury? Were all of those labs really necessary?
A trained eye can quickly figure out the answers to all of those questions and explore other angles that can save time and money. (That’s what we do here at MKC Medical Management – helping claims adjustors and attorneys understand complex medical records and information).
Regardless of who reads the records, it’s important to know that ER records have a lot of moving parts. If you don’t understand what’s in the records, it will be hard to refute what happens later because you never understood how it started.
Emergency Room records
Provides a baseline for a patient’s injuries. An accurate reading and understanding will supply the objective findings to understand how the injured person fared. All sections and information within the ER records must be reviewed and investigated in order to assess mechanism of injury issues, merit, alleged relatedness and casualty issues. Remember: The medical records are a snapshot of the medical care. The care rendered should, in theory, have nothing to do with the payer. The care should be within the known and established protocols for the respective injuries without bias of insurance coverage. However, it’s critical to acknowledge that the filter of insurance coverage does sometimes impact the care documented within an ER record.
Basic ER documentation
Make sure you have it all. It includes RN triage sheet, the ER physician documentation, diagnostics studies and testing, bedside nursing notes, consultation reports, order sheets and consent.
How did they get to the hospital? Did they go by ambulance immediately or wait a few days? What was their recorded status upon arrival? What was the patient’s position on the Triage Acuity Scale? Review the nurse’s bedside notes carefully. You’ll find a treasure trove of information about how the patient behaved, what they said and how they responded to treatments and care.
Symptoms and chief complaint
Compare the nurse’s triage against the physician’s examination and notes. Does their chief complaint match their objective findings? Do the complaints escalate? The initial complaints are always the most accurate. Compare subjective complaints to the objective findings. These should align in some way.
Prior medical condition
Don’t forget to check pre-existing conditions and current medications. Any number of conditions and medications can impact cognition, balance, bleeding times, perception, etc.
What are the test results? Consider chronic versus acute versus degenerative. Are there abnormal lab results? Elevated blood sugar? Prolonged bleeding time? Understand that the rule of thumb is this: A finding should fit what is known. Only when it does not should doctors begin investigating more unusual conditions. And, clearly, not all abnormal findings are directly related to a trauma event.
Check the charges to make sure the services included in the bill are in the documentation. Ask questions. Were the services, tests and labs really necessary? Does there appear to be over-utilization? Are the services appropriate for the reported injury and / or diagnosis?
At the time of discharge, the medical team will provide information to the patient about diagnosis, post discharge care, medications and follow-up care. Did the patient leave AMA, otherwise known as against medical advice? Did the ER physician recommend a specific follow-up specialty or PCP, yet the patient went to a different specialty or did not follow up at all? What condition was the patient upon discharge?
A trained eye can quickly figure out the answers to all of those questions and explore other angles that can save time and money. That’s what we do here at MKC Medical Management – helping claims adjusters and attorneys understand complex medical records and information.
How doctors, patients, employers and insurers can help
By Kari Williamson, RN, LNCC, CCM
For decades, doctors prescribed opioids to fix their patient’s chronic pain. In reality, for some, opioids just made their lives worse, leading to addiction, escalating drug use and even death.
The numbers behind what’s being called an “epidemic,” which I wrote about in this month’s edition of Property Casualty 360, are stark. Opioids were involved in the deaths of more than 60 percent of people who died from a drug overdose in 2014, a year when more people died from overdoses than ever before, according to the Centers for Disease Control and Prevention. Since 1999, the number of overdose deaths from opioids has nearly quadrupled, says the American Society of Addiction Medicine.
To address the issue, the Obama administration in March announced the federal government’s first coordinated plan for reducing the burden of chronic pain. And, this summer, the U.S. Surgeon General Vivek H. Murthy sent a letter to every doctor in the country, asking them to “turn the tide” on the opioid crisis.
“Many of us were even taught — incorrectly — that opioids are not addictive when prescribed for legitimate pain,” Dr. Murthy wrote. “The results have been devastating.”
Doctors are taking a new look at how how they can curb opioid use – and abuse. No longer using opioids as a regular course of action; strictly limiting the number of pills and refills; searching for other therapies and medications; and checking with their state’s prescription drug management program database all are proven ways to limit opioid prescriptions.
But the hard work to defeat this epidemic doesn’t fall only on them.
Patients must be aware of the dangers of opioids; always take the lowest dose; and be ready to try alternative therapies to manage their pain.
Employers should seek out an expanded drug testing panel; ask insurers and providers to look out for warning signs that a patient is abusing opioids; and create a safe zone where employees can ask for help.
Insurers must make sure case managers follow patients throughout treatment and their use of any opioids; insist on periodic, random drug screenings; and look out for warning signs.
I shared many more tips for doctors, patients, employers and insurers in my article in this month’s edition of Property Casualty 360.
The opioid epidemic is serious – destroying lives, families and communities. But, together, we can turn this tide around.
Kari Williamson, BS, RN, LNCC, CCM
Owner of MKC Medical Management, Inc. a nationwide medical legal consulting company that provides a variety of services to the legal and insurance sectors. Kari has twenty plus years as a legal nurse consultant and case manager.
To learn more about Kari, visit the AALNC President’s Blog!
By Kari Williamson, BS, RN, LNCC, CCM
MKC Medical Management
I recently saw a post by a fellow LNC, inquiring: “How do I best manage leads, names, clients, contacts, supportive colleagues, and others while I grow my business?” What’s a LNC to do?
There are many Contact Relationship Management (CRM) platforms which boast a variety of functions—in addition to the ol’ tried and true Excel spreadsheet. Some CRMs are very expensive, while others more reasonable. Excel is on most everyone’s computer, is very versatile and can be effective. So how do you choose what would work best for you? What systems work the best? Does a more expensive tool really give you better results? Click over to the AALNC Presidents Blog to see the full blog post.