Sometimes insurers must spend a little more to get best outcome
No matter what type of insurance line is involved, medical care will often be the largest part of the claim. The associated care and treatment will be the primary driver of damages.
So how do you get a handle on the medical aspects of a claim and the associated charges so that an optimal outcome is achieved?
Here are some tips:
Be proactive: Don’t wait. Work the claim aggressively. Open medical cases take on a life of their own and can quickly spiral out of control. Review all material as soon as you get it. A single diagnosis code can be a big tip.
Use all internal and external resources: Pull out the stops and USE resources – internal and external. Medical review software can help. Medical professionals are just an email away. At MKC Medical Management, we often get questions by phone and email on basic things.
Don’t be penny–wise and pound foolish: Sure, medical reviews through experts or software can sometimes be expensive, but, in the long run, they will pay off. Take advantage of the resources. For smaller claims, more basic reviews are always a great place to start.
Look at the fundamentals of the case: Really focus on the foundation of the mechanics of the injury. Ask for initial vehicle AND bodily impact points and verify initial complaints against the medical visit, records and police report, if available.
Set the reserve early: Early assessment and analysis is key to setting the initial reserve. Do frequent re-assessments against new medical records. If you’re not sure what the records indicate, consult an outside medical provider for additional insight and prognostications.
Don’t jump the gun on settlements: Depending on the diagnoses, it may not be advisable. Conditions such as burns and head trauma often improve with time. In fact, for many conditions, maximum medical improvement, the point when a patient’s condition is stabilized, is not until two years after an injury.
Evaluate, review and consider ALL co-morbidities: Diabetes, hypertension, osteopenia, peripheral vascular disease and many psychiatric conditions can have an influence on the injury sustained. If you don’t know the impact, ask a medical professional.
Look at the medical case as a whole: Don’t just review the narrative or bills on their own. Review the documentation side by side. Are critical pieces of information missing?
Seek an outside film review: This may sound expensive, but, when possible, have a physician review the actual films, especially if you don’t have the written diagnostic report.
Anticipate higher emergency department care: The cost for all emergency department care is going up and becoming more costly every year. Review ALL emergency department documentation carefully. Seek help with an expert in deciphering the records.
Upfront, thorough medical reviews can be costly and time consuming. But, in the end, they can result in the best outcomes for both patient and insurer.
The workforce is getting older. The U.S. Bureau of Labor Statistics reports that the rate of workers age 55 and up in the labor pool has gone up in recent decades – and will continue to climb.
The changing faces at the conference table mean employers must take a hard look at their policies and procedures – especially those that relate to workers’ compensation and other claims. Thanks to normal aging, older workers are at higher risk for chronic diseases, take more time to recover and face other age-related setbacks.
How can employers help? Through innovative programs. Here are six options. Read more in our recent article at Property Casualty 360.
Launch wellness programs and encourage participation. Make sure they address the needs of your older workers and encourage healthy lifestyles.
Offer ongoing workplace physicals. If health issues crop up, an employer may be able to make changes to job duties.
Project costs based on an older worker’s ability to recover. Keep in mind that older workers may take more time to heal from a surgery or setback and could need extra therapy.
Create a committee to discuss all older workers’ claims early on. Quick referrals to the right medical doctor, along with more regular follow ups, may be in order.
Evaluate potentially protracted losses. This depends on the job, but they need to be done early by nurses at a local clinic or through case management.
Let them mentor: If older workers can’t physically get back to work, consider letting them take a leadership or mentoring role, which could reduce loss time and worker’s compensation payments.
After all, older workers bring much more than achy backs to the job. They offer a wealth of experience and knowledge and are playing big roles in today’s offices and job sites.
Four things to watch for when reviewing electronic medical records
In the past decade, health providers have made big changes in the way they document patient visits, monitor lab results and track their patients’ health.
Gone are the paper forms. Here to stay are the tablets and software programs where nurses and doctors record their patients’ health information. Adoption of these Electronic Health Records was among the key pieces of the Health Information Technology for Economic and Clinical Health Act of 2009 and the Federal Health IT Strategic Plan.
So far, the federal government’s efforts to encourage the move to these electronic records has paid off. According to a May 2016 report, by 2015, more than 4 in 5 of all non-federal acute care hospitals had adopted a Basic EHR with clinician notes. About 80 percent of small hospitals with less than 100 beds, rural hospitals and critical access hospitals had done the same.
When used correctly, Electronic Health Records can come with plenty of benefits, including better follow-up of test results; improved care coordination; cost savings and efficiencies; and increased patient participation. But, just because health care facilities have implemented this electronic recordkeeping, it doesn’t mean every doctor fully uses them.
According to a data analysis published in the June issue of Applied Clinical Informatics, researchers found that 43 percent of primary care physicians used workarounds – typically pen and paper. Doctors preferred alternative methods for three reasons: as a memory aid, for improved efficiency and for easier internal and external care coordination. Researchers concluded that future EHRs and work systems need to evolve to meet providers’ needs.
If you’re reviewing Electronic Health Records for a case or a claim, here are four things to know:
Not necessarily easier: It might seem counterintuitive, but electronic records often are much more difficult to cross reference than a traditional record. If the software for a hospital and a clinic, for instance, can’t communicate with each other and access the other’s electronic records, it makes it more difficult to track every record and result.
Not necessarily better: Each hospital has its own Electronic Health Record system and none of them necessarily improve patient care or documentation. Some are pieced together. Some components, even within a single health system, can’t communicate with each other. So always determine if there still might be a paper trail.
Audit trail opportunities: Electronic Health Records do give us important access into the history of a case. The date and time stamps are vital pieces of information for determining whether records were tampered with. Always complete a chronology of any record – written or electronic – so that inconsistencies, gaps and possible tampering are clearly identified.
Shortcuts everywhere: Electronic Health Records require doctors to key in more information compared to paper methods. To save time, providers often simply copy and paste as they move forward through the record, which is sloppy and often leads to inaccuracies. In many cases, standardized templates aren’t appropriate for a particular case. Workarounds are everywhere. These non-standard practices can make for inadequate documentation, poor patient outcomes and potential lawsuits.
When reviewing any kind of record – written or electronic – it’s important to review them with a critical eye and ensure you’re looking at the full picture.
Need help? MKC Medical Management’s highly trained Legal Nurse Consultants review medical records with the knowledge and experience to tease out the most vital information and get it right the first time.
Here’s a collection of studies, reports and stories that caught our eye in the last month.
Health technology to watch in 2017: From security and compliance to informatics and mobile health, Physicians Practice covers the eight health technology challenges and opportunities in 2017. On informatics, the publication writes that the use of electronic health records leads to “dramatic reductions in malpractice claims,” “faster lab results, “ and the “potential for significant cost savings and improved quality of care.”
Are ICUs overused? More than 50 percent of patients admitted to the intensive care unit at Harbor-UCLA Medical Center in Los Angeles may have been too well or too sick to be helped from ICU care, according to an article on MedPage Today. The article says researchers concluded that health care providers must more closely follow ICU priority ranking guidelines set by the Society of Critical Care Medicine to boost patient care and save money.
Innovation needed for senior care: A survey by CareMore found that seniors need more help navigating the healthcare system. According to the report, nearly 65 percent of seniors polled had been to three or more health care providers in the last year, but few have expert help to coordinate their care. Nearly 70 percent relied on themselves or a family member. For those hospitalized, 63 percent said nobody coordinated their care within the critical months after discharge. “Coordinating care across multiple providers who treat a single patient is a key strategy for ensuring positive clinical outcomes, while also reducing costs,” the report says.
OSHA expands reach: WC Magazine writes about the Occupational Safety and Health Administration’s new regulations for reporting workplace injuries, which went into effect in December 2016. According to the article, OSHA has “expanded its reach to encompass almost any employment practice, policy or procedure, whether active or passive, that can be construed as deterring employees from reporting injuries and illnesses.
Claims and comorbidities: Research presented at the National Workers’ Compensation & Disability Conference shows that workers’ compensation claims from employees with pre-existing conditions such as diabetes, obesity, hypertension and addiction come with higher price tags, longer durations and more litigation. “The workers’ compensation industry needs to do a better job of managing underlying chronic conditions along with an employee’s injury in order to better manage claims costs,” an article in Property Casualty 360.
Medical marijuana licensing: Nearly 30 states have medical marijuana programs, but states are struggling with licensing issues for new medical marijuana businesses, according to an article on PBS.org. Some states award just a few licenses. A few have no limit. And others are still developing their program or have combined licensing of medical marijuana and recreational marijuana businesses.
For more information and topics, check out our blog on MKC Medical Management.
7 reasons why claims adjusters should work with Legal Nurse Consultants
As an insurance adjuster, the cases you’re reviewing might not be much different from those examined by the generation of adjusters before you. There are injuries caused by car crashes and slips and falls, along with cases involving faulty products or workplace accidents.
The claims may be, for the most part, the same. But the treatments – and even the records themselves – may be entirely different from what your counterparts were scanning a couple of decades ago.
Electronic health records, for instance, have nearly made paper ones obsolete. Concerns over the country’s opioid addiction epidemic are forcing entirely new ways to handle chronic pain. Telehealth allows patients to consult with doctors in far-flung regions.
But these new health care advances aren’t the only changes. Escalating medical costs and provider fees; more litigated cases; and higher litigation fees make it vital that adjusters review cases with not just a careful eye, but a critical one.
Legal Nurse Consultants, who often bring years of work experience as a registered nurse, are trained to review complex medical records and uncover the facts and tidbits that can make or break a case. They provide adjusters with full medical reviews and analyses for complicated claims of all kinds and sizes.
Are you wondering if you should hire an LNC? Here are seven things you’ll get if you do:
Improved medical understanding: An LNC can translate complicated medical information, records, charges and codes so adjusters understand all aspects of a case.
Accurate record: The more you understand about a claim, the better you can navigate the claim and understand which treatments were related to the case and which were related to pre-existing conditions.
Leg up on the opposition: Without the expertise of a medical professional, claimants and opposing counsel likely will have very little understanding of what’s actually in the record.
Early assessment: An early grasp of a claim’s medical details can improve claim resolution and decrease litigation costs.
Better picture: When adjusters understand the related diagnoses, conditions, treatments and charges, the claim payout is a more accurate reflection of the actual medical costs.
Economic reasons: Nurses are less expensive than a reviewing physician. Because of reduced costs, they are able to review the entire case and build a road map. Physicians are often very expensive and usually hyper-focused on one specific question.
Smaller cases get attention: Historically, medical and nurse reviews have been reserved for big cases. But overutilization, overtreatment and unrelated care can happen at all claim levels. An LNC can help review records and provide a better understanding of smaller cases.
Need help? Find out more about MKC Medical Management’s highly trained Legal Nurse Consultants.
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.