Getting to the ‘tooth’ in dental claims

Posted by on Apr 4, 2017 in Blog

Reviewing dental claims is a regular part of our job at MKC Medical Management. But the work isn’t as clear cut as it might seem when you’re dealing with a cracked tooth or gum lacerations. They often take a lot of sleuthing. Let’s look at one case we reviewed. A man was reportedly struck on the left side of the chest. The claimant 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 records. Checking the facts I reviewed everything and cross referenced the alleged event facts and ALL of the objective data, including the lab tests and diagnostic results. I looked at pieces of information tucked in the emergency room 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  In fact, I reviewed everything three times! And, guess what?! NO oral trauma was documented. There was NO subjective complaint regarding oral, dental, teeth, gum pain or trauma. 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 mucosa, pink and moist.” Wait, no oral trauma? 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. Considering the account of the event and that the description of all of the other injuries was very detailed, it was odd. Then, 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. There was NO billed return visit until four weeks after the alleged accident. Alert, alert! 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 and a HUGE RED FLAG! A person...

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Tips, Trends and Findings

Posted by on Mar 28, 2017 in Blog

Here are studies, reports and stories that caught our eye in the last month. Workers’ comp safety net: Panelists and audience members at the recent Workers’ Compensation Research Institute conference say the workers’ compensation industry must play a role in a broader safety net as “job security, employer-funded pensions and health insurance is weakened,” according to an article in the Insurance Journal. Participants also want professionals and policymakers to clearly define what responsibilities they have for those falling outside the workers’ compensation system, including aging workers with chronic illnesses, undocumented immigrant laborers and those working in the gig economy, the article says. Blood pressure and dementia: Middle-aged people who have a sudden drop in their blood pressure could be at risk of developing dementia and other cognitive decline when they get older, according to new research from Johns Hopkins Bloomberg School of Public Health. An article in Medical News Today about the research says that “temporary, rapid drops” in blood pressure may cause “serious damage” because they “stop the necessary blood flow from reaching the brain.” Impact of arthritis on healthcare costs: New research from the Medical University of South Carolina offers the “first time the relationship between arthritis or joint pain limitations and medical expenses has been examined in a large U.S. cohort,” according to an article in MedPage Today. Researchers found, according to the article, that “activity limitations may explain the difference in medical expenditures between patients with arthritis or joint pain and those who don’t.” Curbing drug use at the ER: A simple conversation about cutting back on drug use during an emergency room visit could be the “basis for a long-lasting drop in a person’s use of illegal drugs or misuse of prescription medicines,” according to new research from the University of Michigan. According to a press release, the “findings, from a carefully designed randomized controlled trial involving 780 people at a Flint, Mich., ER who indicated recent drug use on a health survey, suggest that ER visits might serve as effective ‘teachable moments’ for drug use.” Palliative care boosts quality of life: Patients who received palliative care during a bone marrow transplant report better quality of life, according research at Massachusetts General Hospital, but more study is required to determine the long-term outcomes and costs, reports the National Institutes of...

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Pre-existing conditions matter

Posted by on Mar 14, 2017 in Blog

Study finds that truckers’ poor health could spike crash risk Truckers with three or more medical conditions carry two to four times the risk of being in a crash when compared to healthier drivers, according to a new study from the University of Utah School of Medicine. Researchers say the study indicates that truckers might not just be a danger to themselves – but to other drivers on the road, according to a press release about the study. The results were published in the Journal of Occupational and Environmental Health. “What these data are telling us is that with decreasing health comes increased crash risk, including crashes that truck drivers could prevent,” says the study’s lead author Matthew Thiese, an assistant professor at the Rocky Mountain Center for Occupational and Environmental Health, in the press release. Researchers looked at medical records from nearly 50,000 commercial truck drivers. Nearly 35 percent showed signs of at least one of many serious medical conditions such as heart disease and diabetes that are connected to poor driving. Then, researchers compared a driver’s medical and crash history. According to the study, there were 29 injury-causing accidents among all truck drivers per 100 million miles traveled. For those with three or more illnesses, it spiked to 93 injury-causing accidents per 100 million miles traveled. Accidents increased regardless of a driver’s age or experience. Current guidelines require that truckers stop driving only if they have a major health concern, not a variety of less serious illnesses. Researchers said they need to continue to study the issue to determine the best practices to keep both truck drivers and the public safe on the road. “If we can better understand the interplay between driver health and crash risk, then we can better address safety concerns,” said the study’s senior author Dr. Kurt Hegmann, director of the Rocky Mountain Center, in the press release. Here on the MKC Medical Management blog, we’ve said it before. When evaluating vehicle accident claims, it’s critical to consider pre-existing conditions that could have caused the crash and could impact the level of injuries – not only to the drivers, but to other people involved. A thorough reading of emergency room and other health records is critical to suss out all of the relevant information and how that information impacts the claim whatever the payer source. That should always include pre-existing conditions. Need help? Contact our experienced staff of legal nurse...

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Tips, Trends & Findings

Posted by on Mar 7, 2017 in Blog

Here are studies, reports and stories that caught our eye in the last month. Changes for casualty insurance market: An article in Property Casualty 360 ticks off the 10 trends that are expected to shape the market this year. They include increased employer and workers’ compensation complexities, more underwriting scrutiny and a push for higher casualty rates, among others. Patients skeptical of healthcare information technologies: Concerns about cybersecurity are among the reasons why more than half of consumers are leery of the benefits of healthcare information technologies such as patient portals and electronic health records, according to an article in FierceHealthcare. What’s more, 70 percent of Americans don’t trust health technology, up from only 10 percent three years ago. Sepsis readmissions: Sepsis is a leading cause of unplanned hospital readmissions. And, once there, patients’ hospital stays are longer and more expensive when compared to those with heart failure, pneumonia and other illnesses, according to a study in JAMA. Researchers make recommendations for ways to reduce readmissions and cut costs. Technology helping with diagnosis: An article in MIT Technology Review explores the new technologies, including smartphones and machine learning, that uncover vocal patterns that could help doctors diagnose everything from post-traumatic stress disorder to heart disease. Opioid alternatives: As healthcare professionals and entrepreneurs look to curb the use and abuse of opioids, new technologies on the market seek to offer alternatives to opioids for chronic pain. An article on CNBC.com covers this growing class of FDA-approved devices. For more great information and topics, check out our blog on MKC Medical...

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Google Glass, your doctor and you

Posted by on Feb 28, 2017 in Blog

How technology is helping doctors spend more time with patients, less time with paperwork The next time you’re at the doctor’s office, it might not be just you and your doctor involved in the conversation. A medical scribe also could be listening in thanks to new technology that uses Google Glass, the headgear that looks like a pair of glasses, but is connected to the Internet. It’s touted as a timesaver for doctors, who spend as much as 35 percent of their day on recordkeeping. Proponents also say it’s a better way for doctors to build relationships with their patients because they can look them in the eye instead of down at computer screens or a clipboard to check and update records. With the software, made by Augmedix, doctors put on a pair of Google Glasses, which have a camera and microphone built in, and are able to interact with their patient’s medical records with simply their voice. During the visit, a medical scribe watches and listens in. The scribe, trained to work with a particular practice, can answer the doctor’s questions about a patient’s history, for instance, and, once the exam is over, help ensure the records for that day’s visit are complete. For doctors, the technology allows for hands-free recordkeeping as they direct medical record updates with simply their voice. Doctors must approve any records before it becomes part of a patient’s permanent record. The service also complies with HIPAA requirements. According to an article for Stanford University’s medical school, patients sign off that they want to use the service before they meet with the doctor. Nearly 100 percent of patients agree, said Pelu Tran, the company co-founder who was a Stanford medical student when he launched the company. Scribes for Augmedix work from offices in San Francisco and India in sealed-off rooms and must leave pens, paper, smartphones and other belongings outside, according to an article in the Washington Post. The company is growing by leaps and bounds with big customers – Dignity Health, Sutter Health, and TriHealth, among them – and big investments. So far, funding has totaled more than $60 million, according to an article in Medscape. At the Consumer Technology Association 2017 Digital Health Summit in January, Augmedix cofounder and CEO Ian Shakil called Google Glass the “stethoscope of this century,” according to the Medscape article. And it’s expected to help fuel the medical scribe industry. By 2020, a report in JAMA estimates that doctors will employ about 100,000 scribes or one scribe for about every nine doctors. There were about 20,000 medical scribes in 2014. As the technology and acceptance grows, it could be a boon for patients and doctors. Patients get...

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Banner Business Year

Posted by on Feb 21, 2017 in Blog

Celebrating 2016, ready for what 2017 brings Last year was a busy year for MKC Medical Management. In 2016, we saw a 15 percent increase in business, thanks to multiple newaccounts coming on board and increased referrals from our existing client base. Along with more clients, our roster of employees also is expanding. We now have 10 legal nurse consultants working for us either as full or part-time contractors. Some have been with us for six years, when we started actively working to grow MKC’s presence. Our newest hire came on board four months ago. All are experienced registered nurses who, together, bring decades of experience in medicine. In fact, after so many years hiring such capable LNCs, I recently shared some tips in Attorney at Law Magazine. And we take our job seriously. Being an MKC LNC is a demanding job with a steep learning curve. We require excellence and continuing education. We meet virtually a couple of times each month to analyze and discuss reports. We’re not surprised by last year’s growth. As medical tests, health records and treatments become more complex, attorneys and claims adjusters are turning to us more often to help them ferret out the most important details of their cases and claims. Emergency room records, especially, are critical to building a solid case, but are growing in complexity and difficult for a layperson to fully understand. In fact, 2017, already, is shaping up to be big. Business is up nearly 30 percent over the same time last year as we work to increase referrals and gain visibility across the industry. In the past several months, you may have seen our articles in prominent publications such as Property Casualty 360. Our article, “10 red flags that could signal fraud for vehicle accidents,” was the fifth most popular article on Property Casualty 360’s website in January. We look forward to all of the possibilities and continued opportunities in store for MKC Medical Management in 2017. And we are eager to help our clients – new and existing – get to the bottom of the claims and cases on their desks. Let us know how we can help...

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