Physician Peer Review or LNC Report?

Posted by on Jun 6, 2017 in Blog

What’s the best practice? Both When reviewing medical records, it may seem redundant and not at all cost effective to pay for both a physician’s peer review and a legal nurse consultant’s examination of the same claim or case. They both, however, offer unique perspectives. And, when you combine the two, the result affords you a more complete timeline of both the events that have happened and the medical future for the patient. The Physician Peer Review A physician peer review or medical review of a case can give you a pinpointed, detailed reporting of what has happened to date. It provides intricate details about specific pieces associated with the medical event and how those pieces fit directly together. More myopic in construction than an LNC report, the medical review yields very precise answers and insight into a medical event and the subsequent treatment strategies. Simply put, it’s a very accurate snapshot in time of the patient and the event. The LNC Report Also a major standard in the industry, an LNC takes the medical review and expands it. MKC nurses create a detailed medical record summary with ongoing embedded commentary, helping the reader understand both the material and its impact on the case. Contact us if you would like to see a sample report. An LNC report provides information about peripheral factors relevant to the case as well. It also considers long-term patient care and interaction, pre-accident medical information, specific information about the mechanism of injury and ongoing details pertinent to the injury and case. This broader approach often uncovers inconsistencies that may otherwise go undetected. An LNC’s granular level of review is equally important to the case as the focused review of the physician.  As one claims examiner once explained, “We know we will never have a silver bullet on these cases, but what is more valuable is that with the nurse review the details of the record evolves into a shotgun effect, thus exposing equally important details that are often missed.” Using a Whole Person Approach The patient involved may have a single event or episode, but the effects and ramifications of that single event can weigh heavily on the future treatment of that injured party. By using both reports, you gain a more complete picture of the claim, the specific injuries and the prognosis. Without using both reports, you could very well end up making future patient decisions with one eye...

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Delayed Treatment

Posted by on May 30, 2017 in Blog

Impacts of putting off medical care after injury Legal nurse consultants frequently find that a claimant has delayed treatment. Sometimes the delay may be only days, but many times the delay extends into weeks or months after the injury. The problem Delayed treatment makes it difficult to establish what injuries, if any, are causally related to the incident. With any gap in treatment, we cannot reliably know a claimant’s clinical presentation immediately after an injury, which is key to assessing the legitimacy of an insurance claim. The medical perspective Without a complete understanding of the claimant immediately after the injury, there is no way to unequivocally relate subjective complaints reported well after an injury. What’s more, when analyzing the claim, the rule of thumb is this: Compare subjective complaints to objective findings. Delays make this more difficult. If the claimant is not evaluated within a reasonable timeframe after the incident, any bruising, contusions or lacerations, which may have occurred at the time of injury, would likely have resolved, leaving it impossible to assess for signs of direct trauma. The bottom line As legal nurse consultants, we are asked to review medical records and render an opinion if the alleged injuries are consistent with the mechanism of injury.  So another critical question is this: What the delay may indicate about the injury and treatment. An argument could be made that if someone is really injured they would NOT delay seeking treatment for an extended period of time. Any delay also allows for ADDITIONAL injuries, which could potentially draw into question the legitimacy of the original injury itself. While we may not be able to directly relate subjective complaints reported weeks or months after the injury, what we can do is provide the claims handler with information about why the delay or absence of medical care makes it very difficult to relate the complaints to the incident. Debra West, RN, BSN,CCM, LNC is a legal nurse consultant with MKC Medical Management.  Contact Debra at or...

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Chiropractors vs. Physical Therapists: What’s the difference?

Posted by on May 23, 2017 in Blog

For anyone trying to understand a medical record or condition — including patients — it helps to take a look at definitions and how they’re applied. When chiropractors and physical therapists appear in those records, we often see confusion from clients. How are the professions different? How are they the same? Can they address the same injuries or complaints? We expect those questions to keep coming as both the number of physical therapists and chiropractors grow, in part, to serve a growing aging population. According to the Bureau of Labor Statistics, the number of chiropractor jobs will grow by 17 percent through 2024. For physical therapists, it’s a whopping 34 percent. By comparison, average job growth during the same period is forecasted at 7 percent. Let’s take a look at the definitions of each profession first. Here’s how the American Chiropractic Association defines chiropractic: “Chiropractic is a healthcare profession that focuses on disorders of the musculoskeletal system and the nervous system, and the effects of these disorders on general health. Chiropractic care is used most often to treat neuromusculoskeletal complaints.” Chiropractic therapies mainly consist of pain management through adjustment and manual manipulation. Those therapies could include: soft tissue mobilization joint adjustment electrical stimulation and acupuncture. And here’s how the American Physical Therapy Association defines physical therapy: “Physical therapists are healthcare professionals who maintain, restore and improve movement, activity and health, enabling individuals of all ages to have optimal functioning and quality of life, while ensuring patient safety and applying evidence to provide efficient and effective care.” Physical therapists have a much broader base within their systems. Physical therapy isn’t just for pain relief. It’s also critical for rehabilitation focused on restoring functions and preventing disabilities after disease, injury or the loss of a body part. These practitioners use several techniques to achieve this goal. They include: exercise to strengthen muscles encouraging improved range of motion and retraining individuals to perform activities required for day-to-day living. Promoting healing – in different ways While both professions promote healing, it’s important to remember the differences. The chiropractor focuses on manipulation on the musculoskeletal and spinal system. The physical therapist focuses on maintaining, restoring and improving movement of musculoskeletal and neuromuscular systems through strengthening programs. Most confusion about the difference between chiropractic and physical therapy is a result of how these two very different professions overlap in their treatment of the spine. Keep this in mind: While a chiropractor remains the King of Spinal Manipulation, the physical therapist is the King of Physical Rehabilitation through exercise, activity modification and muscle strengthening. Barriers to access Another significant difference relates to access. Chiropractors are accessible to the general public. Often, a medical referral is required...

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Tips, Trends and Findings

Posted by on May 16, 2017 in Blog

Here are studies, reports and stories that caught our eye in the last month. Auto technology and insurance claims: Technology and consumer expectations are among the issues driving the evolution of auto insurance as we know it, according to an article in Property Casualty 360. The article explores “seven key areas that are ripe for further discussion, research and analysis.” Storefront crashes: “Storefront crashes,” which involve a vehicle running into a commercial, public or retail building, cost insurers millions of dollars a year, according to an article in Claims magazine. In fact, in 2015 and 2016, the Storefront Safety Council is aware of more than $100 million in claims paid. “The trend is increasing as more cases go to trial and plaintiffs find it easier to show that a location was poorly protected against a foreseeable and preventable risk,” says the article, which also details new safety standards and trends to watch. Top liability loses: Allianz Global Corporate & Specialty’s Global Claims Review 2017 recently ranked the top modern corporate liability exposures. The report finds that defective product or work; collisions and crashes; and human error were the leading causes of liability losses. Drowsy driving: At least 21 percent of fatal crashes involve exhausted drivers, according to an article in Claims Journal. But activities to keep drivers alert, including radio adjustments and opening a window, come with their own risks. The article explores the issues, signs of drowsy drivers and ways to ensure drivers get enough sleep before they hit the road. More data needed: According to a report from the National Safety Council, 2016 may have been the deadliest year on the nation’s roads since 2007. Last year, 40,000 people may have died because of a motor vehicle crash. Another 4.6 million were seriously injured. But, the council’s report says that “little is known about key driver behavior factors in these crashes because critical data is under-reported.” The report makes recommendations for law enforcement and those in the traffic safety...

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Case Study: Lead poisoning

Posted by on May 2, 2017 in Blog

Why what’s missing is sometimes the most important detail There is no safe blood lead level in children, according to the Centers for Disease Control and Prevention. But, more than 500,000 U.S. children have elevated levels, which can cause lifelong developmental delays. One of our clients, an insurance company, pulled in MKC Medical Management to review the alleged lead poisoning case of a toddler. The child was healthy as an infant, but he developed significant speech and other developmental delays. Doctors eventually diagnosed the child with pervasive developmental disorder (PDD), which is on the autism spectrum. What we found, according to the medical records, was that the child had lived in a building with toxic levels of lead. Tests also revealed that he had elevated blood lead levels. But, those findings don’t necessarily mean that lead poisoning was behind the child’s diagnosis and delays. In any case under review, correlation doesn’t always mean causation. Here are the facts of the case: Overview: The claimant is a three-year-old child who, the plaintiff attorney alleges, has developmental and behavioral issues because of lead exposure in the home. MKC’s legal nurse consultants worked on the defense team for the insurance carrier.    What the records say about the child’s lead levels At one year of age, the child’s blood level was 5 mcg/dL, which is considered elevated. Five months later, it was up to 5.3 mcg/dL. Six months later, it was up to 6.9 mcg/dL. The blood lead level was later reported to have spiked to 16 mcg/dL before dropping to 11 mcg/dL, but no lab reports for these final two tests were submitted for review. What the records say about the child’s home When the child was age two, city officials sent a letter to the property owners of the building the child was living in to notify them that there were “toxic levels of lead in or on the dwelling.” A lead abatement plan was required. It’s unknown how long the child had lived in the home and whether he had lived anywhere else. After the abatement order was issued, the family was relocated. Red flags Missing lab reports were just one of this case’s red flags. Here are some other warning signs: The child lived with five siblings, ages 2 to 12, but no test results were submitted to indicate that any of the other children had elevated levels of lead in their blood. According to an assessment with the family, there is a family history of genetic issues, sickle cell trait and seizure disorders, but the relationship to the individuals with these medical issues and more specific diagnoses were not identified. If the child has a genetic history...

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More than medical: Tips for reviewing lead poisoning cases

Posted by on Apr 25, 2017 in Blog

Lead poisoning, especially in children, has made headlines in recent years, for good reason. The condition, found in more than 500,000 U.S. children, can lead to lifelong delays, including damage to the brain and nervous system; slowed growth and development; learning and behavior problems; and hearing and speech issues. The most recent blast of headlines began with the crisis in Flint, Mich. There, after the city started drawing drinking water from the Flint River in 2014, the number of children under six years with high levels of lead in their blood almost doubled. Those rates returned to normal levels after Flint went back to its original drinking water source – Detroit’s water system. Several officials face charges in the case. But, those headlines have only continued as further research has uncovered high levels of lead poisoning among children across the country. One examination by Reuters, the news agency, discovered nearly 3,000 U.S. communities with high rates of lead poisoning among their youngest residents. More claims, cases This renewed concern means some of our clients are seeing more claims related to lead poisoning, a condition the Centers for Disease Control and Prevention calls the “most preventable environmental disease among young children.” But, to truly understand the medical records and history in those case files and get to the bottom of the cause, you’ll need to explore more than just the patient’s health information. Everything from whether the child ever lived outside the country to what products their family uses to the child’s own genetic history are critical for a fully informed review of a lead poisoning case or claim. Aware for decades The public and officials have been aware of the dangers of lead for decades. In the 1950s, the first cities started passing laws about lead-based paint. The federal government didn’t take action until the 1970s. In 1978, legislators banned the residential use of lead-based paint. When coupled with the phase down of the use of lead in gasoline, researchers documented a big drop in the average blood lead levels in the United States. These days, the most common sources of lead aren’t from house paint or gasoline, but regular exposure to things such as toys, nutritional supplements, water in lead pipes, residue from a parent’s occupation and dishware, among other items. According to the American Academy of Pediatrics, the annual cost of childhood lead exposure in the United States is $50 billion. Lead toxicity is blamed for the loss of 23 million IQ points among children and is attributed to 20 percent of cases of ADHD. Today’s goal: Prevention Today, the focus is on stopping lead exposure before it happens. According to the CDC, there is no safe...

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