Need to really understand a claim?

Posted by on Feb 5, 2014 in Best Practices, Blog, Case Management, Claims Tools, Legal Nurse Consultant, Legal Nurse Consulting

Need to really understand a claim? Then understand the Mechanism of Injury Understanding and accurately interpreting the Mechanism of Injury are essential to determining if an injury is directly related to an event or accident. Making sense of the facts Insurance claims typically assert that someone with an injury fell in a certain direction and extended their arms to break the fall. In the case of motor vehicle accidents, claims usually detail the placement of an individual in the vehicle, whether they were restrained, the point of impact, speed, and so on. An individual in a car with a rear-end collision, for example, will potentially have much different injuries than someone who is hit from the side at a high rate of speed. These pieces of factual context are used to understand injuries and the legitimate basis for claims. Related or unrelated? Claims often include treatment for injuries related to an accident which are entwined with non-injury diseases or conditions. In addition, medical providers often identify and treat solely on the injury description provided by the patient – whether related to an injury or not. In order to untangle what is not directly related to the injury, there has to be a clear understanding of the injury details and Mechanism of Injury. Appropriately trained and experienced medical providers can separate related and unrelated parts of a claim and reduce the overall claim exposure. That’s because they understand Mechanism of Injury and its physical effects. The bottom line Injuries can be caused by a single event or can have multiple factors, and the presence of risk factors can make the individual more prone to injury. Once the Mechanism of Injury has been clearly identified, attention should focus on potential causes (e.g., internal/external risk factors, pre-existing conditions). The ultimate goal is to ensure appropriate treatment only for injuries directly related to an event. This can help produce cost savings and reduce claims exposure. Debra West is a Registered Nurse and Legal Nurse Consultant with MKC Medical Management, Inc. Contact Debra at or at...

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Batteries Not Included

Posted by on Feb 11, 2013 in Blog, Case Management, Case Management, WC, Workers Compensation

Batteries Not Included A case management perspective: A catastrophic claim can cost millions.  We have a team of professional, clinicians, diagnostics and an arsenal of resources to manage a cost-effective outcome.  What happens when the injured worker comes without coping skills, a pre-morbid history you do not have access to, and an aversion to intervention? How do you identify that a variance or sentinel event may be genetically pre-determined creating an indirect causally related condition that requires savvy case management. no fax payday loans fast Mr. “Smith” is a 29 year old shot on the job.  He sustains a SCI resulting in paraplegia.  The history you have available to you says he lived alone, independent, military background, attending college, with family support.  He flies through inpatient rehab ahead of schedule and is preparing for discharge to the community.  Without warning, he becomes despondent, suicidal, and is unsafe for discharge.  Counseling is called in and determines he has major depressive disorder.  The injured worker is discharged with 24 hr attendant care and an antidepressant.  He and you have left the confines of an interdisciplinary environment. As a case manager you must use critical thinking skills to put a new interdisciplinary team in place, and fast.  Mr. Smith needs medication management from a psychiatrist to start. He should continue with counseling.  Close communication is required from all parties including attendant care to monitor and assess the situation.  The treating physician must be aware of treatment plan and support the expectation for improvement.  Mr. Smith’s “new” baseline is not a cost-effective solution to his long term needs, but some may be tempted to think his needs are being met. Mr. Smith responds to medication and is no longer suicidal however, develops secondary and avoidable complications such as a UTI and skin issue. A good case manager would start to suspect depressive disorder is not the only thing going on.  Collaboration with post-acute interdisciplinary team reveals behaviors that are self-defeating. Poor communication from the injured worker seems avoidant in nature.  A neuropsychological exam can help identify severity of adjustment disorder and possible underlying AXIS IV diagnosis.  In Mr. Smith’s case, an underlying personality disorder has been exacerbated.  The case manager must now add behavior management to coordination of care.  Behavior?! How can behavior management be the responsibility of Worker’s Compensation?  How can it not! In this case, the risks of life-threatening secondary complications proved to be the result of “batteries not included”.  Mr. Smith needs what I like to call an “accountability plan”.  His inability to want to get out of bed, attend outings and appointments, eat, catheterize himself properly, and check his skin now becomes a shared responsibility.  Orders are requested from...

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Tendon Transfers and Decreasing Caregiver Costs

Posted by on Aug 24, 2012 in Blog, Case Management, WC, Workers Compensation

PRICELESS Hand function is, by most, considered the most important ability leading to independence with activities of daily living.  Attendant care is by far considered a medical necessity because of the lack of hand function needed by a person to groom, dress, eat, toilet, drive, use a phone, use a computer, manage money, and the list does go on.  Tendon transfers have been an elective surgical intervention for dozens of years but are for some reason, a well kept secret for populations such as spinal cord injuries.  No one would hesitate to offer Chipper Jones of the Atlanta Braves a tendon transfer if he had an injury that would warrant it.  But take a 23 year old C5-6 tetraplegic, and you will find recommendations such as a power wheelchair, hoyer lift, attendant care, occupational therapy, orthotics, assistive devices and assistive technology that are all costly, and require maintenance and replacement.  You will rarely, if ever find a recommendation for tendon transfers. Three primary tendon transfers, which are deemed very useful to the C5-6 SCI population, have the potential to strengthen pinch, grip, and elbow extension. A “key” pinch procedure might offer the ability turn pages, hold a book, take money out of your wallet, use and ATM, catherize yourself, write with a pen or pencil, brush your teeth, feed yourself with utensil WITHOUT a u-cuff or other device. Improved grip strength might allow you to grasp a water bottle, a doorknob, hold a medicine bottle and even take the cap off! Elbow Extension gives you triceps strength and increases your “work space”.  A person could then prop sit, help themselves scoot and sit, propel a manual wheelchair, and reach outward and upward. A young lady’s story at the Shepherd Center caught my ear.  She had been injured at the C5 level for almost 15 years.  She had attendant care, family and friends, and a husband and 2 small children.  She went through all three procedures on both arms.  The procedures themselves are outpatient.  She returned to therapy 3 weeks later for 3 times per week for 8 weeks.  Now she has a lifetime of independence she did not have for 15 years that does not require maintenance or replacement.  She was able to discard all assistive device and adaptive equipment.  She was able to put on her make-up,  catheterize herself and shave her legs. The best part of all this… she made her kids a homemade macaroni and cheese for the first time!  She was able to grip the egg, crack it, stir it up, get a GALLON of milk out of the fridge, open the top, pour, put a pot of water on the stove, grate cheese and...

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Why We LOVE Case Managers!

Posted by on Aug 8, 2012 in Blog, Case Management

The Main Objective is… The main objective of case management is ‘continuity of care’. Without proper management, recovery can be prolonged and more costly than necessary.  These patient advocates and front-line professionals serve at the epicenter of the health care system for the insurance company or health care organization. They are engaged with the patient’s progression of care from admission to the hospital through discharge, up to and including facilitating post-hospital care. As a result, they have first-hand experience dealing with patient flow disconnects and bottlenecks. Case managers experience up close these hand-off challenges when attempting to manage the progression of the patient’s care from admission to discharge, and into the post-hospital care environment. There are five (5) essential functions of a case manager. Assessment: Establishes the needs of the individual Planning: Ensures service provision is coordinated and comprehensive Linking: Coordinates services to ensure needs are met Monitoring: Stays on top of any changes Review: Review on a regular basis ensures services remain responsive to changing needs The practices of case management are constantly evolving. Changes in health care laws, regulations, reimbursement methods, accreditation standards, and innovations in care delivery systems are some of the factors that affect such evolution. Remaining current about the most recent practices of case management is important for ensuring that their clients receive best care...

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Case Managers and Legal Nurse Consultants Help Identify Fraud

Posted by on May 14, 2012 in Blog, Case Management, Legal Nurse Consulting, Litigation Tools

There’s a group of people who really love the U.S. health care system — the fraudsters! Like sand through your fingers, fraud can cost untold money losses for your company. Today’s smart business companies must focus on protecting their assets through proactive measures to identify insurance fraud. Hiring a Case Manager (CM) and or Legal Nurse Consultant (LNC) can help to identify both provider and claimant insurance fraud. The knowledge they provide can save your company thousands of dollars per case. We all know that false claims cost your company millions of dollars a year but providers are habitual offenders as well. The health care providers who commit these fraud schemes encompass all areas of health care, including hospitals, home health care, ambulance services, doctors, chiropractors, psychiatric hospitals, laboratories, pharmacies, and nursing homes. Violators may be prosecuted under: 18 U.S.C. 1347 Health Care Fraud. Case Managers’ and Legal Nurse Consultants’ education and experience come directly from working within the health care system and because of that they can identify many fraud indicators that an insurance adjustor might miss, whether it’s a claimant or a provider. CMs and LNCs represent powerful tools, so why would an adjuster not use all the tools available? That’s a good question but only the adjuster can answer it. Case Managers Play Critical Role In Identifying Provider Fraud This is because they actually work with the patient and some of the patient’s providers. They’re able to verify if the patient’s needs are being met through observing if the patient has the proper medication, equipment, diagnostic testing and services.  They act as your very own Private Detective, so to speak. CMs can alert you to red flags such as: Billing for services not rendered. cash loan for bad creditEasy Money Cash Advance Billing for services performed by a lesser qualified person. Misrepresenting procedures performed to obtain payment for non-covered services. Billing for a more costly service than the one actually performed. Billing each stage of a procedure as if it were a separate procedure. Legal Nurse Consultants Play Critical Role In Identifying Claimant Fraud  Legal Nurse Consultants are highly educated have state licensing as Registered Nurses. As such, they have much to offer at the claim negotiating table. Their vast medical knowledge and experience can provide an insurance adjuster with valuable insight into reducing the monetary claim demand. LNCs can alert you to red flags such as: Pre-existing conditions. Varying diagnostics results. Over utilization of services. Exaggerated symptoms. Malingering behaviors. Drug seeking behaviors. Analysis of ambiguous and subjective symptoms. Case Managers and Legal Nurse Consultants can be worth their weight in gold. Your gold! An average CM case costs approximately $1200.00 a month. An average LNC...

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The Commission – The Critical Role of the Case Manager for Health Care’s Future

Posted by on Dec 21, 2011 in Blog, Case Management

Case managers remain an integral part of the health care system. They oversee and interact with patient treatment plans, as well as offering assistance, guidance, and education. While their role holds great importance, confusion surrounds the profession for many and standards have appeared remarkably vague in the past. A new movement has begun in the healthcare system, pushing for case managers to become board certified.  Certification will help to remove the mystery surrounding the occupation and install a clearly defined standard of quality- an important and crucial step. Because certified case managers must meet such a high bar of excellence, the trust and confidence placed in them will naturally increase.  Especially in the midst of a changing health care system, it proves important for those in authoritative positions to clearly understand what case managers actually provide to the people in the health care system, and how board certification can help them do it better. For some groups more than others, such as those on Medicaid/Medicare, this awareness has become critical.  The confusion and difficulty encountered while navigating the health care system can leave underprivileged individuals or those on fixed incomes in a dangerous situation.  Board certified case managers will provide an indispensable resource for those in need of assistance while moving through the health care system. The enormous value of board certification for case managers has become obvious. As the need for these capable individuals’ increases, the number of case managers seeking certification will hopefully rise in response.  Awareness of the value board certification holds as well as encouragement by employers, policy makers, and healthcare providers will help make this goal a reality.  To read more about board certified case managers and their important role in the future of health care, check out Barbara Johannsen’s article here. low fee pay day loansresponsibility credit   Photo credit: eurasia-usa dot...

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