Delaying Treatment & Its Impact

Posted by on May 11, 2014 in Blog, Legal Nurse Consultant, LNC, Medical Conditions/Terminology Blog Series, Uncategorized, WC

By Debra West, RN, BSN, CCM, LNC 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 post injury, there is no way to unequivocally relate subjective complaints reported well after an injury. 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.  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 the necessary information why the delay or absence of medical care make it impossible to relate the complaints with the incident. Debra West, RN, BSN,CCM, LNC is a legal nurse consultant with MKCMedical Management.  Contact Debra at or...

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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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Five Reasons to Use NCM Services on a Workers’ Comp Case

Posted by on Sep 16, 2011 in Blog, Case Management, WC, Workers Compensation

A qualified and experienced legal nurse consultant (LNC) assists a hiring firm’s litigation team or insurance adjusters in numerous critical ways, one of which includes case management. Case management services often include managing the medical aspect of claims resulting from catastrophic events (trauma, CNS injuries); accidental injury claims; automobile and general liability claims; private health care standards claims and many more. There are multiple reasons why a Nurse Case Manager (NCM) is helpful on a case.  I have listed 5 reasons below. However, it should also be remembered that NCMs can be used in a variety of ways including- the group health setting, with catastrophic illnesses, elder care and in the public sector. Five Reasons to Use NCM Services on a Workers’ Comp Case Always bear in mind that NCM are governed by individual state laws, regulations and the standards of practice as put forth by the Case Management Society of America. Hire an NCM to elicit information from the doctor that you, as the adjustor, cannot.  Due to her medical background, the NCM can obtain more accurate and detailed information from the physician regarding treatment strategy and protocols. Hire the NCM to observe a predetermined number of doctor visits with the patient. She can talk to the physician on a peer-to-peer level; thus, gaining valuable information about his treatment plan and timeline. For example, a scenario where an Independent Medical Examiner (IME) advocates ongoing disability or off-work status for a patient with a sprain- or strain-related injury who has been down over six weeks, and relates it back to the workers’ compensation injury begs for the services of an NCM.  In addition to obtaining medical information, the mechanism of injury of the event/causation of the conditions need to be established /commented on by the physician as soon as possible. The NCM should find out the exact diagnosis and treatment plan, nature of the backup plan, whether the physician is considering referring the patient to an orthopedist for evaluation. The treating physician will see that you are actively working the file and that you will not allow ongoing failed conservative treatment strategies. In addition, early intervention and referral helps to obtain information regarding casualty issues. Hire an NCM if you’ve been assigned a claim in an unfamiliar state or region with physicians you do not know. An experienced NCM from the state or region will know the area and the doctors. Frequently, she has resources allowing quick access background information about the treating physician. Pertinent background information will include reference to the doctor’s past success with compensation claims and common treatment plans ordered. For example, although they should, some surgeons do not attempt conservative treatment plans before recommending surgery. The...

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Medical Implications in Reserve Setting

Posted by on May 26, 2011 in Blog, Claims Tools, Reserve Setting, WC, Workers Compensation

How much is my case worth? No matter what side you are on, the question “How much is the case worth?” is the all important one!  Accurate reserve setting takes into account multiple factors including: venue, job/earning ability, the specific injury; current and future medical expenses, treatment, diagnosis, prognosis, permanent loss/damage and specific claimant information. The goal of this process is to not to over or under reserve a claim, but to find the truest amount, and do it as quickly as possible. Many of the factors involved are medically driven.  As a LNC/ NCM, I am often asked to help with analyzing medical information/records on a claim to assist with reserve setting. The clearer the medical information, the more accurate the reserve will be. Unfortunately, sometimes the medical details can get lost in the overall process. Here are a few ways a LNC/NCM can assist with initial reserve setting and/or periodic reserve assessment: Help determine damages sustained by the injured party. same day pay advances Medical record review for analysis and comment of current medical information and proposed treatments. If appropriate, communication with the client to obtain information about injuries, medical care, personal specifics, and complaints. Onsite medical assessments to gather medical information from the medical providers and client Life care plans Task assignment for real time analysis of medical information. Attorney, client or adjuster education on disease process, condition, healing parameters and/or recovery timeframes. Field or telephonic case management Sometimes getting a clear understanding of the medical aspects of a claim can be challenging. However, with the help of a LNC, NCM, physician and other medical providers, an accurate analysis of the available medical information can be obtained and analyzed. Remember a small amount of accurate medical information can make a BIG difference in dollar expenditures!...

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Knowing Your Provider

Posted by on May 12, 2011 in AALNC, Blog, Case Management, Legal Nurse Consultant, LNC, WC, Workers Compensation

As a LNC/NCM I am often asked to help identify physicians to assist/work on a file/case OR help navigate the provider-client-payor waters. This is especially true in the Workers Compensation arena. Most recently this topic was discussed at length in a LinkedIn discussion group. Several excellent points were made. Noted in the discussion group: Does a provider have experience in your desired service? Be aware of reimbursement issues. Learn the State Rules and Regulations concerning WC. Check out the State website for details and reporting guidelines. Check out guidelines such as ODG, or MD Guidelines to verify that the client is tracking along with their recovery or rehab. ACOEM (American College of Occupational and Environmental Medicine) provides a guide to help assess outcomes. Some of the more basic ones that I utilize are: bad credit instant approval loanspayday loan online direct lender no credit check Check with other adjusters and attorneys for their experiences with the provider. Local NCM/LNC are very knowledgeable about the physicians in the area and can give solid insight as they often deal with the providers on a first hand basis. An employers will also know which doctors are easy to work with, take a certain type of case, etc. especially providers that will provide front line care such as family practice, occupational medicine, etc. If possible ALWAYS pre-screen the physicians. Learn how they report, communicate, how they interact with a NCM/attorney/insurance company, etc. Try and learn the “particulars” of the office staff. Periodically re-assess the physician and support staff. People change within a practice; physicians get busier and become unable to communicate as well; practice philosophies, and goals change. Seek feedback from the employers as to how their provider choices are or are not performing. Ongoing assessment of the physician(s) should be done. Help to educate the payor, employer, and provider on what to expect in regards to reporting, State regulations, employer RTW philosophies, etc. Does a physician embrace modify duty? We sometimes forget that the medical arena is consumer based. Knowing how your provider is performing is critical to successful...

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