The claimant in this case was a 21 year old involved in a Motor Vehicle Accident. According to the medical records, the claimant suffered minor Date of Loss injuries followed by reports of several versions of the Mechanism of Injury and of evolving stated injuries, including a rectal abscess.

The event and injury

The claim was a result of an MVA involving a head-on impact with the trailer portion of a tractor trailer.


A thorough nurse review and analysis is essential to the management of injury and illness-related claims.

Mechanism of Injury (MOI)

The nurse reviewer noted that the MOI in the police report was the same as that first reported by the claimant; namely, that the claimant’s initial complaints of hand abrasion from the airbag deployment and minor soft tissue complaints were consistent with the impact caused by the MVA.  However, the claimant’s medical records showed that there were eventually six versions of the MOI subsequent to the initial MOI reported in the physician and emergency medical records and that documented by police.  In the last version of the MOI, the claimant expanded the facts of the claim.

In addition, in the process of determining whether the subjective complaints aligned with the MOI, the reviewer discovered that although the initial complaints correlated with the MOI, there were gaps in treatment.  After these gaps in treatment, according to the nurse review, the claimant reported symptoms inconsistent with the initial findings.

Finally, the nurse reviewed and analyzed whether the areas of impact on the vehicle or body corresponded to the claimant’s subjective complaints. The nurse found that while the initial complaints correlated with the MOI facts, BUT the claimant’s expansion of symptoms did not correlate with the loss.

Comparison of Pre and Post Date of Loss Records

The nurse reviewer examined the records for pre DOL information which confirmed that the claimant was possibly treated for pre DOL injuries that were reported post DOL.  No pre-DOL records were submitted. However, during the post DOL records, documentation supported post incident treatment for a pre-existing condition, namely a rectal abscess.  Finally, no radiological findings pre or post date of loss were submitted, making comparison impossible.

Inconsistencies

The nurse reviewer found several sets of data points that impacted the analysis of the claim.

  • The claimant’s medical records revealed subjective complaints reported too late in the timeline to clearly correlate with the MOI, along with large gaps in treatment with reports of inconsistent symptoms months post loss. The claimant was seen the day after the loss with no objective soft tissue injury, but reporting perirectal drainage.  According to the records reviewed, the exam noted only facial tenderness without swelling or bruising to support anything other than minor facial impact.  There was no abdominal, rectal, buttock or lower back trauma documented.
  • In reviewing the radiological x-ray reports, no acute pathology, the nurse reviewer concluded that these data did not support acute or chronic pathology.  A nasal x-ray performed after the loss did not document any fracture. Moreover, the report of obvious deviated septum months post loss was inconsistent with x-ray and initial exams.
  • The claimant had unrelated rectal drainage that required ER work-up with diagnostic testing and laboratory studies which was unrelated to the MVA.

Conclusions

The nurse review significantly impacted the exposure, as only initial ER treatment and the nasal x-ray performed the day after the loss appeared related to the loss.  A bill review along with a nurse review were completed. The submitted total meds were just over $26,000. A total of $7,860 was recommended as being related to the DOL as well as reflecting UC allowances for services.

This analysis used a tailored nurse report format — one of several formats MKC offers clients — which provided the client with the necessary information for claims resolution, as well as a line-by-line bill review. The nurse review and bill review provided the necessary information for successful claim resolution, identified unrelated medical data points and accurate UC allowances and coding practices. This claim highlights that even with cases under $30,000 of medical specials, tremendous potential savings can be identified.   

Bottom line

MKC’s client wanted the nurse review to verify that the rectal issue was not related or exacerbated by the MVA.  In many cases, a client knows something is not related, but needs confirmation that explains it.

KARI