Emergency room visits are on the rise. One study from the American College of Emergency Physicians found that 28 percent of ER doctors polled have reported a spike in the number of cases since the Affordable Care Act took effect. Another 47 percent have seen at least a slight increase.
The costs are on the upswing too, especially for personal injury claims, as
hospitals attempt to recoup money thanks to changes in the health care system and other factors. In fact, charges can vary wildly – from $4 to care for a sprained ankle to $24,000, according to one study. There is no associated fee schedule with property and casualty claims. This, by default, allows providers to set their own fees with the expectation of full reimbursement.
Still, the ER is the first place many go for medical care. And those ER records provide a critical, but complex window into a patient’s health and injuries, establishing a medical baseline at the time of the incident. To the untrained eye, the codes, test results and billing practices can be a confusing garble of medical terms and figures. But, when insurance claims are analyzed by MEDICAL consultants they provide vital clues into a patient’s actual injuries, the inciting event and billing practices.
Did the injured person actually suffer serious injuries or is there some inconsistencies in their reporting? Are the provider charges verifiable with the medical record? Were the ordered and completed test indicated for the injuries and reported conditions? In my mind, appropriate care is appropriate care regardless of payer source. Unfortunately, this is not always true. In ERs, doctors practice “defensive medicine” to avoid malpractice claims, which can drive up health care costs. Liability claims also are the only kind of claim to not have an applicable fee schedule. Other types, such as workers’ compensation, Medicare and private insurance claims, pay out at a specific level. With liability, there are no specific allowed fees for a test or procedure.
The ER records are where you analyze and begin to build your case. An accurate reading and understanding will provide the objective findings to understand how the injured person fared after that slip and fall or car accident, and contrast those findings against subjective complaints and reported history.
If you’re analyzing them, here’s what you need to know:
Basic ER documentation: Be sure you have all of the paperwork. In the ER, that includes the RN triage sheet, the ER physician documentation, diagnostics studies and testing, bedside nursing notes, consultation reports, order sheets and consent. Look at what was ordered? Is it consistent with the working diagnosis? Was the physician confirming a suspicion or ruling something out. These details matter because they help us grasp the records and course of events and help lay a foundation of understanding.
Patient arrival: How did they get to the hospital? Did they go by ambulance immediately? Or did they wait a few days and drive themselves to the ER? What was their recorded status upon arrival? What was the patient’s position on the Triage Acuity Scale, which ranks the severity of a person’s injury? If they arrived by ambulance, what information did EMS provide?
Symptoms and chief complaint: Carefully review the physical examination. Compare the nurse’s triage against the physician’s examination and notes. Look for inconsistencies. Does their chief complaint match the objective findings? Do the complaints escalate? Are there new ones? The initial complaints are always the most accurate. Review those first complaints against the reports from EMS.
Bills: Check the charges to make sure the services included in the bill are in the medical documentation. Ask questions. Was it medically appropriate to order a CT scan? Was the skill level the hospital charged appropriate for the injury? Were all of those labs really necessary?
A trained eye can quickly figure out the answers to all of those questions and explore other angles that can save time and money. (That’s what we do here at MKC Medical Management – helping claims adjustors and attorneys understand complex medical records and information).
Regardless of who reads the records, it’s important to know that ER records have a lot of moving parts. If you don’t understand what’s in the records, it will be hard to refute what happens later because you never understood how it started.
Emergency Room records
Provides a baseline for a patient’s injuries. An accurate reading and understanding will supply the objective findings to understand how the injured person fared. All sections and information within the ER records must be reviewed and investigated in order to assess mechanism of injury issues, merit, alleged relatedness and casualty issues. Remember: The medical records are a snapshot of the medical care. The care rendered should, in theory, have nothing to do with the payer. The care should be within the known and established protocols for the respective injuries without bias of insurance coverage. However, it’s critical to acknowledge that the filter of insurance coverage does sometimes impact the care documented within an ER record.
Basic ER documentation
Make sure you have it all. It includes RN triage sheet, the ER physician documentation, diagnostics studies and testing, bedside nursing notes, consultation reports, order sheets and consent.
How did they get to the hospital? Did they go by ambulance immediately or wait a few days? What was their recorded status upon arrival? What was the patient’s position on the Triage Acuity Scale? Review the nurse’s bedside notes carefully. You’ll find a treasure trove of information about how the patient behaved, what they said and how they responded to treatments and care.
Symptoms and chief complaint
Compare the nurse’s triage against the physician’s examination and notes. Does their chief complaint match their objective findings? Do the complaints escalate? The initial complaints are always the most accurate. Compare subjective complaints to the objective findings. These should align in some way.
Prior medical condition
Don’t forget to check pre-existing conditions and current medications. Any number of conditions and medications can impact cognition, balance, bleeding times, perception, etc.
What are the test results? Consider chronic versus acute versus degenerative. Are there abnormal lab results? Elevated blood sugar? Prolonged bleeding time? Understand that the rule of thumb is this: A finding should fit what is known. Only when it does not should doctors begin investigating more unusual conditions. And, clearly, not all abnormal findings are directly related to a trauma event.
Check the charges to make sure the services included in the bill are in the documentation. Ask questions. Were the services, tests and labs really necessary? Does there appear to be over-utilization? Are the services appropriate for the reported injury and / or diagnosis?
At the time of discharge, the medical team will provide information to the patient about diagnosis, post discharge care, medications and follow-up care. Did the patient leave AMA, otherwise known as against medical advice? Did the ER physician recommend a specific follow-up specialty or PCP, yet the patient went to a different specialty or did not follow up at all? What condition was the patient upon discharge?
A trained eye can quickly figure out the answers to all of those questions and explore other angles that can save time and money. That’s what we do here at MKC Medical Management – helping claims adjusters and attorneys understand complex medical records and information.