Digging into the facts

MK Consulting, Inc. was recently asked to look at a case in which a man was reportedly struck on the left side of the chest.  The claim

Dental injuries to ice hockey players like Dany Heatley are so common and inherent that they're axiomatic.  How do you deal, however, with insurance claims where the trauma and supposedly resulting injuries are anything but prima facie?

Dental injuries to ice hockey players like Dany Heatley are so common and inherent that they’re axiomatic. How do you deal, however, with insurance claims where the trauma and supposedly resulting injuries are anything but prima facie?

reported that he fell and injured his left knee and chest.   Buried in the same records, however, was a costly dental restoration plan.

Based on the facts, I wondered how the claimant could justify such a thing.  So, I started with the Emergency Department   ED records.

I reviewed everything and cross referenced the alleged event facts and ALL the objective data.  I looked at pieces of information tucked in the ER nurse’s triage notes, what the EMS documented the treating physician’s exam and  the discharge orders.

In other words, I looked at everything. I really focused on the subjective complaints and reported information   Actually, I reviewed everything three times!

Guess what?! NO oral trauma was documented. There was NO subjective complaint regarding oral, dental, teeth, gum pain/trauma, etc.  In fact, the claimant self-reported NO head trauma.  Furthermore, there was an entry documenting “no oral trauma.”

None of the hallmarks of oral trauma were there:  No blood, no laceration, no missing or cracked teeth.  NO oral pain. Instead, the exam stated, “Oral musoca, pink and moist.”

So I am thinking, why did the carrier send this file? 

I kept digging.  Because nothing is really obvious, is it?

I discovered that the records reported that the claimant received chiropractic care about three days after the incident date. But there was no mention of facial or oral trauma in the chiropractic notes.  Odd, inasmuch as the description of the event and ALL injuries was very detailed.

More review…this time the dental records.  The injured man was seen by the dentist the day of the alleged incident. More mystery, as there was no documented problems.  I concluded that he must have been seen before the accident as well.

Next, I pulled out the dental billing statement. NO billed return visit until four weeks after the alleged accident.  I then went back to the handwritten dental documentation. The corresponding notes clearly   documented NEW findings involving MULTIPLE teeth:   A fractured bridge, damaged  crown, cracked/loose teeth and a FRESH laceration around the gum with an associated a tooth fracture.

These findings were significant.  HUGE RED FLAG! A person would likely not wait four weeks to seek dental evaluation or treatment. And while some of the findings might be a mixed bag of acute and non-acute, the findings clearly did not fit the alleged mechanism of injury and the self-report of no facial/head trauma.

Final recommendations? 

I recommended that BEFORE payment consideration be made, the carrier request additional documentation that supported the initial MOI and lack of oral injury, a-long with requesting that the treating dentist explain the current findings in light of a four-week  treatment gap. At the time of this blog, final disposition of the outcome was not available.

We often review claims having to do with dental injuries.  These can be tricky.  The information documented in a dental record is often presented very differently than a medical record.  There may not be the familiar “dictated” note.  The daily visit notes are often handwritten abbreviations and acronyms known only to dentists and hygienists.  Obviously there are other components of the dental record such as medical and dental histories, diagnostics/xrays, personal information, electronic record, etc.  But this information is often not submitted with a liability claim.  So, getting to the truth takes ingenuity, a willingness to dig and a practical understanding of trauma care.

Best practices when reviewing a claim

Here are some basic take–aways for review and analysis of any complex dental claim:

  • Clearly understand the dental acronyms/information in the records.
  • Review the INITIAL ED/EMS documents for specific information about the alleged injury. Cross check everything.  ALL info should be consistent.
  • Follow a linear line of thinking.  In other words, what is the typical trauma timeline for something like this to develop? Think in terms of mechanism of injury , timeframes, expected treatment protocols, etc.
  • Think about the documented findings in an obvious and practical way.  For instance, is it really possible for someone to sustain damage to seven teeth and a partial bridge  AND not seek dental care/evaluation for four weeks?   Possible, but not probable.  If something did legitimately delay the care, it will (or should be) documented.
  • Check out these sources/sites:  www.ada.org and www.dentalcare.com
  • Find a picture/diagram of the mouth with each tooth numbered.
  • Think about each tooth individually.  Where it is located, and how it was allegedly injured? Does the dental condition fit the alleged injury?
  • Does the causal relationship make sense?
  • Does the proposed treatment FIT the problem?

Finally, it may require help deciphering the records.  Utilize your available resources! As Virgil put it, obscuris vera involvens – or, the truth [is] enveloped by obscure things.