This plaintiff was a 51-year-old female, restrained driver, alleging unspecified injuries and demanding policy limits following an MVA.  She was traveling in a parking lot when she was hit on the passenger side by a semi-truck moving at <10 mph.

There was no airbag deployment.  She was ambulatory at the scene.

Mechanism of Injury (MOI)

While the claimant’s report of the MOI was consistent, she told the chiropractor that she hit her chest and knees.  Note that there were no reported knee or chest injuries, and this was the only time she raised these conditions.  No police report was submitted.

Her subjective complaint of neck pain aligned with the MOI, and her complaint of headache may be an extension of her neck pain.  However, the claimant had a history of migraines and also denied hitting her head.  Objective exam findings did not support any sign of head trauma.


The mitigation of this case illustrates the importance of analysis of complete records.  Here’s a post of ours that helps explain why missing records wave a big, red flag for a nurse reviewer.

Comparison of pre and post Date of Loss (DOL)

No pre-DOL records were submitted, and the claimant denied any significant past medical history.

Inconsistencies

The first documented date of service was seven days post DOL.  The claimant reported at that time that she was seen two days post-accident at the same facility and had imaging.  However, no records were submitted for that DOS.

The emergency department physician recommended use of a TENS (transcutaneous electrical nerve stimulation) unit, for which there was no medical necessity criteria.  After the ED visit, there was a 17-day lapse in treatment.

The claimant’s initial chiropractic exam was one month post DOL.  That was when she added a new complaint of left shoulder pain, explaining that she hit her knees and chest.  An objective exam did not reveal any sign of injury to these areas, and it was too late in the treatment timeline for new injuries to present.

Conclusion

The nurse review mitigated overall exposure. This was a very low-speed accident with low-acuity injuries.  The claimant exceeded treatment standards and duration for minor soft tissue neck strain.

My takeaways

This case is a teachable moment in understanding the need to have access to all records and also to pay attention to gaps in treatment.  Gaps in care say a lot about the overall severity of injury.

In addition…

  • Gaps in care and evaluation should be questioned, as they can indicate possible intervening injuries/events
  • Gaps can indicate resolution of an injury.  Treatment and follow-up care should be driven by the injury and, as such, follow a typical recovery pattern irrespective of payer source.
  • Gaps can indicate noncompliance and/or lack genuine desire for rehabilitation and recovery
  • The injured party has a duty to participate in minimizing injuries/damages. Gaps in treatment or care can draw this goal into question.
  • Gaps can also indicate attorney influence, where the injured person is encouraged to go back to the provider or resume therapy.