Three Types of Medical Records Often Missing in Workers Comp Claim Files

Using an MD proactively can improve IME results and save money. Spending more can save money! A well-trained MD can improve the outcome of an IME and reduce overall costs by making sure all pertinent records are in the file. Dr. Dubin identifies 3 types of medical reports that are often missing in workers’ comp claim files.

1- Emergency Room Records were not included in file– In one company we reviewed, 4 out of 30 claims at one claim office the emergency room records were not included in the file. The adjuster did not even know they were missing and had not requested them. These are critical because the injured employee will usually give the most accurate account of how the injury occurred during the ER visit.

2- Pre-injury records may be relevant to determine if there is an underlying degenerative process still progressing. For example, one worker had been having shoulder problem for 18 years. He injured his shoulder at work but then recovered. Six months later he needed shoulder surgery but the IME physician was not asked whether the surgery would have been needed regardless of the workplace incident. The workers’ comp insurer paid for the whole claim even though the answer to the unasked question was “yes.” An MD review of the claim would have uncovered the claim was more properly paid by the group health provider. An opportunity for saving was lost.
In another claim, where an overnight driver had driven over a minor bump in the road and then complained of extreme pain the MD looked for and found found another possible source of pain — Paget’s disease of the bone, as evident on the MRI; the pre-injury records were then obtained and the company successfully challenged the claim saving over $50,000.
In another claim an employee was injured in a minor automobile accidents and weeks later complained of back and neck pain, the medical advisor found indications in existing x-rays of possible Hill-Sachs deformity which suggests prior shoulder problems most likely from past dislocations of the shoulders. Pre-injury records were necessary to challenge the claim saving over $100,000 in medical and lost-wage costs.

3- Waiting on Reports– If reports from specialists are not yet in the file, it may be better to schedule the IME AFTER the report is received, especially in states that allow only one IME every six months. Also, sometimes an IME is done before the MRI results are in. Because MRI results can suggestcausation or degree of injury, such as in the above case of Paget’s disease, the IME should be done after those test results are in the file.

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Do not use this information without independent verification. All state laws are different. Consult with your corporate legal counsel before implementing any aspect of a cost containment program.