Ten Things a Medical Doctor Should Review in a Work Comp File

When I begin a consulting project, I like to have an MD review a sampling of files from each claim office, or 3-4 offices randomly selected from around the country. I have found that having an MD on the file review team gives me a much better idea of the problems with file handling. And, if the files are being handled in an above average manner, I like to know this too.

Here’s what an MD should look for:

1-Over and under-utilization of services such as medical treatment, physical therapy, chiropractic, diagnostic procedures and surgery

2-Effectiveness of medical cost containment services, including Nurse Case Management

3-Completeness of cover letters to Independent Medical Examination Doctors

4-Effectiveness of Independent Medical Exams, including timing and cover letter requesting IME.

5-Doctor cooperation with Return to Work Program and Transitional Duty

6-Accuracy of diagnosis and causal relationship to workplace. Nurses do add a lot to the workers comp claim adjusting team, but I believe only an MD (workersxzcompxzkit) is capable of evaluating accuracy of diagnosis.

7-Recognition of subtle medical language indicating symptom magnification

8-Whether the injury was caused or aggravated by work or whether other possible causes should be explored

9-With older files, additional opportunities for Second Injury Fund reimbursement are found

10-Percentage of claims where length of disability is proportionate to time out of work.

Even though doctors cost more per hour than a nurse, they are the only professional qualified to make the above determinations. And use of an MD is more cost effective overall, normally saving 4$ for every 1$ paid in fees. In every project for the last 20 years, I have used an MD to review files. It may make the difference of saving 20% vs 50% of losses.

Try the:
WC Best Practices Quick Check: http://www.workerscompkit.com/intro/
WC Calculator: www.reduceyourworkerscomp.com/calculator.php
TD Calculator: www.ReduceYourWorkersComp.com/transitional-duty-cost-calculator.php
WC 101: www.ReduceYourWorkersComp.com/workers_comp.php

Do not use this information without independent verification.
All state laws vary. Check with your insurance agent or broker about work comp insurance issues.