If you are handling a pesky claim that just will not go away, or the objective signs are just not lining up, chances are a key diagnostic test is what you need to tie it all together. A well done MRI or EMG could be just what the doctor ordered (literally). However you must keep in mind that not all diagnostic testing is warranted. Below we point out some surprising statistics, and ways to prevent you from authorizing testing that may not be of any help:
- The right EMG test needs to be done at the right time
This is especially true for insurance claims, whether it is work comp or an auto accident injury. And it is especially true when dealing with Medicare, although it’s not necessarily applicable to our thoughts here. Doctors and their businesses sometimes are under the impression that once an insurance claim arrives at the waiting room looking for treatment they have free reign to treat at will. This is a big no-no, since if you get the wrong test done in the wrong location, what good does it do? Sure, numbness in the hands can mean impingement at the wrists or elbows, but what about the neck? Cervical radiculopathy can be the culprit underneath what seems like simple and basic carpal tunnel syndrome.
So if a doctor performs an EMG at the wrist, which is negative, then they will be doing another test at the elbow, and possibly one at the shoulder, and one at the neck. When it is all said and done, they have performed 4 EMGs, when 1 would have sufficed if done properly at the neck level.
Adjusters need to think outside the box a little, and look at the other symptoms as well as the medical history. Adjusters can also utilize their Utilization Review department, a nurse case manager, or a Record review from another physician to see what type of test should be done. All of these steps need to be taken in order to avoid medical cost leakage due to a hunch from the treating physician.
- Does an MRI really need to be performed?
The best way to see why a back injury will not subside is to obtain an MRI test. MRIs are probably the most common test performed, since a back injury is one of the most common injuries in the occupational world. However, if a back injury is not getting better after 3 weeks, obtaining an MRI may be jumping the gun. Other symptoms need to be present, such as leg weakness, numbness, radicular pain, etc. If the claimant complains of just pain, should that warrant obtaining an MRI? Pain is a subjective complaint, not necessarily something that warrants expensive testing, other than possibly a series of routine X-rays.
It is my opinion that doctors sometimes want to pacify the patient by doing some sort of test. Plus, there are patients out there that want something objective and/or invasive to be done in order to feel “better.” So, to make lives easier on themselves, doctors will just order the MRI. When it fails to show anything remarkable, they move on to the next step in the course of treatment that they would have moved to anyway.
This is not to say that every spine MRI is unnecessary. If months have passed and the claimant is still in considerable pain with functionality issues, then yes it is time for additional testing to see what is going on. But not within the first few weeks after an injury occurs. Bearing in mind again that the other obvious symptoms are not there, those being the leg pain, foot drop, muscle atrophy, etc.
- Does the injured worker need months of physical therapy?
By default, there are many clinics that will see an injured worker, then dump them into their physical therapy program to help rehab their injury. The adjuster must stay on their toes when this situation happens. Oftentimes the patient will get prescribed a course of physical therapy after an injury, and this is the correct course of treatment for soft tissue injuries. But, to take a back strain injury and dump a person into a 6 week therapy program, then have the doctor reevaluate them 6 weeks later is not acceptable. The physician should be involved in the program, seeing the patient at least on a weekly basis so they can modify the frequency and duration of the program if needed.
Dumping a patient in a long term therapy program happens more often than you would think, especially when the program is run inside of the treating doctor’s office. This means the doctor is getting two sources of income coming in: one from treating the patient, and one from the therapy program.
Even if an injured party needs surgery, post-op patients need to be carefully monitored during recovery. Again, the doctor needs to be involved in the program, and watching the hopeful steady progress back to full duty. It is easy for these docs to forget about the patient, and just let the 6-8 week therapy run its course. What if the patient is not attending all of their therapy sessions? What if the patient tells their adjuster that therapy is causing an increase in pain? What if the patient is not being compliant with their home exercise and stretching program? All of these questions need to be addressed, and they need to be addressed right away, not 8 weeks later after the program has completed.
- Some statistics to keep in mind (stats pulled from GAO Analysis of Medicare Part B Claims data; Boden et al. JBJS, 1990; Friedly J, Chan L, Deyo R; Spine, 2007)
- Billing from 2000-2006 increased from $6.89 billion to $14.11 billion for lumbar imaging.
- MRI research with patients that had “no back pain” showed that of those under age 60: 36% showed herniated discs, 21% had spinal stenosis, 79% had a bulging disc, and 93% had a degenerated disc.
- The Medicare population increased 12% from 1994-2001, but billing for services increased 637%.
Summary
Diagnostic testing and physical therapy can be two keys to helping discover what injury a patient has, and how they can get better. For the most part, these tests and therapy programs are done properly and when needed, but not all of the time. Adjusters have to use their network of professionals to help gauge what is needed and when. Nurses, Utilization Review departments, IME physicians, and Peer Record Reviews all can be implemented should testing or therapy not seem like the right course of action. The adjuster has to take the time to get involved in the claim, question why these things are being recommended, and keep the patient on the track to recovery. Just because a doctor recommends a certain action doesn’t make it in the best interest of the patient, or the carrier/TPA as a whole.
Author Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher. www.reduceyourworkerscomp.com. Contact: mstack@reduceyourworkerscomp.com.
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