One of Biggest Shams in Comp Claims Is Unwarranted Diagnostic Testing

I saw an article in the newspaper the other day where a doctor in was diagnosing patients with “Cancer” and sending them for treatment they did not need, while billing Medicare millions upon millions of dollars. Some of the patients needed this testing and treatment, and others did not. I really did not know whether to feel shocked, saddened, outraged, or all of the above.

As with everything in this world, I draw the conclusions of that article back to the Insurance claim industry. Boy, imagine if doctors were guilty of that type of behavior within an auto or work comp claim! Ha ha, you the know for a fact that there are doctors out there that see dollar signs as soon as they see an injury from an accident, be it auto or work comp. Some studies have shown that the prices go through the roof once a doc sees an accident claim, due to lack of fee schedule allowances and so on.

A Good Percentage of EMG Tests Are Useless

One of the biggest shams in injury claims is unwarranted diagnostic testing, especially EMGs and MRIs. They are usually clinically unwarranted, performed too soon, performed too late, or performed multiple times.

A positive EMG test can bury the defense of a claim, especially if it is taken for its word on its own merits without taking into account the doctor that is performing the test and their experience, training, and background.

Rationale for an EMG can come in many forms, but the usual reasons for the test are to correlate or objectify positive findings on clinical examination. They also provide a baseline for future comparison testing, differentiate between organic and non-organic pain complaints, and provide assistance on surgical opinions.

A good percentage of EMGs are also useless. Any doctor can get an EMG machine and perform the testing. This does not make them qualified to perform EMG testing. In some states you do not even need to meet certain training qualifications to perform the testing. Really all you have to be is a physician. In my opinion, the only person that should perform an EMG that relates to an injury claim is a physician that is AANEM certified (American Association of Neuromuscular & Electrodiagnostic Medicine). Physicians with this certification have received extensive training and have board certification in Neurology or Physical Medicine & Rehabilitation. They have also completed numerous continued education credits along with a laundry list of other criteria they have performed. Remember, you can always obtain a second opinion on an EMG, and get a second test ordered to compare with whatever the treating doctor had performed.

There are several variables that can affect the outcome of an EMG, resulting in a false positive. These include:

• Physician training

• Physician experience

• Use of a technician

• Skin temperature

• Wrong nerve group study in relation to injury

• Wrong muscle group study in relation to injury

• Over interpretation of test results

• Under interpretation of test results

• Examination bias

Study Shows 68.1% of EMG Tests Were Not Needed, Or Not Accurate

In a study performed by Dr. J.E. Robinton, Dr. A.L. Seidner & Dr. J.M. Pearson entitled “Evaluation of the Medical usefulness of Electrodiagnostic Reports by Physicians not Prequalified to Meet Set Standards” results showed that 68.1% of EMG tests studied were either not needed, or were not accurate. As if that were not shocking enough, 40% of the physicians studied that were performing EMGs were performing studies below acceptable levels. These numbers should serve as a wake-up call in the insurance industry.

Think about the impact this has. If the patient hears that they have a positive EMG, you know the next thought in their mind is that surgery is the only way to resolve whatever pain they are feeling, be it “real” pain or just plain subjective issues. But the problem with this testing is not just on the shoulders of the patients. After all they are just going along with whatever the doctor is telling them.

The reality remains that EMG testing is a good way to make easy money. The machines can vary in cost, but the fixed cost of the machines can easily be made up in excessive profits after a few months of testing on your injured patients. This money goes right into the pockets of the physician. Even better is the doctor selling bilateral testing of limbs so they can use the “good, uninjured” side as a comparison. If you didn’t need an EMG on your left arm, then why get one? The answer is you get one because the doctor said you should and you are trusting that your doctor has your best interests in mind to heal from whatever injury you sustained.

Oftentimes adjusters become complacent with whichever doctor is ordering the testing to be performed. The adjuster thinks if the doctor has an EMG machine and can perform the EMG, then they must be qualified to do so and whatever the results are they are what they are. Fact is that EMG findings are subjective and up to interpretation of the physician completing the test. If this doctor is a good businessperson, then obviously positive EMG results lead to more treatment, more billing, and more profits. Ethics aside, it is what it is. You sure would like to think that every doc has the ethical capacity to do the right thing. Sadly, all you have to do is open the newspaper to get the real answer on this issue.

Time for my normal disclaimer: Not every doctor is unethical, not every doctor is unqualified to perform and interpret EMG testing, and not every doctor is motivated by profit.

Get A Second Opinion on EMG & Ensure Physician is AANEM Certified

My opinion is this: If you have a case where an EMG was performed, before surgery is recommended or scheduled, get a second opinion and make sure that the physician is AANEM certified. You are going to be surprised at how many cases get turned around and how much money you save by not having to deal with unnecessary surgeries and their complications. Actually a lot of cases are probably going to go from having positive EMGs to negative EMGs, which will posture your defense on further disability. After all, if you were the one injured, wouldn’t you want accurate testing to begin with?

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: [email protected].

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