Learn To Diagnose Your Diagnostic Test Diagnosis

When an injury fails to resolve within 4-8 weeks (sometimes sooner) physicians will likely order a diagnostic test to be performed. The test will give them an inside look at what is going on structurally, and provide evidence to injury or pain generator, so they can focus care on resolving the issue.

Surprisingly enough, these tests are open to physician interpretation. If the answer is not a clear silver bullet, such as a massive disc herniation or radically pinched nerve, you will see some difference in opinion on what could actually be wrong and how it is related to the work injury.

This is where the adjuster plays a key role. Their relationship with a diagnostic provider or certain physicians can be what can swing a claim one way or another. It can mean the difference if the injury is surgical or not, and even bigger, whether the claim and ongoing treatment is related to this work injury rather than an ongoing degenerative issue.

EMG Should Be Performed By Independent Physician

If a worker claims on occupational injury that was not traumatic in nature, chances are the injury was caused by repetitive motion within the course of their employment history. After treating for a period of time and the worker has made no progress, the physician will likely perform an EMG to see what is going on.

Believe it or not, every doctor is not an EMG expert. Even though they perform EMG tests and they make it a part of their regular practice, this doesn’t make them effective at interpreting the results. It is typically not in your best interest to have the treating doctor performing the EMG. A physician is in business to treat people. This is how they make money. And by giving “positive” EMG results, this leads to possible surgery, more physical therapy, more treatment and overall more money for this doctor and for their practice. We would like to think that all doctors are ethical and would do the right thing, but unfortunately this is not always the case. If this is going on with your claim, the adjuster will likely get an outside opinion from another physician, likely one that is credentialed by the “American Association of Nueromuscular Medicine (AANEM). These physicians have strict criteria for performing EMGs and interpreting their results. And since they have no financial interest in the overall treatment plan in the claim, they can give you an objective opinion without bias.

If the adjuster fails to obtain another opinion, and decides to go with the treating doctor’s opinion, this can lead to huge surgical costs and other medical costs that may not be related to this work injury. This practice over time leads to thousands and thousands of dollars wasted by the insurance carrier or TPA, otherwise known as “Leakage.” The worker puts themselves through possibly unnecessary surgery, rehab, medication, and so on. Your adjuster should get a second opinion every time. It is better to be safe than sorry, especially when it comes to claims and surgical costs.

MRI More Difficult to Interpret

It is typically more difficult to interpret the results of an MRI. If 20 people off the street that had no back pain took an MRI, many of them would have arthritis, bulging discs, herniated discs, and so on. Just because these things are present on an MRI does not mean that they are pain generators, or that they are related to whatever work injury may have occurred.

A treating physician may or may not decide to interpret the MRI themselves. Some will rely on the radiologist’s opinion, and just repeat the conclusion to the patient. Others will ask to see the actual films, and they will draw their own conclusions, in addition to whatever the radiologist concluded.

Results Should Be Confirmed With Second Opinion

This can lead to an ethical treatment issue. The key is the doctor relating a positive MRI back to the work injury. This should not just be stated, they should be using objective medical evidence and the mechanism of injury to tie it together. Even if this done properly, a good adjuster will obtain another opinion from a qualified physician or get the MRI read by another radiologist with credentials to interpret the results. If you have ever viewed an MRI report, two radiologists can read the same films and one report may be three paragraphs, and the other may be three pages long. This depends on the style of the radiologist. Your adjusters should have certain ones that they like and whose opinion they trust.

Despite the radiologist’s opinion, they will only read the MRI. It is typically up to the surgeon to determine the cause of the injury. A radiologist may offer an opinion, but it is rarely a clear yes or no answer. There are too many variables involved since everyone’s body and function in day to day life is different. It is up to the adjuster to work on the treating doctor, using thoughtful objective questions, to push him to make a decision on the causal relationship of the injury. If this correlation cannot be made, then by no means should a surgery proceed with authorization by the claims adjuster.

Failure to Obtain Causal Relation Statement Can Cost You

Failure to properly obtain a causal relation statement can yield thousands of dollars spent in error. Once a surgery is performed, there is no taking it back. Your worker had an invasive surgery performed, and medical complications are always a risk. In addition, a surgery doesn’t always mean a cure for all of ailments. Significant leakage can occur if a positive MRI is not work related and your adjuster deems a claim, surgery, rehab, etc. compensable. If the surgery was a multilevel spinal fusion, then you have medical cost leakage, wage leakage, vocational issues, further surgeries, and so on.

Before you authorize any surgery, take the time to get a few other opinions from not only qualified physicians, but qualified radiologists as well. Most IME vendors and diagnostic providers will also have a radiologist on their roster, and this person can oftentimes be an overlooked resource. In the end, it could save you tens of thousands of dollars, if not hundreds of thousands upon the lifetime of a particular claim.

Summary

Remember just because a person is a physician, it doesn’t make them automatically qualified to properly read and interpret diagnostic reports. Unreliable interpretation of diagnostics can lead to costly results for you and the worker. Communication with the worker at this point is critical. The injured worker may know nothing about medical, and they are going on the advice of their treating doctor. Facing a surgery or major injury is a scary thing, and you want to relay to the worker that you are taking the time to get all of these extra opinions for their benefit, not only for the overall compensability of the claim.

Some injured workers respond to this as “Doctor shopping until you can find one that will deny my claim” but this is not the truth. Adjusters have to have a clear, concise answer to causal relation. My response to the “doctor shopping” question is to respond by saying that the worker is the one that has to undergo the surgery, the lost wages, the rehab, the medication, the travel time, and the overall stress of dealing with an injury. Whether it is work related or not, I’m going to want to cover all of the bases so you get a proper diagnosis and treatment plan.

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%. He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: [email protected].

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