Members of the claim management team need to take control of their files to reduce workers’ compensation costs by spot unscrupulous practices by medical providers. While a vast majority of providers are ethical, never let down your guard, and be proactive in identifying red flags when it comes to over-treatment by medical providers.
- The medical records are “template” style or barely exist at all.
A careful review is required when medical records all look the same. It is important to note “template” style records that repeat does not mean you are dealing with a shady doctor. It could just be that the doctor is very poor at note-taking. Great doctors do great analysis and back up opinions with objective medical facts. They arrive at this point by walking through the medical records and creating a great conclusive medical report.
- Missing dates of service, or no date labels on the medical notes
Missing dates of services are often paired with “template “style medical records. The doctor uses a fill-in-the-blank system. Typical examples include: Patient came in with complaints of _______ which they attribute to work causing them _____ pain out of 10, with 10 being the worst pain imaginable.
Pay attention to medical records generated by health care providers. If anyone is watching, a physician will not get far by doing this. On the other hand, if nobody is paying attention, thousands of dollars could be paid for unnecessary medical care and treatment. Make sure the notes are clearly labeled, dated, and legible. If not, you need to contact that physician’s office immediately.
- Different handwriting or inks on the same dates of service.
Some medical providers are not fully digital when it comes to the preparation of medical records. A nurse or the medical assistant may make notes in a medical record before the doctor attends to the injured employee. However, in some instances, this could mean notes are being manufactured. Carefully review these records.
- The medical provider will not send medical records or state that they do not keep medical “records.”
All legitimate medical providers should keep records of patient interactions, including telephone calls and messages. Even the most trivial of companies store records of some sort. As a matter of best practice, refuse to pay any bill ever without a medical record.
- The medical notes showed continued high levels of pain.
All legitimate medical care and treatment should provide some relief to an injured employee. If it is two months post-injury and the employee reports a pain level of “10 out of 10,” questions need to be raised as to what care is being provided, and why the injured employee is still suffering from the effects of the injury. If the physician is not doing anything about it, or the person is no better, then you must find out what is going on medically and get that person to a specialist or set up an Independent Medical Exam(IME) to address these ongoing complaints.
- Conflicting medical reports or conflicting subjective complaints.
Take the following example: You are reviewing a stack of medical records on a claim. The injured employee states they are in very bad pain, 8/10. It is hard to bend and walk. The next day they show up for therapy, and they tell the therapist they are doing great, and they think treatment is really helping them. Two days later they go back to the doctor and say they feel the same, about 7-8/10 pain. Then the same day they have therapy and tell the therapist they feel great, and are looking back to getting back to work.
Therapy can flare pain up a bit, but over a few weeks, the pain should be gradually lessened. If you start to notice inconsistent pain complaints, and pain out of proportion to the injury, think about getting an IME to better understand what is going on.
All health care providers should have consistent billing practices. They should be using standard billing forms such as a CMS/HCFA-1500 form so the bill can be processed and paid in a timely manner. All medical bills should conform to the medical record that is often required to be attached to the bill. If not, ask immediate questions. It is also important to ask questions if red flags are raised when reviewing medical records. Failure to do so can result in excessive money being spent.
Author Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%. He works as a consultant to large and mid-market clients, is a 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 & lead trainer of Amaxx Workers’ Comp Training Center .
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