A recent news article that came out of California will tell you that Worker’s Compensation regulators have suspended 178 medical providers just in the first eight months of 2022 alone for fraud. Moreover, if one goes back approximately six years, just in California alone, that number rises to approximately 650 medical providers. It was also reported that in the last six years more than 63,000 liens (additional money claims) were dropped totaling more than $775 million. These individuals were suspended for fraud. And in short, fraud equals a lie.
Yet we, in the Worker’s Compensation industry, are asked to believe what the providers tell us in their progress notes or reports are the truth so that we can make appropriate clinical decisions. Clearly, a challenge.
In my clinical career, a basic axiom was that common things happen commonly, and rare things happen rarely. The question becomes, why should I believe that this extensive amount of pathology happened because of a very minor trauma?
I do not remember much of my physics class as the testing was completed on Friday, and by the hangover on Saturday morning, not much was left in my cortex. However, from a clinical perspective what one should always consider is the reported mechanism of injury relative to the actual injury complained of and the pathology objectified. Does the force behind the injury equal the damage done? The body is very resilient and can absorb a significant amount of force without any specific damage or harm.
Perhaps a better standard relative to the extent of injury should be what happened to me when I was four. My mother would either A.) kiss it and make it all better or B.) rush me to the emergency room. In most cases, in my personal situation, the choice was clear. Growing up in a family of five boys, the net result was being on a first-name basis with the ER nurse.
The point is, there are always going to be “bad actors” in any type of financial situation. This occurs in every single jurisdiction where Worker’s Compensation is in force. Take a gander at the list of providers sanctioned by the Texas Division of Workers Compensation or the 25 providers sanctioned by the Texas Medical Board at every meeting. If your gut is acting up or your nasal passages find something particularly odiferous, there probably is a very valid reason for that biological response.
However, there is a particularly easy solution to any situation where there is a question. As our friends at CSI (Thank you CBS) will tell us, follow the evidence. Obtain a comprehensive assessment of the clinical records and have that evaluator apply the concept and standards of evidence-based medicine. Simply put, “because I said so” might have worked for my parents when I was a small child (and what parent has not used that phrase?) but now the standard has to be “show me the competent, objective, and independently confirmable medical evidence”. Demonstrate to the adjudicator/decision-maker/hearing officer exactly why the reported “findings” noted in the progress notes simply do not work or meet the standards of the most competent current thinking.
You may or may not win at the hearing, but at least you can show your client you did everything possible so that the real truth may prevail. I grew up in a world where Ann Landers taught you to trust and believe in your doctor. However, such blind faith does not work in far too many instances in our current world. As noted by one of our past presidents, “trust but verify.” Therefore, if the assertions cannot be proven with competent objective, and evidence-based medicine, this is a very clear reason that will tell you that something really smells.