Reserves get blown out by a simple clinical mix-up: treating a finding like it is a diagnosis. An MRI shows a disc bulge. An X-ray shows degenerative changes. The exam notes tenderness to palpation. None of that is a diagnosis. It is data that assists one in reaching a conclusion (aka diagnosis).
How Clinical Findings Become a Diagnosis
A diagnosis is the clinical conclusion a provider reaches after combining the mechanism of injury, the symptoms presented, the physical exam findings, and the imaging data obtained. Skip that step, and the treatment plan can drift far past the sequelae of the compensable injury.
When Imaging Drives the Claim Instead of the Injury
Here’s where it goes wrong on a file: multi-level disc bulges and facet disease show up on imaging, treatment starts, and nobody asks whether that treatment belongs to the work injury or to a spine that was already degenerating long before the claim opened.
Four Questions Every Claims Professional Should Ask
Before you sign off on a treatment plan, ask:
- Does the diagnosis match the reported mechanism of injury?
- What objective findings are presented that actually support the diagnosis assigned?
- Are those findings acute or degenerative?
- Would the diagnosis still hold if the imaging had never been done?
Close the Gap Before Costs Escalate
You are not being asked to diagnose anything. What you are being tasked with is to spot the gap between what was found and what was concluded. That gap is exactly what a Baseline Clinical Assessment is built to catch, early, before the treatment plan runs past the injury. If you have a file where the diagnosis does not quite add up, obtain an independent clinical perspective, one that will tell you plainly what the record supports.
