The First Reported Diagnosis Isn’t Always the Full Story
How many times have we seen the initial paperwork indicating that the injured employee sustained a “shoulder strain” or perhaps the more generic low back injury. At first glance, it would appear the diagnosis is straightforward. Appropriate steps are pursued, reserves are set, and the expected treatment plan is predictable.
However, this identified injury continues to be problematic, and ongoing treatment is being pursued, and any number of administrative issues are popping up. Some would argue, at first glance, this is a function of poor claims handling. However, all too often this is not the case. The problem is that the originally communicated injury did not accurately reflect the pathology that had occurred.
What becomes apparent is that the diagnosis originally listed on the first report of injury and the actual condition sustained, driving current claim costs are all too often vastly different clinical issues. One must step away from the issue of the initial diagnosis being a “placeholder” type scenario. This is the starting point. Get clinical input early to confirm what actually happened. The key take away is that the initially reported diagnosis should be viewed as a point of reference and not the definitive answer.
Why the Mechanism of Injury Matters
A key question to be answered as early on in the life of this claim is what is the specific mechanism of injury, and what is a reasonable response to that event from a clinical perspective? If the mechanism of injury does not fit the current diagnoses, the claim file handler should take a breath, ask several questions, and obtain those clinical details necessary to appropriately handle the file.
Imaging Supports the Claim, But Doesn’t Define It
And as I had talked about previously, imaging studies are helpful but are not always the answer in establishing the sequelae of the compensable event. Imaging studies will note age-related degenerative changes, other pre-existing pathology, and incidental findings completely unrelated to the reported mechanism of injury. Another rationale to obtain independently confirmable medical evidence and establishment of what is and what is not the pathology associated with the compensable event.
When addressing unrelated comorbidities, it is those items which can cause excessive treatment, delay recovery, precipitate unnecessary referrals and drive any number of costs up. The benefit of accurate objective data demonstrating the extent of the compensable injury leads to better treatment decisions, a discussion with the injured employee relative to appropriate expectations, and the overall claims process is strengthened.
Therefore, that initial injury listed is not always the pathology being treated, or the rationale behind whatever disability is pursued. Treating beyond that the scope of the compensable event nearly always drives up claim costs. Successful claimant management requires a detailed understanding of the actual mechanism of injury, the initial clinical assessment completed in the emergency department or other health care facility, tempered by clinical findings noted by additional providers. This information is then mitigated by diagnostic imaging studies and other evidence, and clarification as to what was present prior to the date of injury is necessary.
Don’t Let the Initial Diagnosis Drive the Entire Claim
An all-too-common mistake is that relying on the first reported diagnosis can become quite expensive when managing the diagnosis you were informed of, as opposed to the objectification of the current clinical situation that is an actual function of the mechanism of injury.
