That new claim lands on your desk. It is a relatively simple slip and fall type of injury. However, the injured employee is not as close to 18 as they want to be, there are significant past medical and surgical history issues noted, and there are a variety of complaints. When being mindful of cost-containment protocols, one has to realize that the medical costs you are addressing are not just a downstream problem. This, somewhat less than a straightforward problem, does not become overly expensive overnight, it becomes expensive as the trajectory of the file was not adequately controlled in the first round.
Establishing the Medical Direction of the Claim
If addressing this as a heavyweight boxing match, your first “KO” punch starts with an early onset, thoroughly informed objectified determination of what the medical direction of this claim should take. To be clear, this is not a denial. We are not delaying appropriate care for the actual injury sustained. What is being accomplished is the correct onset of a near surgical precision to establish what occurred as a result of the identified event.
As with any encounter, the movement towards recovery is established within the first several interactions. Conversely, movement towards complexity could be seen if not addressing the medical aspects of the claim.
The Importance of Understanding the Mechanism of Injury
The “weight-in” for this match starts with the clarification of the reported mechanism of injury. Understanding this aspect allows for a clear shift into applying appropriate clinical reasoning for the entirety of the claim. The noted diagnosis assigned must be a true function of that reported mechanism of injury. The diagnosis being treated is not a function of the imaging findings identified, the treatment pursued needs to be a cause-and-effect analysis of the pathology noted.
Separating Work-Related Injuries from Pre-Existing Conditions
This analysis needs to include a soft tissue versus specific structural loss distinction relative to the injury sustained, clear establishment of the expected timelines for recovery and that there is no mismatch between the reported symptoms and the physics of the compensable injury. As an example, a slip and fall forward onto the anterior aspect of both knees does not equate to bone-on-bone arthritis with bony sclerosis within the knee. Those degenerative findings need to be waived off as pre-existing clinical findings unrelated to the reported injury.
When managing this claim, do not be passive or take a “rope-a-dope” mentality. Be more active, approach the problem and ensure that care provided is based on the expected clinical course outlined. Have certainty in the diagnosis assigned and that it is a function of the compensable injury sustained.
Objective Medical Evidence Drives Better Outcomes
Make certain that there is a clear list of reported symptoms versus competent, objective, and independently confirmable medical evidence and physical examination findings. Request documentation that separates the reported symptoms from the objective findings on physical examination. Prior to any escalation in treatment, certify there is appropriate clinical support for the additional treatment. Be cognizant of those triggers that often precipitate the claim going sideways. Understanding the importance of findings noted on MRI is significant, however these are not the drivers of appropriate treatment for the injury sustained. Any escalation in treatment, not accompanied by a detailed clinical assessment, should be questioned. And do not delay any intervention that is appropriate for the injury sustained.
Preventing Claim Escalation Through Effective Cost Containment
Not applying your cost-containment strategy can lead to mismanagement of the claim, prolonged disability, and other significant cost drivers. One must remember that cost-containment starts with the opening bell, this is not a late-stage comeback activity and should be applied with every opportunity.
