Ten Red Flags Indicating Medical Providers May Be Over Treating

Wednesday, December 14, 2011 | 0

Chiropractors may receive a bad rap.  If anyone mentions excessive treatment that may not heal a patient, chiropractors are first on the list.  But, there are certain medical practices, in every medical specialty, in every medical area, that may have a “chiropractor” of the known group.  This group may be known within the medical community for having liberal treatment styles pairing up with liberal prescription dosage, and that is never a good combo in a workers comp matter.  Workers comp adjusters can probably list a good handful of doctors or practices that fall within this realm, and cringe when seeing that letterhead come across their desk.
 
To determine if an injured worker may be treating with a “red flag” clinic, check the criteria below.  If you have concerns, discuss with the adjuster.
 
 1. The diagnosis is inconsistent with the treatment. Maybe this started out as a simple enough back strain, but the diagnosis reads “multilevel disc herniation with severe radiculopathy” … that could be an issue.
 
2. The practice is known for questionable/suspicious treatment.  Is this practice featured on  billboards?  Are their TV commercials on all the time? When you mentioned them to the adjuster, is there an audible groan? If the answer is yes, you should be talking about the plan of action on this claim with the adjuster.
 
3. The doctor will not release the patient from care.  Sometimes doctors will keep a patient on a rotation of coming back to the clinic, maybe every 3-4 months or twice a year.  If so, this should raise an eyebrow.  Not only is that excessive, but it is probably unnecessary.
 
4. The clinic treats without prior approval or authorization.  This will vary by jurisdiction, and by treatment, but if the doctor rushes a potential workers comp case into surgery without verifying any information or taking an insurance card, then that is a problem.  “Slash for cash” doctors will operate first, ask questions later.  They know they will be paid by somebody, and they do not care who it will be.  It could be comp, personal insurance, Medicare, etc.  As long as they get paid, that is their main concern.  Check with the counsel about rules regarding invasive treatment without authorization and make sure to be as proactive as possible so the company is protected against unnecessary expense.
 
5. The bills include extra body part codes.  The worker has an injured left arm, but the clinic bill states they performed treatment on the arm, wrist, elbow, shoulder, neck, and head.  Be sure to read the records carefully, the billers may be trying to slide in some extra body parts and extra treatment that is already covered.  Known as “unbundling,” this is where a clinic tries to bill separately for services that are usually combined into one already negotiated rate.
 
6. Unexpected high cost.  The worker goes to the chiropractor for 12 visits to resolve a lumbar strain.  He is a lot better, and it appears this doctor did a great job but then the bill arrives for $8,000.That is not so great and should prompt a call to the doctor for explanation.  Sometimes when doctors see that a workers comp case is involved, the costs go sky-high.
 
7. Doctors that steer patients to plaintiff counsel. Every now and then you will see in the medical notes a doctor that flat out tells a patient to go see someone for a legal opinion. That is a red flag. The doctor is not there to give out legal advice. Some doctors have a tie in with certain plaintiff counsel, and they pass people back and forth to create new business. Beware.
 
8. The doctor will not answer the questions or return phone calls. Why is the doctor dodging calls from the claims adjuster? Doctors that have a practice know they have a business to run.  An empty waiting room means you are a great doc and a poor businessman. The doctor wants that waiting room to be full all day and everyday.  And the more they can do to keep a person coming back, the doctor may try and do.
 
9. The physician refers patients to specific medical specialists.  Now, this one is not all bad.  Sometimes this doctor knows which specialist docs are successful and have a good track record, and will refer the worker to this doctor with confidence.  But there are those docs who are just passing a patient on to a pal, and chances are these docs do this a lot between the two practices. Just be on alert if  this is happening frequently between clinics.
 
10. The physician prescribes unneeded and/or unnecessary durable medical equipment (DME).  And the reason why the doctor does this is because they are probably getting some sort of kickback (referral fee) from the DME provider, such as paid golf, concert tickets, etc.  When entering the doctor’s office and he has one drug company calendar,  pen,  paper,  clock, and poster, then I think I know which medication you will be receiving….
 
 Part 1 of this 2-part series should raise the awareness of the red flags that can affect the workers compensation cases.  Do not be alarmed as this does not happen in a a huge number of cases.  But it can happen, and the more vigilant you are, the better you can protect the company.  To find out more about questionable physicians or clinics in the area, contact your adjusters or attorneys.

Attorney Rebecca Schafer is president of Amaxx Risk Solutions. This copyrighted column was reprinted with her permission from her blog, http:blog.ReduceYourWorkersComp.com.</i>