Medical Management for Claims Examiners - Part 3

Saturday, August 3, 2002 | 0

In our last article we looked at specific issues in orthopedic medical management. Just as important as the treatment itself is diagnostics, and understanding what is good for various medical issues can assist the conscientious examiner maintain quality in the claim.

Two of the more common diagnostic tools are MRIs and CT Scans. Both of these techniques revolutionized medical imaging by providing detailed cross-sectional images of the inside of the body. However, though it would seem that they are similar, each modality is fundamentally different.

An MRI (magnetic resonance imaging) is a non-invasive imaging that produces very detailed images of the body without radiation. The MRI uses a magnetic field generated by a large magnet to produce images. Because of the magnet, an MRI cannot be used on patients with pacemakers, aneurysm clips, metal in the body or similar issues. But an MRI is indicated where discrimination between different types of soft tissues and processes within the soft tissues is called for, or for views of bone detail or evaluation because it detects calcium easily.

The typical MRI produces 100-200 images. They are are acquired in sets, and labeled to show sensitivity and placement to other soft tissues. MRI images look like slices through the body and in fact the images -step-through the body at the rate of 4-12 images per inch.

Some of the advantages to an MRI are that it can visualize both soft tissue and bone marrow, there is no radiation, flowing blood provides a contrast so you don't need to use an injection and it is safer than many other diagnostic tools with fewer side effects.

However, MRIs are not without disadvantages. Because an MRI machine is basically a big tube, it requires a more cooperative patient who can stand a confined space. Experience with pregnant patients is limited and potential risks are unknown. Finally, as noted above, metal in the body precludes use of an MRI.

CT scans are a different diagnostic technology. The CT is an X-ray based imaging modality that uses ionizing radiation to produce cross sectional images of the body. Generally there are 2-25 images per inch, and this technique is useful for bone detail/evaluation as it detects calcium easily.

Advantages with the CT are that it is a very fast imaging technique and has good sensitivity to calcium.

Disadvantages to the CT are that it uses x-ray radiation and is less sensitive to soft tissue changes compared to the MRI.

Now this discussion of MRIs and CTs is fine, but what we need to remember is how knowledge of these techniques is important to the claims examiner's job. Remember that the Claims Examiner is fully responsible for the management of the file. This means that it is the Examiner who must take active steps to direct the medical plan and the course of treatment, as this is the most expensive benefit within the claim (and growing more expensive). This includes the approval and monitoring of all medical treatment, including diagnostic studies, and the review and approval of medical bills before payment. As a claims examiner, you are the Gatekeeper and pave the way for medical control by guiding the doctor and medical vendors.

In your role as a Claims Examiner, remember that communication is critical; make your expectations clear! Encourage the injured worker, or his/her representative to actively participate in developing the medical plan. When a particular treatment results in actual cure of the injury, it may be assumed that the expense was reasonably required. However, you should always ask yourself, what other treatment might have achieved the same result at much less expense? The next claim may provide an opportunity to consider a more cost effective way to cure and relieve the injury.

Depending on your state jurisdiction guidelines, medical management nurses and review physicians may assist the Examiner with recommended and appropriate treatment plans. But, if an issue arises, you are responsible for the resolution of medical disputes. REMEMBER, it is the Examiner who is the Gatekeeper.

Author, Cyndi Koppany, directs training of claims examiners and others at Cambridge Integrated Services, Inc. She can be reached at (323) 467-4430, or by e-mail at ckoppany@earthlink.net.