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Medical Management for Claims Examiners - Part 2

Sunday, March 3, 2002 | 1278 | 0 | min read

We started off this series of articles with some basic concepts of medical management from the claims examiner standpoint. Now we will take a look at some of the more specific issues, and in particular issues involving orthopedic medical management since orthopedic injuries are the most common workers' compensation claims. Having a basic understanding of the normal course of treatment for certain types of injuries is essential for identifying potential problems as the case matures.

Among the most common orthopedic injuries are those to the back or spine, shoulders and knees. Back injuries may include strain/sprain, disc bulge, disc rupture, fracture or cord injury. Shoulder injuries can consist of strain, sprain, impingement, tendonitis, sublaxation, dislocation/instability, partial rotator cuff tear, complete rotator cuff tear or fracture. In Knee injuries you will see strain, sprain and meniscal tears.

Orthopedic injuries have common time-lines relative to diagnosis and treatment. During the first three months of a specific injury there are three general phases. These three phases are discussed in the IMC treatment guidelines for low back (and other) injuries:

Symptom duration is classified as acute (one month), subacute (one to three months), and chronic (> three months). If an injured worker experiences more than one recurrence of low back pain in a year, except in cases of a new injury, it should not be classified and treated as an acute back problem.

During week one to two you can count on medication, physical modalities (pt, chiropractic, occupational therapy), orthodics (ace bandage, brace), TTD status and x-rays.

From weeks two to six you can expect to see medication, physical modalities, orthodics, local injections ( ex: trigger point), TTD, and repeat x-rays.

Weeks six to twelve will often be marked by medication, physical modalities, orthodics, consultations, epidural injections, mri, surgery, and TTD.

Red flags to pay attention to during these first 3 months include: Chronic Pain (ex: Reflex Sympathetic Dystrophy), Pregnancy, Diabetes, Non-steroidal anti-inflammatory drugs (which can lead to ulcers), and creeping symptoms such as fibromyalgia and transfer stress.

Medications prescribed during the course of treatment need to be watched carefully as these can also raise red flags. Many cases end up unnecessarily complicated simply because of the indiscriminate prescribing of medications. The reality is that narcotics can be addictive! Commonly prescribed narcotics include Codeine, Oxycodone, Percocet, Morphine, Demoral, and Darvon.

Finally you need to know how to distinguish between chronic and acute pain. Pain may be chronic when there is no obvious evidence of injury because the healing process should have ended. Acute pain results from a recent injury in which the body's attempt to heal is not yet finished.

Knowing these basics is necessary to understanding where the claims examiner's medical management duties come into play. Next in this series we will examine a couple of common diagnostic tools, and discuss the role of the claims examiner in managing the medical in a case.

Author,Tina Chong, is a partner in the firm Corporate Training Solutions. With her partner, Cyndi Koppany, Corporate Training Solutions offers intensive claims department training programs. They can be reached at (323) 467-4430, or by e-mail at ckoppany@earthlink.net(Cyndi Koppany) or ctschong@earthlink.net (Tina Chong).


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