This article is part of a series on the top reasons why insurance carriers object to a workers’ compensation report and return it to the medical practice unpaid. This article is intended for medical providers, administrative staff, office managers, as well as insurance claims adjusters.
We have now covered two reasons that an insurance claims adjuster may object to your impairment PR-4 report: First, due to an incomplete history of symptoms, and second, because of an incomplete activities of daily living (ADLs).
It is the intention of the claims adjuster to be skeptical about any and all things that can set off red flags in the review process of your reports. Should they find any documentation regarding a previous claim, the insurance company will go through the worker’s history of injuries in the workplace with a fine tooth comb to ensure that the current injury is not a result of symptoms of a prior injury.
Reason #3: Prior Injuries
If an employee gets hurt at work, the patient’s previous medical history may be relevant to the claim.
For example, imagine that someone has had back pain for a long time due to a childhood injury. Then she gets a job. One day while at work, she falls off a ladder and hurts her back even more.
The physician’s work comp report should include information not just about the current injury—the falling off the ladder incident—but also about the previous injury.
Well, the patient has symptoms—back pain, inability to sit for long periods of time, difficulty dressing—but it’s possible that some or all of these symptoms existed before the work-related injury. The question becomes—which symptoms were caused by the work-related injury? Which symptoms existed previously, but are now worse due to the work-injury? Make sure to listen very carefully when taking your patient’s history.
These questions are all oriented around the one central question: what was the patient’s life like prior to the injury?
When it comes time to write the impairment report and calculate the impairment rating for the injury, information about all previous conditions will be critical for calculating apportionment—but that’s a different story.
For now, the important thing to remember is that the history of any injuries affecting a body part that has been injured at work should be included in workers’ comp reports. If the claim’s adjuster is reviewing a report on an employee’s spine injury, and the adjuster knows that the patient’s spine had been previously injured but doesn’t see any information about that prior injury in the report, it will raise a question: how much of the symptoms are caused by the work injury?
The goal is to answer that question before the adjuster can ask it. This way, there will be no reason for the insurance carrier to deem your report incomplete.
Note that the prior injury is only applicable to the specific body part injured in the current impairment report, e.g., a prior injury to the left arm is not applicable to an injury in the right leg.
In your workers’ comp report, include a section for each prior injury that is relevant to the claim. In RateFast, information about prior injuries is automatically presented under a “Medical History” heading, and organized by each body part. Information should include how any prior injuries affected the patient’s ADLs, whether there was surgery, medications currently being taken for the prior injury, and so forth.
Here’s an example of a decent description of a prior injury:
Employee reports that her cervical spine was injured in a car accident when she was 12 years old. Symptoms included limited mobility (range of motion unknown) and pain. Prior to work-injury, took 300 mg ibuprofen daily. ADLs impacted: sleeping (caused patient to wake up) and driving (difficulty turning neck).
Here’s a poor description of a prior injury that is likely to raise questions in the insurance adjuster’s mind:
Employee reports that her cervical spine was injured.
But the worst description of all is no description. Always ask about prior injuries, and take detailed notes.
In an impairment report, the description of prior injuries should be like a miniature report in-and-of itself. The physician must work with what he/she has in order to ensure that the prior injuries are thoroughly and accurately described. It may be difficult to obtain a detailed record of an injury from many years ago, but if the information about prior injuries doesn’t satisfy the claim’s adjuster, then the report may be returned—unpaid and with questions.