The Case for Comprehensive Medical File Review in Workers’ Compensation Cases

by | Published on Mar 4, 2015 | Workers Compensation

In a workers’ compensation case both employee and employer are responsible for exchanging the medical records in their possession for review and analysis. This is very significant from the point of view of arriving at a fair decision. According to the HHS, the HIPAA Privacy Rule does not apply to workers’ compensation insurers, workers’ compensation administrative agencies, or employers to the extent they otherwise be covered entities. These entities may however, need to access the health records of injured workers to process or adjudicate claims, or to provide care under the WC system. Understanding the genuine need of insurers and other entities involved in WC systems, the Privacy Rule allows disclosures of health information for workers’ compensation purposes in a number of ways as authorized by state or other law. More details about this are available here.

Typically, workers’ compensation cases are evaluated on the basis of medical document reviews. Such record reviews will focus on evaluating causation, injury and appropriateness of care provided. Insurers, legal firms, corporates, and third party administrators can all utilize timely and efficient medical file review services in the place of an independent medical examination and save considerable money. What is remarkable about a reputable medical review company with an impressive track record is that it takes care to maintain the strictest standards of objectivity and clinical integrity. A thorough review of the patient’s healthcare data will highlight the specific nature of the injury such as those caused by sprain and strain, internal injuries, head and neck injuries, and those associated with the shoulder and rotator cuff among many other. An accurate and comprehensive review is ensured by the physicians and registered nurses that are usually part of the review team. They are personnel whose exposure to diverse medical specialties allows them to offer clear concise reports to their clients.

Sometimes, workers’ compensation benefits denied vide state rules are granted at the appeal level, as this recent report shows. In this case, the state’s Supreme Court of Appeals ruled that the employer should have paid the injured worker’s medical expenses related to intravenous chelation therapy performed in a medical office, notwithstanding a specific state regulation that precluded the reimbursement. The worker who was diagnosed with peripheral neuropathy due to toxic exposure to heavy metals at his workplace was provided chelation therapy at his treating physician’s office. There were no chelation programs in West Virginia hospitals treating chronic heavy metal toxicity, and therefore the procedure had to be performed at the physician’s office. The injured worker’s medical records are valuable proof showing his diagnosis, the treatment provided, and the reason for providing it. Emphasizing the medical necessity of the procedure to treat the employee’s compensable condition, the Court maintained that the regulation denied the due reimbursement unreasonably, infringing W. Va. Code § 23-4-3.

Workers’ Compensation attorneys work to secure denied benefits for injured workers. Employers also find their service immensely beneficial in settling injury cases fairly, ensuring that the case is valid.

Discover our medical record review solutions and partner with us for your next case.

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