Key Points to Note about Medical Records in Workers’ Comp

by | Feb 10, 2023 | Workers Compensation

Workers’ compensation coverage is designed to provide a worker injured or taken ill at the workplace with the treatment required to recover from the work-related injury or illness, and partial replacement of the wages lost due to absence from work. Medical records play a key role in a workers’ compensation claim because they are the main evidence to show that an injury or illness occurred and that it is work-related. A provider of medical review service can extract the required medical evidence from the medical records to establish the injury and its extent, as well as the need for appropriate treatment.

Employees need to ensure that their medical records are accurate and contains all the important facts. It is vital that information that supports the work-related injury is necessarily included in the records. If such information is missing from the records, the insurer cannot be convinced regarding the validity of the workers’ compensation claim.

Essential Aspects Regarding Medical Records in Workers’ Compensation Claims

Now, let us discuss some important points to note about medical records in workers’ compensation.

  • HIPAA and the workers’ compensation laws in individual states regulate the way in which sensitive medical information is disclosed and transmitted. HIPAA also determines how medical records are stored electronically and physically. HIPAA allows medical care providers to provide the required medical information of a person to his/her employer, state workers’ compensation administrators, and workers’ compensation insurance companies. The medical records disclosure act of each state clearly defines the information an employer is allowed to request.
  • The medical details about the workplace injury must be collected and maintained on a completely separate form. Such records must be maintained in a separate file along with any other information that needs to be maintained in a confidential manner.
  • There are restrictions as regards what information can be disclosed. A medical provider can disclose only the information that is required to pay for or treat an injured/ill worker. This means that the employer or workers’ comp personnel cannot gain access to the complete medical chart of a worker.
  • Typically, employees may have to provide a medical authorization for release of the relevant medical records, if the insurance company makes such a request. Employees should not sign a blank release form because they are required to release only those records related to the treatment of their injury or illness. The authorization form should contain the name of the medical provider to which the employee is signing a release of information. Ideally, a separate release of information can be made for each provider.
  • Medical records are important legal evidence. To ensure fair claims processing, all records relevant to the claim will be considered.
  • The obligation to pay for the medical records ordered falls on the defendant.
  • The medical records that are inadequate could be used to deny even legitimate claims. Some of the reasons for claim denial are:
    • The injury was not immediately reported
    • Discrepancies are seen between the worker’s accident report and initial medical records
    • The worker’s medical records show the presence of illegal drugs in his/her system
    • The employee refused to give a recorded statement to the insurance company or sign medical authorizations.
  • Medical records help in determining medical necessity of a particular procedure or treatment provided to the employee.
  • Medical records provide information regarding any pre-existing health conditions. In most US states, workers’ compensation insurance covers only the aggravation of an employee’s physical condition caused by the work-related injury or illness, not those caused by pre-existing conditions. If the employee’s pre-existing condition is medically related to their workers’ compensation claim, the benefits are likely to be affected.

Inadequate medical documentation is the main reason for workers’ compensation claim denials and delays. Therefore, workers’ compensation attorneys filing claims for their clients need to make sure that the complete medical chart is available. The workers’ compensation insurer or a judge considering reimbursement for an injured worker’s medical treatment would be looking for medical records showing the type of treatment that the physician is recommending. Apart from these, they would also need medical records stating that the worker needs the medical treatment for a medical condition caused by the workplace injury or his/her repetitive job duties.

Complete medical documentation can be ensured with efficient medical record retrieval and review services. Companies providing medical review service and related solutions can make the entire claims processing simple and uncomplicated.


Disclaimer: The content in the above blog is sourced from reliable internet resources, and is meant for informative purposes only. For a professional opinion, contact a workers’ compensation attorney.

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

Related Posts

Scheduled vs Unscheduled Injuries in Workers’ Compensation

Scheduled vs Unscheduled Injuries in Workers’ Compensation

Workplace injuries can have a profound impact on both employees and employers. When an employee gets injured on the job, he/she is entitled to workers' compensation benefits, which provide financial support and medical coverage during their recovery. Workers'...

Workers’ Compensation Coverage for Firefighters

Workers’ Compensation Coverage for Firefighters

Firefighters get injured in the line of duty on many occasions such as when rescuing people from burning buildings, in traffic accidents involving fire department emergency vehicles responding to or returning from incidents, from activities at a non-fire scene, and...