Key Points to Note about Medical Records in Workers’ Comp

According to a study by Atticus, 10-50% of workers’ compensation claims are denied due to insufficient or incomplete medical documentation. This stat underscores the indispensable role medical records play in the worker’s compensation claims process. Medical records lay the foundation for determining whether the injury was work-related or not, evaluating the extent of injury and making sure the plaintiff receives benefits. However, any missing information or improper documentation can lead to delays, disputes, or even denials.

Navigating through this complex environment can be challenging for employees, employers, attorneys and insurers. In this blog, we will discuss the essential aspects of medical records in workers’ comp claims, how medical records can aid attorneys, and why partnering with an expert medical record retrieval firm can make all the difference.

Essential Aspects Regarding Medical Records in Workers’ Compensation Claims

Medical records provide crucial insights into establishing a link between the workplace injury and its subsequent physical/mental impact on the employee. Here are some of the important things to note about medical records in workers’ comp claims:

• Proving the Incident: The foremost task involved with comp claims is to establish the connection between the accident and the claimant’s injury. His/her medical records must detail the nature of the injury along with physician’s notes, lab results and treatment procedures that would help prove causation. However, if these records are vague/incomplete, the claim would be denied.
• Presenting Severity of the Injury: A comprehensive medical record details the nature & extent of the injury which will provide its impact on the claimant’s ability to work. This is very important to determine whether the individual is qualified to avail temporary or permanent disability benefits.
• Timeline & Consistency: Insurance companies thoroughly examine medical records to validate the link between the reported accident and treatment timeline. Any discrepancies or delays in seeking treatment, can lead to disputes and even denials.
• Denial Appeals: When claims are denied, medical records are used to help overturn the decision. Proper analysis of the submitted records can identify errors, thereby assisting to secure the rightful benefits.

How Does Medical Record Review Help Attorneys in Workers’ Compensation Claims?

Attorneys who are representing the workers, often heavily rely on medical records to build compelling cases. Here are a few advantages:

• Evidence Analysis: Attorneys utilize medical records to obtain necessary evidence to support their claims. An in-depth review can identify the most relevant medical data, like lab reports and treatment procedures to strengthen their case. For example, pinpointing records that directly link the injury to the workplace incident is vital for the case.
• Finding Discrepancies or Errors: Incomplete medical records can weaken the case and turn the decision against producing a favorable outcome. Independent medical experts analyzing the records can not only point out and fix errors, but also offer unbiased and objective assessments of the medical records, which could aid the case.
• Strengthening Negotiations: Attorneys can review medical records and use the findings to negotiate better settlements. They can argue with the opposing party, insurers, and/or medical professionals for a fair compensation based on the discrepancies in the documents and subsequent, long-term impact of the injury.
• Supporting Appeals: When a claim is initially denied, attorneys may have to look for comprehensive medical records or bring in experts to support the necessity of treatments, recovery period and other details that may back their claim. A detailed review ensures that expert opinions can support the appeal and the presented facts are aligned with the case.
• Cost-efficiency: Comprehensive and precise review can help attorneys identify cases with relevant medical evidence that can solidify their case, thereby potentially saving time and resources by focusing efforts on cases with a higher likelihood of success.

Additional Considerations to Keep in Mind

• Privacy and HIPAA Compliance: All workers’ compensation claims contain sensitive, personal medical information, which makes it mandatory to adhere to the latest HIPAA regulations. Therefore, it is important that employers, attorneys, and insurers manage medical records with utmost care to avoid any legal pitfalls.
• The Role of Technology in Managing Records: Now, with technological advancements, digital tools have made medical record retrieval and analysis a less-stressful task. Cloud-based platforms, AI-powered data extraction, and automated data processing have transformed how attorneys and claims adjusters work and interpret records.
• Expert Medical Review Services: Considering the complexities involved, professional medical record review services can prove to be indispensable. These experts can offer insights into medical terminology, treatment guidelines, and identify potential gaps in the records, enabling attorneys and insurers to be prepared and make informed decisions.

Medical records are pivotal in ensuring a favorable result for workers’ compensation claims. Whether you are an attorney, a claimant or an insurer, it is critical to make sure that these medical records are accurate, complete and prompt. Collaborating with experienced professionals like Managed Outsource Solutions (MOS) can support your efforts of securing compensation and avoid delays/denials in your comp claim.