Impact of Medical Chart Review on a Workers’ Compensation Claim for Back Injury

My name is Jessica Schwartz. I am the Solutions Manager at Managed Outsource Solutions and I am here to talk to you about what impact does a medical chart review have on a workers’ compensation claim for back injury.

00:14 Importance of medical chart review

Medical chart review has a very important role to play as regards a workers’ compensation claim for back injury. The information contained in medical records has considerable impact on whether the claim will be paid or denied. When an injury is reported to the workers’ compensation insurer, the insurance adjuster typically makes the decision whether the claim is valid or not based on the details available in the medical records that are extracted via a comprehensive medical record review. Even if a claim is denied initially, the insurer may later decide to accept it if more medical records are produced and those records contain the necessary medical evidence. If the case goes to court, is heard by a judge, he/she may ask the insurance company that denied the claim to accept it and pay for medical expenses for the injury based on the medical record data. So, at all stages of claim processing, chart review is a major consideration.

01:14 What to note in the medical record review report?

The medical documentation must support the back-injury claim, and all records must be prepared and signed by either the treating physician, physician assistant, nurse, or any other qualified medical provider. A medical record analysis should clearly show the type of treatment the physician is recommending. Also, the documentation must state that the treatment is medically necessary to address the back injury caused by the nature of work. A judge or an insurance company reviewing the claim would want to see the following information in the medical record review report.

• The worker has a debilitating back injury that prevents him or her from earning full wages. The treating physician would have made notes such as “do not lift heavy objects,” “light duty only,” “no work,” and so on.
• The injury is caused by the specific nature of the worker’s job.

There may be instances where the doctor is not completely sure regarding the cause of the back injury. Even so, workers’ compensation benefits may be granted to the worker if the medical chart review shows that the back injury “more likely than not” was caused by the worker’s job. According to workers’ compensation law, the doctor must provide an opinion regarding the cause of the injury or the need for treatment based on probability, not just a possibility.

02:30 Information extracted through medical record review

Here is a look at some important information that can be extracted through a comprehensive review of the medical records, and which has a bearing on the claim.

• Any pre-existing condition the worker may have
• Doctor’s note whether the nature of the worker’s job caused the injury
• Documentation that proves how the back pain impairs the worker’s ability to sit, stand, lift, carry, or walk
• Opinion of any consultant doctor that supports the fact that the injury is work-related
• Status of the injury and present disability status
• Additional treatments the worker may require
• Objective findings from X-rays and MRIs that support the amount of pain the worker is experiencing

Review of the injured worker’s medical records helps establish that the disability is ongoing and consistent. All diagnostic and lab tests undergone and other medical evidence would support the back-injury claim. Also, information about the medications the worker is on, side effects, symptoms such as fatigue or pain that restrain the worker from functioning in the work environment are all important factors in the medical documentation that emerge during the review process.

03:43 How can a medical review company support?

The medical evidence obtained through a medical record review can make or break a workers’ compensation claim for back injury. It is easier to win the claim if there is adequate medical evidence that supports the back-injury claim; such evidence can be lab tests and findings, medical opinion from a licensed provider, and medical records. A medical review company assisting workers’ compensation attorneys will focus on obtaining as much medical documentation as possible to prove the case. Attorneys find their service valuable because professional reviewers sort through the records and determine what are or aren’t relevant to the claim. With a reliable and accurate medical review report, attorneys would find it easier to establish the nature and severity of the back injury and determine the amount of compensation the worker may be eligible for.

Thank you for listening and hope you have a good day!