MKC Medical Consulting | Case Management and Legal Nurse Consulting
ur mission is to provide the most comprehensive medical management and nurse consulting services. We strive to work in tandem with our clients in a collaborative effort. Our people become a critical, embedded asset of our client’s team. The MKC approach produces a cohesive work product while maintaining a clear understanding of the client’s goals.
recent trucking industry article illustrates how attention to medical records
can help mitigate costs and maybe even prevent claims associated with
musculoskeletal injuries (MSD).
“Baseline Testing Provides a Win” tells the story of how a
long-haul trucking company based in the Midwest created baseline medical data
on its drivers and compared it to data from a claimant’s post-injury condition.
First, a little background. MSD claims are on the uptick as our workforce continues to age and the changing demands of work take their toll. This is especially true in the trucking industry, where the rate of MSD cases for heavy and tractor-trailer truck drivers is more than three times greater than the rate for all private sector workers.
The Centers for Disease Control and Prevention defines musculoskeletal injuries as injuries or disorders of the muscles, nerves, tendons, joints and cartilage. Sudden exertion or prolonged exposure to physical factors contribute.
the article notes:
Companies are faced with increasing exposure from MSD
claims, not only from state regulations but from compliance with federal
mandates that increase potential exposure for these types of injuries.
Many drivers maintain a poor diet, rarely get enough
sleep and are sedentary. As a result, they find themselves more susceptible to
heart attacks and diabetes, as well as a myriad of strains, sprains and other
musculoskeletal disorders. Additionally, the percentage of older workers is
higher in transportation than in most industries. [A]s many as 25% of truck drivers will be
older than 65 by 2025….
how did a long-haul trucking company – with markets throughout the U.S. and
Canada – use medical records to improve its bottom line? The article details
Transport needed to provide better care for MSD injuries while not accepting
liability for injuries occurred outside the scope of work.
to the article, Marten put an EFA Soft Tissue Management (EFA-STM) program in
place in February 2015 to determine which injuries were work-related and which
were not, as well as to provide better care.
The company’s workers’ comp claims manager reported that Marten uses the
EFA-STM “as a fact-finding tool to help us, our employees and their
medical providers better understand the nature of their injury and determine
the best course of action going forward.”
get a baseline test, and, after a reported injury, a second test is conducted.
That claim-related data is compared with the baseline test to identify the new
acute condition, distinct from any pre-existing chronic conditions.
The bottom line
company compared workers’ compensation claims data from 2010-2014 to its claims
data from 2015, the year that Marten implemented the EFA-STM program. The result was a 60 percent drop in the rate
of MSD injuries per 100 hires in 2015. This translated into almost 40 fewer MSD
claims in 2015. Using the 2010-14 average cost per MSD claim, the EFA-STM
program yielded a direct ROI of 3.7: 1.
EFA-STM program is a big shift in workers compensation. It provides bottom-line benefits by
accurately separating work-related injuries from those that are not
work-related and by providing objective information…which translates into
better care for the work-related condition. The EFA-STM program helps determine
the physical condition of the employee before the incident and what needs to be
done to return them to pre-injury status.
are four action steps for you to take when considering an EFA-STM program for
your company:Investigate the baseline EFA-STM model to determine if it’s right you
Quick response with all EE injuries is a must, as is improved overall baseline health awareness
Early nurse involvement/case management can effectively control claims
Look to industry for other innovations to help with workers comp claims/injuries
Finally, whether it’s workers comp claims or some other health care cost, MKC Medical Management has nearly 30 year of experience helping businesses nationwide. Contact John Moberly(firstname.lastname@example.org) to talk about your needs and to explore how we can help.
MKC was a proud sponsor of the annual meeting of the Georgia Defense Lawyers Association, June 6-9, 2019, Ponte Vedra, Fla. It was a great conference, giving us a wonderful opportunity to learn from many leading members of the region’s defense bar!
GDLA’s outgoing president Hall McKinley was one of the conference participants to visit MKC’s sponsor’s booth at the association’s 52nd annual meeting in early June.
In addition, I’m thrilled to report that Pat Iyer, MSN RN LNCC — one of the top
professionals in my field — has invited me to appear on an upcoming special
segment of Legal Nurse Podcast.
On the podcast, you’ll hear Pat and me discuss how my team and I built MKC from a small legal nurse consulting business to a national medical record and bill review company. Pat and I also discussed specific challenges of the insurance and defense sectors.
Nurse Podcast is the only podcast for legal nurse consultants,
with listeners in 62 countries. My segment will be available August 12, and
I’ll let you know when I have a link to share!
It’s Springtime! A season for house cleaning, for falling in
love, for renewal and more.
At our company, Spring is also a time for
rebranding. After nearly 30 years of
focusing on helping claims examiners, litigation lawyers and businesses facing
thorny medically-related insurance claims, we’re turning more of our attention
to corporate executives’ concerns about saving money and avoiding costs in the
Our new logo and tagline — Claims Understood. Solutions Delivered. — reflects our markets’ C-class perspectives and needs.
Corporate executives throughout the U.S. tell us that they and their bottom lines benefit from our first-hand, practical experience and technical knowledge of the insurance claims process.
Our intimate knowledge of the insurance claims
process is one of assets that corporate executives want…and that sets us apart
in our sector. The refreshed MKC Medical
Management logo and our new tagline align with what our clients are telling us.
We have a new ad, too, that reflects the way we match up with our clients’ interests in their bottom line.
The piggy gets its debut in a couple of weeks,
when MKC Medical Management will be one of the grateful sponsors of the 52nd
annual meeting of the Georgia Defense Lawyers Association. I’ll share my
take-aways from what promises to be one of the region’s top events for the
client’s problems – such as reducing service costs and upping provider
performance — depends on getting a handle on the client’s needs.
John Moberly, our new VP for Business Development, gets it. He understands that all clients want someone who’ll help solve their problems and make their lives easier. Plus, he’s a nice guy. That’s a client satisfaction attitude that has been a cornerstone of our growth for nearly 30 years.
John shared a recent client story that illustrates this. It’s about an international service provider in the transportation sector, a company that had a service-delivery concern in its U.S. market.
He learned that the company was getting
complaints from one of its key customers – a Top 10 state department of
transportation – about the company’s poor level of service from its provider
network. Over the course of an on-going
conversation with his client, John heard about the company’s needs…about how
its provider network did not have a true nationwide solution with the latest
communication technology or service quality standards.
That’s when John engineered a solution in
collaboration with his client. John’s
team put together a tactical program that harnessed web-based service
performance metrics that were regularly communicated and managed. In addition, John recommended higher provider
intake metrics along with the use of incentives to amp up customer response
The bottom-line result? John’s client reduced its service-delivery
costs 20-30% and upped customer feedback when it deployed the improvements he
Our insurance, trucking, and retail clients —
as well as our clients in other industries — rely on MKC Medical Management
for the same listening and creative problem-solving skills that John used with
the company in this story. Since our
founding nearly 30 years ago, we’ve learned that keeping clients satisfied
requires strong technical skills, solid analytical training and experience and
a practical understanding of the client’s business and industry.
The review and analysis of claims involving PTSD and TBI may include functional Magnetic Resonance Imaging (fMRI), which measures brain activity by detecting changes associated with blood flow, an acknowledgement that cerebral blood flow and neuronal activation are coupled.
Claims examiners and defense lawyers often ask my colleagues and me to review and analyze medical records involving Traumatic Brain Injury (TBI). The difficulty of getting to the truth of these complex litigation and insurance-related matters was recently underscored by a report presented to the annual meeting of the American Academy of Psychiatry and the Law.
The author of the report — forensic
psychiatrist Jeffrey Guina, MD –noted the difficulty of diagnosis and
treatment of TBI. That’s partly because
of the complexity of brain physiology, the nature of the claimant’s injury or
condition and TBI’s similarities to Post-Traumatic Stress Disorder (PTSD).
Since PTSD and TBI have similar symptoms and are both most commonly diagnosed in veterans, it may be increasingly difficult to distinguish between the two, particularly since anywhere from 6% to 44% of those with TBI also have PTSD.
While PTSD generally results from past trauma, and TBI often follows a physical brain injury such as direct force, a blast injury, or diffuse axonal shearing, both can have similar Functional Magnetic Resonance Imaging (fMRI) findings, particularly within the dorsolateral prefrontal, orbitofrontal, medial frontal, and anterior cingulate cortices….
These diagnostic similarities and the difficulty of a reliable analysis often come into play when reviewing the medical records for a TBI or PTSD claim for evidence of possible malingering. A recent case of ours illustrates this.
The difficulty of performing an accurate analysis is compounded by the claims and awards process. As MedPage Today explains, some patients may deliberately falsify their symptoms in order to up their disability payments or to expand medical costs and impairment. Moreover, while moderate forms of PTSD are automatically qualified to receive 50% disability in the VA disability system, a moderate form of TBI may get 30% to 40% of disability.
In other words, the differences in the way the
VA and private disability systems function may be contributing to patients
reporting false claims of either illness.
take-aways and best practices
Do a thorough review of ALL the medical records, especially pre-injury records. Request any missing records.
Remember that different conditions (i.e. PTSD, TBI, concussion, other psychological conditions, etc.) can have similar complaints, symptoms or clinical pictures.
Review all raw data, especially any neurological, cognitive or psychological testing; don’t simply accept the written report.
Analyze the timeframes as to when subjective complaints and objective findings were documented, especially as it pertains to your event. For instance is there a pre-injury event or condition that could be impacting/influencing your specific injury? Brain injury symptoms are typically seen at the time (acutely) of the injury; PTSD may present several weeks, months or even years after the event.
Look at all the medications — pre and post injury — as the medications can be indicators of underlying and possibly contributory conditions, not to mention potential side effects.
Remember the cognitive and intellectual baselines may not be readily available, so look at school, employment and military records for hints into the pre-morbid state.
So, remember that a thorough review of a
claimant’s medical records is just part of the quest for the truth. Getting to the bottom of a claim requires an
experienced eye and the ability to analyze what’s in the record…and what isn’t
John T. Moberly — our new VP of Business Development — and MKC
Medical Management pledge to solve your problems, make your life easier, and be
easy to work with. Reach John at
615.943.8001 or email@example.com.
Thanks to our great clients, staff, and peers, MKC Medical Management had a record-breaking year in 2018…and it shows. Some of the highlights include…
number of referrals to date.
case to date. Over
17,000 medical record pages.
new clients. In addition to
our core strengths, we’ve expanded into new services and industry sectors,
including criminal cases, nontraditional LNC work, more formal claims,
consulting and education.
first international client. We’re
handling motor vehicle and trucking cases for this cross-border corporation.
speaking engagements and lunch and learns. Our clients and peers in our industries are increasingly
turning to us as thought leaders.
Another big way to demonstrate our strategic growth and responsiveness to our clients’ needs is the recent addition of John T. Moberly as our Vice President of Business Development.
results-driven career in national account sales, John has always had a passion
for helping his customers improve their bottom-line results. Here are a few of
the market leading companies
that John has helped:
· Johnson & Johnson
· Hershey Foods Corporation
· National Service Industries
· And, most recently, TTN Fleet Solutions
John is also a
US Navy, VietNam Combat Duty Veteran, having served aboard the USS Epperson
DD719, 1972 – 1974.
Now, as our
first VP of Business Development for MKC Medical Management, John is doing what
he has always done – sharing best practices to improve YOUR bottom line!
So, if you’re
an insurance company, TPA, attorney, trucking company, or other business with
medical management needs anywhere in the U.S., John wants to get together with
you to create better bottom line results for you!
first. Thank you for helping make 2018 our best year ever!
Not many things surprise
me after 20-plus years in the Legal Nurse Consultant business. But 2018 took me aback…as a year full of
milestones, market firsts and tons of gratitude for awesome clients.
Here’s a snapshot of
news of interest from last year for our clients and others:
Millions of dollars reviewed. Our cases often involve complex, high-exposure claims with millions at stake.
Largest number of referrals to date.
Largest case to date. Over 17,000 medical record pages.
31 new clients. In addition to our core strengths, we’ve expanded into new services and industry sectors, including criminal cases, nontraditional LNC work, more formal claims, consulting and education.
Our first international client. We’re handling motor vehicle and trucking cases for this cross-border corporation.
11 speaking engagements and lunch and learns. Our clients and peers in our industries are increasingly turning to us as thought leaders.
14 conferences attended. Spending time networking is a key way for us to stay current with the latest developments in insurance and injury defense.
Thousands of pages of reports, review and analysis generated for attorneys and claims adjusters, involving difficult cases and claims of all sizes and types.
Hundreds of hours teaching and mentoring new MKC nurses. Our team of 11 experienced professionals is constantly improving.
Reserve dollars decreased and untold dollars saved. While we seldom know settlement amounts, our clients regularly tell us that we help them reduce waste and avoid leaving money on the table.
New governmental clients. More and more municipalities and other public sector clients turn to us for help when they’re facing a difficult claim, whether it’s a motor vehicle accident, a worker comp matter, or some other big, bodily injury event.
Bottom line…and another big thank-you!
We wouldn’t be where we
are without awesome clients and peers.
I’m very grateful and humbled by the trust they put in me and our
team. I’m looking forward to thanking
each one of them personally…and to an even bigger and better 2019.
All good sleuths know that what is missing tells a story and raises a red flag.
Our clients — particularly insurance
adjusters and defense attorneys — understand the importance of medical
records when they’re looking for the truth of an injury-related claim. Whether a claim or dispute involves a head
injury or some other trauma, our clients know that one of the biggest
hindrances to a complete, comprehensive review and analysis of a personal
injury or malpractice case is missing or incomplete medical records.
That’s because missing or incomplete medical
records make it very difficult to give a complete and accurate review.
There may be lots of reasons for missing and
incomplete medical records. For example:
The records weren’t requested
correctly…or requested at all
There was conflicting medical care
or an intervening injury
Certain information about pre-Date
of Loss conditions, work history, or other injuries could impact or even
counter the current allegations or narrative.
Finally, a missing record might have been
deliberately omitted because it documents a base-lined/pre-DOL medical picture
that is contrary to the narrative from opposing counsel.
Let’s say you’re an adjuster working on a
claim involving an injury with a visit to an emergency room.
In this scenario, an incomplete
medical record could be the Emergency Department record where only the ED
physician’s notes are provided for review, but there aren’t any RN notes,
radiological reports, lab test, treatments or discharge notes.
Hospital records provided for
review may only include the MD’s progress notes, but not any operative notes,
RN notes, radiological reports or treatment notes from ancillary services such
as physical therapy.
Ask yourself, What do these missing or
incomplete records have to say…and why are they missing or incomplete? Information should be consistent, certainly
through the same ED visit or hospital stay.
Medical records may be purposefully omitted
for a variety of reasons. A key takeaway is that for whatever reason, be aware
that it does happen and that missing record(s) could negatively or positively
influence the case depending on what side you are on. The entire record should be submitted so that
all objective and subjective data can be properly analyzed.
do about missing records
Here are some best practices my team and I use
when we encounter the red flag of a missing or incomplete medical record:
Cross reference all medical
information and physicians; are the physicians’ known, treating or ordering physicians? Know their roles within the context of the
Match billing statements to
narrative; look at dates, descriptions and codes
Look for timeline gaps
Look for provider names referenced
in the narrative, BUT there are no medical records from that provider
Watch the tenses of the narrative;
is the info in past or current tense?
Add it all together and you get a possible
path toward the truth of a injury claim.
The new year is a good time to take
stock. 2018 has been a year of
historically significant growth for MKC Medical Management. That includes…
New clients and cross-border
assignments throughout North America, many involving catastrophic-injury
insurance claims or litigation defense
More growth internally, with the
expansion of our team to 11 experienced Registered Nurses and Case Managers
Continued thought leadership in
the form of panels, publications, and presentations – as well as lots of
lunch-and-learn time – focused on the trucking industry, municipalities and
statewide agencies, insurers, law firms, and the other key industries we serve
We’re poised for even greater service to our
markets in 2019. We’ve established
ourselves as unique in terms of our size, our experience, and the breadth of
the services and products we deliver.
This is also a great time to say thank you! When I started this business over 20 years
ago, I had no idea that we’d be where we are today. It’s happened because of a lot of hard work
AND because of countless times when a client, peer, or colleague has stepped up
Happy Holidays and a safe and healthy New Year!
An emergency room is the first place many go for medical care. And those ED records provide a critical, but complex window into a patient’s health and injuries, establishing a medical baseline at the time of the incident.
We recently looked at the importance of Emergency Department records and what to do in the likely event that there are missing or incomplete records. Here’s that post. In Part Two, we’re going back to the basics.
Emergency room visits are on the rise. One study from the American College of Emergency Physicians found that 28 percent of ED doctors polled have reported a spike in the number of cases since the Affordable Care Act took effect. Another 47 percent have seen at least a slight increase.
The costs are on the upswing too, especially for personal injury claims, as hospitals attempt to recoup money thanks to changes in the healthcare system and other factors. In fact, charges can vary wildly – from $4 to care for a sprained ankle to $24,000, according to one study. There is no associated fee schedule with property and casualty claims. This, by default, allows providers to set their own fees with the expectation of full reimbursement.
If you’re reviewing medical records for a case or a claim, here are eight things you need to know.
Emergency Room records provide a baseline for a patient’s injuries. An accurate reading and understanding will supply the objective findings to understand how the injured person fared. All sections and information within the ER records must be reviewed and investigated in order to assess mechanism of injury issues, merit, alleged relatedness and casualty issues. Remember: The medical records are a snapshot of the medical care. The care rendered should, in theory, have nothing to do with the payer. The care should be within the known and established protocols for the respective injuries without bias of insurance coverage. However, it’s critical to acknowledge that the filter of insurance coverage does sometimes impact the care documented within an ER record.
Basic ER documentation…make sure you have it all. It includes RN triage sheet, the ER physician documentation, diagnostics studies and testing, bedside nursing notes, consultation reports, order sheets and consent.
Patient arrival info…such as How did they get to the hospital? Did they go by ambulance immediately or wait a few days? What was their recorded status upon arrival? What was the patient’s position on the Triage Acuity Scale? Review the nurse’s bedside notes carefully. You’ll find a treasure trove of information about how the patient behaved, what they said and how they responded to treatments and care.
Symptoms and chief complaint info is key. Compare the nurse’s triage against the physician’s examination and notes. Does their chief complaint match their objective findings? Do the complaints escalate? The initial complaints are always the most accurate. Compare subjective complaints to the objective findings. These should align in some way.
Check prior medical condition. Don’t forget to check pre-existing conditions and current medications. Any number of conditions and medications can impact cognition, balance, bleeding times, perception, etc.
Diagnostic findings. What are the test results? Consider chronic versus acute versus degenerative. Are there abnormal lab results? Elevated blood sugar? Prolonged bleeding time? Understand that the rule of thumb is this: A finding should fit what is known. Only when it does not should doctors begin investigating more unusual conditions. And, clearly, not all abnormal findings are directly related to a trauma event.
Examine billing info. Check the charges to make sure the services included in the bill are in the documentation. Ask questions. Were the services, tests and labs really necessary? Does there appear to be over-utilization? Are the services appropriate for the reported injury and / or diagnosis?
Discharge records. At the time of discharge, the medical team will provide information to the patient about diagnosis, post discharge care, medications and follow-up care. Did the patient leave AMA, otherwise known as against medical advice? Did the ER physician recommend a specific follow-up specialty or PCP, yet the patient went to a different specialty or did not follow up at all? What condition was the patient upon discharge?
PS: The panel presentation at the annual Trucking Industry Defense Association (TIDA) seminar went off without a hitch in Austin, Texas, and we got great feedback on our presentation…thanks to my co-panelists, Dave Goldstein and Nicole Spellecy (on the right). Let me know if you’d like a copy of our TIDA PowerPoint and notes. Our topic, by the way, was “Stop Your Soft Tissue Claim from Spiraling Out of Control.”
An Emergency Department is often the first place where the medical record complete or not gets built by medical professionals.
All facts in an injury-related claim or dispute are important. However, some facts are more important than others.
As attorneys, insurance examiners and others know, the emergency department’s medical records often reflect the first time a claimant is seen by a medical professional following a motor vehicle accident or other injury incident. While an EMS may be the first to see a claimant following an injury incident, that’s not always the case.
Once an injured person passes through the ED doors, the nurses and physicians build an emergency department medical record, including…
Primary Registered Nurse and ED physician notes
Physician orders and instructions
Radiological studies and laboratory tests
Diagnoses and possible prescriptions and
The fact is that some of these component parts are often missing from the record or are incomplete. In our years of experience, we’ve encountered all kinds of gaps in the ED record, such as no radiological studies or lab test performed. Sometimes, we we’ve seen the medical records presented for review that are incomplete or ones from which the RN notes may have been omitted or others in which x-rays were ordered but then there are no x-ray reports.
Here’s a closer look at some of our best practices in dealing with ED records…
The triage or primary RN notes can be the first documentation regarding the Mechanism of Injury and any alleged injuries the claimant reported. The ED physician record may be the next time the MOI is documented. It is imperative to compare these MOI descriptions. If the MOIs differ between providers and or the EMS report this could be considered a great, big red flag. Inconsistent MOIs can make it difficult to render an opinion about any alleged injuries. The claimant could also be attempting to adjust the MOI to fit the symptoms they’re reporting. Additionally, the MOI is the main foundation for the alleged injuries, to the specifics of the MOI must align with the physical clinical data.
A Legal Nurse Consultant will look at the diagnoses documented and then compare them to the alleged injuries described by the claimant and any testing done in the ED. Any differences between reported injuries and actual objective findings are important in assessing the veracity of the claim. The ED record is important to set the baseline for alleged injuries and can be used for comparison with future visits to other medical providers. This is important especially of there is expansion of symptoms/complaints or additional injuries reported to providers seen later in the treatment timeline.
Did the injured party follow discharge instructions? For instance, did the person fill prescriptions and follow up with the specified specialist? Failure to do so can not only impact care and recovery, but can indicate compliance issues and severity of injuries.
Review the billing statements against the narrative documentation to verify and insure that all procedures/care was in fact completed and billed appropriately.
We’ll take another look at this topic in a couple of weeks or so in Part Two. Meanwhile, for more about Mechanism of Injury and why it’s so important when analyzing a claim check out this post and this one.
Litigating injury claims and the importance of ED records were front-and-center recently at the annual 2018 Arkansas Trucking Seminar. Attorneys, insurance examiners and other professionals from across the U.S. met September 18-20 in Rogers, Ark., to share peer-to-peer insights about emerging trends, best practices and current issues.