Welcome to the Ask Approach Service Spotlight. Each month in 2020 we’ll take an in-depth look at a different service offered by Approach. For a quick look at all of the services available to Approach clients, download our Approach Services infographic.

Find all of our Service Spotlight posts at https://approachms.com/category/ask-approach/service-spotlight/

Forensic Reviews

If you or your Approach Retro Coordinator think there are questions about a claim that require a more exhaustive medical review/opinion, we can coordinate a forensic review to get answers from a qualified medical specialist. Forensic reviews can be a great help when there are questions relative to claim allowance and/or medical case management.

As covered before on Ask Approach, we can request an IME (independent medical examination), which is a physical examination of the injured employee by a qualified, impartial medical specialist. IMEs can be great for getting definitive answers to our questions on a claim, but we must coordinate with the L&I claim manager in order to have one scheduled. It can also take several weeks or more before the actual examination takes place.

So, what if we want to get an impartial opinion outside of the IME process? In these cases, Approach offers complimentary forensic review services to our clients.

Forensic reviews are like IMEs, but do not involve an in-person physical examination. Instead, we locate a provider who specializes in the type of injury or occupational disease being treated on the claim. The specialist reviews the pertinent documents, along with our specific questions about the claim. Then, we receive a written report answering our questions as a qualified medical opinion regarding treatment or other aspects of the claim.

There are many reasons why we may want a qualified second medical opinion on a claim, including:

• Claim allowance – is this a valid workers’ comp claim?
• Contended conditions – is the condition related to the claim?
• Treatment plan – is it appropriate for the injury or occupational disease?
• Pre-existing conditions – how is it impacting recovery?
• PPD rating – is the rating accurate based on the accepted conditions of the claim?
• Occupational disease – have other employers contributed to the disease and should some percentage of liability be assigned to them?

Forensic Review Case Study #1

An employee for one of our clients filed a workers’ comp claim for a muscle sprain. The employer had their suspicions about validity but chose not to contest the claim at first. The injured employee might have gotten away with it, until he refused to come back to any sort of work. This red flag resulted in surveillance and, sure enough, the injured employee was more active in the real world than would be expected from someone completely unable to work. Moreover, a disc herniation had been added to the claim, raising the possibility that the employee might receive compensation for permanent partial disability (PPD). It was time to get another opinion through a forensic review:

Key findings of the forensic review

• The herniation was not related to the initial injury on the claim
• The worker could have worked full duty immediately following the initial injury

Vanessa Hughes, a retro group lead at Approach, was successful at getting this new evidence allowed on the claim file. “It was big effort, but ultimately the evidence from the forensic review was strong enough to prove our case,” says Vanessa.

After a lengthy review, the L&I claim manager, the attending provider, and the other examiners on the case all agreed that the findings of the forensic review were correct.

Positive outcomes for the client

• The L&I claims consultant reversed the order allowing herniation onto the claim, which will prevent a PPD pay-out
• The employee injured also had to repay the time-loss distributed while he was off work without objective medical justification

These outcomes have saved the employer thousands of dollars in retro refunds and rate increases.

Forensic Review Case Study #2

One of our Retro Coordinators, working on behalf of a client, realized that a claim filed as an injury should actually have been an occupational disease claim. “It was clear to me that the worker hadn’t suffered a sudden injury, but rather was feeling the effects of a condition that developed over time,” says Lesa Ford, retro coordinator. “He hadn’t suffered a traumatic event and had been doing strenuous work for more than 20 years.”

Our first protest resulted in L&I affirming the claim as an injury. It was time to request a forensic review in order to bolster our case.

Key finding of the forensic review

The doctor supported our contention that this “injury” was actually an occupational disease claim.

As always, it takes effort from the Approach Retro Coordinator to get the evidence from the forensic review accepted into the claim file. We were successful and L&I issued a new order allowing the claim as an occupational disease.

Positive outcome for the client

Only a small portion of the claim costs will be assigned to our client.

With an injury claim, the employer would have had 100 percent of claim costs assigned to their account, lowering their retro refunds and increasing their rates for years to come. Now, because much of the occupational disease is attributable to prior employers, we believe our client will save up to 75 percent on this claim.

Your Retro Coordinator can help you determine if a Forensic Review is right for your claim. It’s just one of many risk management services available to Approach clients at no additional charge.