A Case Study in:
AdvancedRM was contacted by the personal injury attorney regarding his need for assistance with a difficult case. His client, who was injured in a motor vehicle accident, sustained a serious injury to his foot. The attorney indicated payment for medical treatment has been refused by his client’s insurance carrier. He noted the carrier does not believe this is a new injury. He noted the carrier cited a lack of documentation by the hospital, as well as the treating physician, to support a new injury.
Roger underwent foot surgery prior to his accident for fallen arches and chronic foot pain. He was recuperating from surgery and involved in physical therapy when he was in the accident. He jammed his foot on the brake pedal in an attempt to avoid the accident and experienced immediate pain. He was taken for emergency care. The hospital examined him and discharged him with a prescription for pain medication. Roger continued to experience pain. Although a new injury was not diagnosed by the emergency physician, he sought another opinion. His new physician ordered an x-ray of Roger’s foot and noted a fracture as well as broken hardware from his previous surgery. Roger underwent additional surgery to repair the fracture and hardware.
- The AdvancedRM care manager requested records from Roger’s primary care physician, initial orthopedic physician, and pre-surgical, surgical, and post-surgical records. All pre and post-accident therapy reports were also obtained along with x-ray findings and all other diagnostics.
- The care manager interviewed Roger for an understanding of his overall medical status, functional status pre and post-surgery, and pain levels before and after the accident.
- A thorough review of all gathered records and information obtained from Roger was completed by the care manager.
Upon review of the medical records, the care manager noted a full union had not occurred in the foot following Roger’s initial surgical intervention for a fallen arch. The care manager identified health issues noted in Roger’s records, which place him at higher risk for non-union of the fracture.
Films and surgical reports were reviewed from the second surgery that noted fractured hardware at the surgical site. Careful review of the physical therapy notes indicated Roger had increased pain and decreased strength and mobility following his motor vehicle accident.
The care manager located documentation, which demonstrated immediate complaints of pain following the accident and a decline in ambulation and functional status. With approval from the attorney, the care manager coordinated a orthopedic Peer Review.
We prepared a letter for the physician outlining questions as well a chronology of Roger’s medical issues. We spoke with the physician before his review of records provided by AdvancedRM. The physician was able to clearly document Roger’s fracture, broken hardware, and current issues in a report to be provided to Roger’s attorney.
The care manager was able to establish clear documentation to demonstrate a new injury resulting from the accident and have this position clearly supported by the Peer Review doctor. Roger’s attorney was able to secure further documentation from the treating provider and easily establish the impact this accident had on Roger’s recovery. A sizable settlement was obtained on Roger’s behalf.