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By The Numbers: "42"

"42". This is the highest number of diagnostic codes from a single provider we have seen. Providers are becoming more and more expansive in their use of diagnostic codes. It’s tempting to dismiss these as a “laundry list”. There is some truth to that, but it is also a mistake. Let's put this in perspective. In order to clinically confirm 42 different diagnoses, a provider would likely have to spend the better part of a day completing tests and double checking their findings. But that doesn’t happen. This number of diagnoses gives the impression of severity without actually confirming it.

Long diagnostic lists aren’t just about implying that injuries are severe. They are also a stepping-stone to more involved and invasive procedures. In order to combat this, it’s important to understand why a long list of diagnoses is wrong. Here are some key questions to consider when examining records: 1. What is actually wrong with the claimant? Examinations are not performed to expand the list of diagnoses, but to limit them. Differential diagnosis is the process of elimination that rules out diagnoses with the goal of finding which is most accurate. Poor diagnostic quality creates serious issues for the provider explaining what the claimant’s condition even is. For more insight, read this Medical News Today article. 2. What are the odds? Long diagnostic lists create another credibility problem for the provider. While the probability of some diagnoses being accurate may be higher than others, the probability of all of them being accurate is near zero. Remember, it’s the provider that will have to defend its diagnostic list, not you. 3. What was treated? The assessment that leads to the right diagnosis is critical because it drives decisions about treatment. Not all conditions are treated the same. If provider treat all injuries with the same treatment plans, that is telling. Treatment plans that use evidence-based medicine use the approach that is demonstrated to be most effective for the specific injury. When a provider has a long list of diagnoses, they can defend a wide range of treatment decisions, but only if these diagnoses are accurate. The reality is, they aren’t, and this impedes effective treatment planning. 4. Who has the correct diagnosis? Different providers. Different diagnoses. The lack of clinical rigor isn’t isolated to single providers. The lengthy list of diagnoses across providers leads to another frequently missed issue: Providers themselves don’t agree on the claimant’s condition. In fact, their diagnoses might be fundamentally different from one another. In this case, someone is providing treatment for the wrong injury.

How does this translate into better settlements?

First, it reduces the amount of treatment that should be considered compensable. Common examples include, among others, inappropriate use of MRIs and unjustified services, such as injections, surgeries and excessive treatment. MRIs, for example, aren’t supposed to be used to find diagnoses. They are used to confirm or rule them out. Ordering an MRI without defining the differential diagnoses to be considered is unjustified. Second, it impacts the severity of the injury, which reduces the pain and suffering consideration. Issues with the accuracy of diagnoses almost always align with a lack of objective findings of injury severity, inconsistencies in medical documentation (both within a single examination by a provider and across providers), and issues with pre-existing conditions. The resulting confused picture becomes more and more difficult for providers to explain. These combinations raise the bar on the burden of proof for plaintiffs. Most adjusters don’t have the time to unlock this value. Casentric does. Our customers use us to build better cases for settlement.

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