The MedRisk Blog
Some days, we’ll come across a certain event – one that isn’t too rare, but also isn’t too common – and simply brush it off. “It probably doesn’t mean anything,” we say to ourselves. But what if it does?
This was the exact case with David. He had a diagnosis of right shoulder strain after complaining of injuring his shoulder while carrying heavy boxes. Following initial medical diagnosis, he was initially prescribed 12 sessions of physical therapy. He attended his first session, seemingly eager to play his role in the journey to recovery. And then he missed the second session… and the third… and the fourth.
On the first instance of David missing his PT session, the adjuster didn’t think much of it. Something probably came up, but it probably isn’t too serious. This initial miss would generally not be alarming as some data suggest that 5-15% of musculoskeletal injuries resolve within 24-72 hours post-acute injury. But after David remained on limited duty and missed two more sessions, his adjuster knew this was concerning behavior – perhaps there’s something else behind it.
Eventually, the claim went into litigation, and it was found that David was in fact moonlighting. It turns out he had another job that made it impossible to attend his PT sessions. If it weren’t for his adjuster noting his lack of attendance as a red flag, his current employer wouldn’t have known this fraud was going on.
Attendance can be such a basic thing that it’s easily overlooked. But as seen with David’s case, if an adjuster knows when and where to look, there’s more to attendance than meets the eye.
It’s all in the communication
While one might think that you would need AI or machine learning or some fancy tool to unlock key insights from attendance, the answer really lies in good communication with the treating provider. Open dialogue with a provider, access to notes, and specifically, access to scheduling and attendance data, can be used to monitor claims.
In schools, for example, an attendance record is kept for each student. This record is then evaluated by their teachers and sent home for their parents to review. While there are exams to test a student’s knowledge, their attendance is also another indicator of their performance and essentially, their readiness to move on to the next grade.
For claims, things are no different – a patient’s readiness to return to work must be measured not only by their performance in the actual therapy sessions but also by their attendance. After all, erratic attendance (or none at all), will hinder their recovery progress.
In David’s case, the attendance report from the treating provider was the important information his adjuster needed to sound the alarm. With a look at this shared information, it’s seen when he should be going for sessions, the actual dates that he showed up, and the dates that he didn’t.
Getting the most out of your communication
While good provider communication can provide the data you need, it won’t be of much use without a benchmark.
Going back to our school example, it’s likely that at the start of the year, a standard is set for both the students’ test scores and attendance. If halfway through the term, it seems like a student is falling below these standards, his teacher will likely want to speak with him and his parents. In this conversation, they start to ask important questions to both uncover the drivers of poor performance and come up with a plan that will help the student perform better for the rest of the term.
In claims, it’s a similar case – an overall standard must be set for patient attendance. This standard may vary from organization to organization and can be informed by previous claim data. Combining this attendance standard with additional medical evidence modeling a standard “report card,” an adjuster would know when a patient’s attendance record is “alarming,” and when it’s time to double-check on a case.
Additionally, communication must be timely, and shared data must be easy to interpret. A simple tool like a shared calendar, for instance, can be used not only to schedule therapy sessions but also to evaluate attendance. As much as possible, this should be created so that in one look, an adjuster can effortlessly make initial inferences about a patient’s status.
Making it a strategic partnership
None of the above will be possible without a strong relationship across the key stakeholders in a claim. When providers, vendor-partners, and adjusters work seamlessly together, they’re able to unlock the power of data and harvest important insights. And when constant communication is in place, the right steps can be taken at the right time.
In a nutshell, attendance, while seemingly simple, should not be taken for granted. While it can tell the basics of when a patient is scheduled to attend and when they actually do, it can also be a gateway to uncovering deeper insights such as a patient’s lack of motivation or like in David’s case, a bigger red flag. Moreover, clear and concise communication with providers throughout treatment is crucial to ensuring claims are caught before they go off track.
Beckett, Kathy. “How Pt Attendance Can Tell You More than You Think It Does.” WorkersCompensation.com, Workerscompensation.com, 15 Aug. 2022, https://www.workerscompensation.com/news_read.php?id=41713.
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