"Diagnosis Pending"

National Guard

Has anyone ever went to an emergency room or clinic and walked out of their with the Dr telling them "I'll get back to you on that diagnosis!" or in other words, put "Diagnosis Pending" on the discharge papers?

Well, I just had an ee fill out a workers comp claim and put down that he bruised his knee and the diagnosis is pending. I don't know, maybe he is really on the ball and knows that he will be hurt in the near future so he went to the emergency room and the Dr. put diagnosis pending!

So, my question is: How would you all handle this? I'm thinking of requiring medical information accompany the WC claim before it will be processed. Does that violate any privacy issues? Or maybe there is just a better way to handle it and not get wrapped around the diagnosis pending issue?

Thanks, I hope this one stays out there. I guess the forum crashed right after I put this up last time.

juju

[font size="1" color="#FF0000"]LAST EDITED ON 12-10-04 AT 09:21AM (CST)[/font][br][br]Our policy is that if an employee is seen in the ER, they must follow up with a panel provider within 24 hours. We have found that ER docs are very hesitant to address work status, as they should be since they are not familiar with the type of work our EEs do. Our panel docs have physical job descriptions for all our EEs' jobs, therefore we rely on them to determine diagnosis/ability to work.

We usually report the claim as soon as we get the forms unless the employee is actually en route to the panel doc when we find out (then we'll wait a few hours for those results). Otherwise, we will update the carrier with info from the panel doc if need be.

National Guard

Thanks for the info. I'm not necessarily trying to figure out is he can return to work but whether he is even injured in the first place. Maybe that's what the ee was trying to say - that he is definately injured but return to work is pending. Maybe I read it wrong?

juju

Maybe I read this wrong. I thought the EE actually went to the ER and got a "diagnosis pending" response from the ER docs, hence my earlier post to go to a panel doc. Regardless of whether they were seen or not though, we log any WC report whether or not there is treatment. If they say they are injured we treat it as such.

stilldazed

Don't know if Florida and Maryland are significantly different in worker' comp, but it sounds like your question relates to compensability--trying to determine if there was actually an incident so that a decision on who will pay the ER costs can be made. To answer questions at that level, go back to your company policy/procedure on incident reporting and review Maryland's statute on reporting requirements under W/C. If the employee reported properly, describes an incident, and says there were no witnesses, and that report fits your state's requirement for W/C coverage, sounds like you get to pay the bill. Any liability after the initial ER visit should depend on validating "the need for further care" for a "work related injury." Your company should be able to discern whether the incident is disputable. A medical professional should validate whether additional care is required.

I would agree with the prior post about exercising the referral requirement if it is a requirement at your company. In Florida, W/C is managed care. An ER visit is generally viewed as a self-referral, a no no in managed care. If your incident occurred in Florida, we would look for evidence that the incident was reported, pay the costs unless there is blatant evidence to contradict that an incident occurred, and the employee would be sternly warned that further benefits would be denied unless the employee got on board with the managed care idea--appointments made by W/C reps to participating providers, no more self referrals, and do what the W/C providers say to do (such as return to work). The next question would then be whether follow-up care is needed. If it is, the participating provider would be required to determine (based on medical assessment) whether an injury exists, whether it is work related, and whether further follow-up is required. Once the provider says it's over, it's over. That's a fairly simplistic rendition of the process, but a fair overview.

HRinFL

I agree with stilldazed. How you determine if the ee can perfrom transitional duty if you do not know the extent of the injury or any restrictions. I would require the ee see the physician used by your facility for OTJ injuries. Addressing your concern that asking for medical information violates privacy laws, HIPPAA does not apply to Workers' Compensation or OTJ injuries. Employers/Insurance providers must be aware of diagnosis in order to schedule appointments with the appropriate specialist, make decisions on treatments, etc. You have the right, if it is work related, to research this and make sure you understand the extent of the injury.

Whatever

Submit the claim to the workers' comp. carrier. If the insurance carrier needs additional information, it is their responsibility to get it. Under our policy, a nurse (from the ins. co) contacts the ee and doctors directly (and keeps us up to date on the what's happening). If there is a question of the validity of the claim, let the insurance carrier know your concerns.

Second, did you consider giving the ee the FMLA paperwork?

Third, whether or not an accident is reported to the carrier, we require the ee (or their supervisor) to complete an accident form. We use this form as a starting point to investigating the incident.

Don D

The carrier, not the employer, is responsible for riding herd on the process of gathering paperwork from medical providers, including diagnosis, prognosis and release to work information. HIPAA does not cover WC information so there is no need to worry about a privacy matter. But, the employer, not the carrier, makes the determination as to return to restricted duty. Don't get twisted around the axle with who has what level of responsibility. Know your carrier and their procedures, get familiar with their adjusters and, yes, put the guy on FMLA as soon as you can.





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