Diagnosis of the Month

Worker's Compensation
Knee Torn Cartilage
Robert Dennis, MD  

This is an example of the unnecessary costs incurred when added delays in certifications cause interruptions to treatment. 

CASE HISTORY:  41 year old, hard working waitress. No past history.  While working, slips and drops a tray of food, landing on her right knee, which took a direct impact.  The initial orthopedic consultant suspected “Impact Patella Chondromalacia.”

Three weeks of physical therapy produced little relief.  MRI was recommended by the fourth week.

Case Manager requires IME.  Set up and executed.

IME performed three weeks later.  Report arrived one week after the IME.

It took approximately two weeks to get the MRI approved. (IME doctor agreed with the need for an MRI.)

Two more weeks to get the MRI done and reported as well as appointments scheduled with treating doctors.

MRI confirmed Chondromalacia Patella.  More physical therapy recommended until simple Arthroscopy could be set up.

Medical management company halted physical therapy until IME could be set up to determine if Patella Debredement and Lateral Release could be done.

IME set up and done three weeks later.

IME doctor agreed with recommendation for surgery.

Two weeks to set up surgery after certification was received.

One week post surgery, operating surgeon orders six weeks of intense physical therapy.

Approval for post op therapy takes two weeks.  Six weeks are approved.

Her leg stiffens at the end of six weeks of physical therapy.

There was a two week gap to obtain an additional six weeks of physical therapy.

Her knee stiffens further, she needs another six week course of physical therapy.

Gaps in care are now totaling two months.  This has caused Sympathetic Dystrophy to set in.

Six months later, the waitress finally returns to work.

Discussion: How could the costs in this case have been reduced?

This case history is not uncommon.

The overall medical costs have increased 50% because of the gaps in care.  Indemnity payments for wages have been increased 300% because of gaps in care.

Suggestions:

New Jersey permits insurers to direct the care.  Use this tool and select an Orthopaedic Surgeon that you can trust and allow him the tools that he needs to meet the return to work date that he is asked to target on his third visit with the patient.  The Orthopaedic Surgeon should be micro managed only if he is more than two weeks late on his own estimated return to work date.  Actual gaps, costs, and the cost of an IME would be minimized.  The long term high settlement cost would also be significantly lowered.

Savings are estimated to be over 50% of the current costs for providing care for similar cases….

Summary:

1. Work closely with an orthopaedic surgeon that you can trust.

2. Request that he provide an estimate of when the injured worker will be able to return to work very early in the care.

3. Try to avoid micromanaging the case, but try to hold the physician to his target date and make it clear that the explanation for charges will be required.

4. Give him the tools that he requests so that he would have no excuse to easily justify wide variation in his own estimation.

5. In this way you harness the huge ego of the Orthopaedic Surgeon and his need to prove that he is right.

 Result:

You would lower costs significantly.  The patient goes back to work sooner and we avoid the complication of Reflex Sympathetic Dystrophy and everybody wins.