JACKSONVILLE, Fla.--(BUSINESS WIRE)--Insurance companies and other payers in the workers’ compensation industry must be aware of an alarming trend in electrodiagnostic medicine: a large number of tests known as Electromyography (EMG) and Nerve Conduction Studies (NCS), which help to determine the extent of muscle and nerve damage in injured workers, are being conducted by providers who do not have appropriate training, experience or credentialing in the field. As a result, these tests may be inappropriately performed, possibly leading to inaccurate diagnostic information.
Quality is not the only concern. Some unscrupulous providers are engaging in outright fraud and abuse to manipulate the system. To educate the industry on these issues, John E. Robinton, M.D., medical director of electrodiagnostics at One Call Care Management (One Call), curated and moderated a session panel on “Quality Issues, Fraud and Abuse” at the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) Annual Meeting.
“Dr. Robinton has long played a leadership role in evaluating and addressing quality in electrodiagnostics and has also served as consultant to the NJ state attorney general and insurance companies regarding fraud and abuse in the insurance industry—which made him the perfect candidate to organize this session at AANEM,” said Pamela Landefeld, president of One Call’s Diagnostics business unit.
“Our goal was to bring to light quality concerns and to raise the bar on clinical excellence in electrodiagnostic medicine,” said Dr. Robinton. “In some cases, unqualified providers are performing inaccurate or incomplete studies—and in the case of fraud and abuse, some providers are actually fabricating tests. With payment for an EMG or NCS ranging from $3,000 to $6,000, fraudulent practitioners can make $50,000 a day performing useless and unsubstantiated exams. Only a diligent commitment to quality can combat these issues.”
With unreliable test results, patients may receive an inaccurate diagnosis and an inappropriate recommendation for surgery or other medical procedures, such as epidural injections, that they do not need, while other claimants may not receive the treatment they require. As a result, billions of dollars in medical costs are being wasted or misdirected.
The panel represented a mix of medical, insurance and investigative experts who addressed these concerns from several different perspectives:
- Adam Seidner, MD, MPH, “Neurology Testing Quality and Billing Fraud, Waste and Abuse Watchouts”
- Mitchell Sherrod, MPA, BSCJ, AHCFI, “Red Flags and Keys to Neurodiagnostic Fraud Investigations”
- John Robinton, MD, “Fraud or Abuse?”
Dr. Robinton is also slated to speak on electrodiagnostic quality, fraud and abuse at state conferences in New Jersey and New York, and a national meeting in Chicago.
“I’m excited about the clinical direction One Call is taking across the board in diagnostics,” said Dr. Robinton. “We’re developing expertise in multiple specialties involving the care and treatment of injured workers, and we’re in the early phases of evaluating clinical outcomes and defining clinical excellence in a number of areas, which marks an exciting new phase for our organization.”
“Over the years, we’ve collected extensive data on diagnostics,” said Landefeld. “This intelligence along with our advanced analytics have allowed One Call to consistently place injured workers with the best, most qualified providers to ensure an accurate diagnosis, quality care and optimal outcomes. As we move forward, we’re finding new ways to leverage these assets to drive the quality that has long set the standard in the industry.”
About One Call Care Management
One Call is the nation’s leading provider of specialized solutions to the workers’ compensation industry. One Call’s solutions enable faster, more efficient and more cost-effective claims resolution with a focus on injured workers’ needs across the continuum of care. One Call provides reliable, consistent connections to care with expertise in high end diagnostics, physical therapy and transportation services, post-discharge home care and durable medical equipment, dental and doctor specialty services, complex care management, and the language services required for today’s multicultural workforce. For more information, visit www.onecallcm.com.