Workers' Comp

Empowering Claims Professionals with Medical Insights through Legal/Liability Nurse Reviews

October 6, 2023

Legal/Liability Nurse Review has emerged as an invaluable tool in the world of claims adjustment and as a defense strategy. Catering to a broad spectrum, including auto, liability, workers’ compensation, and medical malpractice claims, it streamlines the process of claim evaluation by offering expert clinical insights.

Understanding the Process

At its core, there's no distinction between a Legal Nurse Review and a Liability Nurse Review; they represent the same service. There are three predominant types of reviews:

  1. Legal/Liability Nurse Review: A comprehensive service that entails a chronology, summary of medical history, actionable recommendations, and negotiation points
  2. Chronology Review: A detailed narrative timeline of medical events
  3. Consultation: Tailored responses to specific queries or educational requirements

Role of Legal/Liability Nurses

Legal/Liability nurses review the medical details of a case. Their responsibilities encompass:

  • Reviewing and interpreting medical records
  • Identifying missing or possibly tampered records
  • Flagging conflicting descriptions related to the accident, medical treatments, or recovery progress
  • Determining adherence to and deviations from accepted standards of care
  • Unearthing pre-existing or unrelated health conditions
  • Evaluating the appropriateness of medical treatments – checking for excesses, duplications, or unrelated treatments
  • Addressing the causation or mechanism of injury

A Specialized Skill

Legal/Liability Nurse Reviews isn't just about reviewing records. It's a nuanced field, where specialized and highly credentialled nurses apply their expertise to medical-legal challenges. They assess healthcare delivery in a claims context and the subsequent outcomes. Referrals usually stem from questionable causality, suspected unrelated injuries, excessive treatment requests, catastrophic injuries, or when a concise medical summary or medical explanation is required.

The Need for Expert Medical Review in Claims

Claims professionals and attorneys occasionally require a nurse's expertise to decipher medical records and recommend steps related to care appropriateness, projected future treatment, or ties to the original injury. In liability claims, this can also encompass a comprehensive demand package review.

When referred for a Legal/Liability Nurse Review, a nurse will:

  • Analyze records to clarify diagnoses and treatments
  • Identify missing documents for a complete assessment
  • Draft detailed reports based on research and industry treatment standards, such as the ODG and MDGuidelines
  • Recognize "red flags" in cases
  • Suggest actionable next steps
  • Determine the veracity of claimed injuries and their possible connection to the incident
  • Review treatment proposals for the future
  • Pinpoint excessive treatments

Proven Outcomes

Legal/Liability Nurse Reviews have led to significant successes in a variety of situations including:

  • Clarifying injury/illness causation by researching medical literature to support or dispute the claim
  • Identifying discrepancies between reported injury dates and medical service dates
  • Recognizing treatment that may be exceeding usual and customary treatment guidelines

In a recent case, a legal/liability nurse had substantial impact on a case and helped bring it to resolution. According to the claims professional,

“[the legal/liability nurse] was extremely helpful. The attorney on the claim was adamant that certain injuries were related to the motor vehicle accident in question. I used the points [the legal/liability nurse] made in her report to negotiate with the attorney. He finally conceded and said he couldn’t argue with the points I was making and explained the same to his client. We were able to reach a good settlement this week, thanks to [the legal/liability nurse]. I really appreciate it!”

Opting for Legal/Liability Nurse Reviews offers claims professionals and attorneys a wealth of knowledge to help resolve the toughest claims. They receive a comprehensive case evaluation, ensuring no detail is overlooked. Additionally, when litigation comes into play, an unbiased perspective can be provided, paving the way for clarity and transparency. With expert guidance, the chances of claim success are significantly amplified. Moreover, equipped with insights from the review, claims professionals and attorneys can harness enhanced negotiation prowess, ensuring favorable outcomes. Legal/Liability Nurse Reviews are a strategic choice that promises efficiency, clarity, and success in the intricate world of claims.

Streamlines the process of claim evaluation by offering expert clinical insights today. Reach out to your local sales representative today.