28.2 MILLION DOLLAR LAWSUIT FOR NOT ORDERING AN MRI

[DrCommonSense]

$28.2 Million Jury Verdict in Late Diagnosis of Bone Cancer Case

So I guess that whole thing about "not ordering too many MRIs for plain back pain" by our efficiency heros like Rodger Chou really paid off for this doctor.

I mean didn't the jury read the studies that getting an MRI for back pain too quickly is bad?

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[hyperalgesia]

If we're doing population health, individual patients shouldn't be allowed to sue.
Only the state should be allowed to sue for damages to the health of the population at large...

 

[DrCommonSense]

If we're doing population health, individual patients shouldn't be allowed to sue.
Only the state should be allowed to sue for damages to the health of the population at large...

Yeah thats the problem though.

They talk outside of both sides of their mouthes. One minute its "don't order so many MRIs for back pain" but if something goes wrong then its "well the doctor should've known better".

Reading this case seems like textbook management. Considering there was no neurological signs, ordering an MRI of the lumbar spine for acute plain back pain is supposed to only occur after PT and other treatments.

 

[lobelsteve]

Anna Rahm, 17, began experiencing back pain without relief. Anna’s parents took her to a chiropractor who suggested that she be taken to a physician so that she could undergo an MRI scan. Anna met with her primary care physician at Southern California Permanente Medical Group and was prescribed steroids.

Anna’s mother requested that Anna receive an MRI in light of her 8 months of back pain. However, the doctor said that she could not authorize the test. Anna consulted a physical medicine physician at the HMO clinic who denied her request for an MRI and instead recommended an epidural injection and exercise.

Anna’s back pain increased despite attempts to treat it with acupuncture.


Anna’s mother then talked to the physical medicine specialist and again made the request for an MRI scan. The physician denied the request and instead referred Anna to physical therapy, which she was forced to discontinue because of her extreme pain.

Two months later, Anna finally underwent an MRI, which revealed an aggressive pelvic mass. She was subsequently diagnosed as having osteosarcoma and underwent chemotherapy and multiple surgeries, including amputation of her right leg and portions of her pelvis and spine.




Umm, she should have gotten millions. Red flags all over the place just reading the above.

 

[willabeast]

I was not there but i bet this is what happened - the PMR doc was willing to order an MRI if the patient was willing to have an epidural. That is probably the normal "flow" and "pathway" for this particular doc. This is not part of the SCPMG PMR guidelines - so the doc was going counter to his/her own guidelines. When you violate your own guidelines you are sunk.
I want to make another point here - an ESR test is cheap, fast, and would have raised the Dx of cancer immediately in most cases. This is not part of ISIS guidelines but IMHO it should be.
I will now climb off my soapbox, and you all owe me 2 cents.
addendum - I have just read 3 DIFFERENT accounts in the media as to what happened. None of them refer to epidurals. So we really have no idea what went on in the courtroom. This is fake news.

 

[willabeast]

Anna Rahm, 17, began experiencing back pain without relief. Anna’s parents took her to a chiropractor who suggested that she be taken to a physician so that she could undergo an MRI scan. Anna met with her primary care physician at Southern California Permanente Medical Group and was prescribed steroids.

Anna’s mother requested that Anna receive an MRI in light of her 8 months of back pain. However, the doctor said that she could not authorize the test. Anna consulted a physical medicine physician at the HMO clinic who denied her request for an MRI and instead recommended an epidural injection and exercise.

Anna’s back pain increased despite attempts to treat it with acupuncture.


Anna’s mother then talked to the physical medicine specialist and again made the request for an MRI scan. The physician denied the request and instead referred Anna to physical therapy, which she was forced to discontinue because of her extreme pain.

Two months later, Anna finally underwent an MRI, which revealed an aggressive pelvic mass. She was subsequently diagnosed as having osteosarcoma and underwent chemotherapy and multiple surgeries, including amputation of her right leg and portions of her pelvis and spine.




Umm, she should have gotten millions. Red flags all over the place just reading the above.

I have just read 3 DIFFERENT accounts in the media as to what happened. None of them refer to epidurals. So we really have no idea what went on in the courtroom. This might be fake news.

 

[VA Hopeful Dr]

Anna Rahm, 17, began experiencing back pain without relief. Anna’s parents took her to a chiropractor who suggested that she be taken to a physician so that she could undergo an MRI scan. Anna met with her primary care physician at Southern California Permanente Medical Group and was prescribed steroids.

Anna’s mother requested that Anna receive an MRI in light of her 8 months of back pain. However, the doctor said that she could not authorize the test. Anna consulted a physical medicine physician at the HMO clinic who denied her request for an MRI and instead recommended an epidural injection and exercise.

Anna’s back pain increased despite attempts to treat it with acupuncture.


Anna’s mother then talked to the physical medicine specialist and again made the request for an MRI scan. The physician denied the request and instead referred Anna to physical therapy, which she was forced to discontinue because of her extreme pain.

Two months later, Anna finally underwent an MRI, which revealed an aggressive pelvic mass. She was subsequently diagnosed as having osteosarcoma and underwent chemotherapy and multiple surgeries, including amputation of her right leg and portions of her pelvis and spine.




Umm, she should have gotten millions. Red flags all over the place just reading the above.

I'm just a family doctor, but 8 months of back pain especially in a teenager seems MRI worthy to my mind

 

[DrCommonSense]

I'm just a family doctor, but 8 months of back pain especially in a teenager seems MRI worthy to my mind

Skip the MRI for Low Back Pain?

According to Chou, ordering MRIs for "acute" back pain is a no no.

What is the time frame for a younger person after PT that the person should get the MRI? He ordered it at the 8 month period after extensive conservative therapy.

Should he have ordered it at 1 month, 3 months?

Where are these "guidelines"?

 

[DrCommonSense]

I was not there but i bet this is what happened - the PMR doc was willing to order an MRI if the patient was willing to have an epidural. That is probably the normal "flow" and "pathway" for this particular doc. This is not part of the SCPMG PMR guidelines - so the doc was going counter to his/her own guidelines. When you violate your own guidelines you are sunk.
I want to make another point here - an ESR test is cheap, fast, and would have raised the Dx of cancer immediately in most cases. This is not part of ISIS guidelines but IMHO it should be.
I will now climb off my soapbox, and you all owe me 2 cents.
addendum - I have just read 3 DIFFERENT accounts in the media as to what happened. None of them refer to epidurals. So we really have no idea what went on in the courtroom. This is fake news.

So he should order an ESR in all patients with back pain?

Where are these "guidelines" again that show you aren't supposed to wait to obtain an MRI?

Skip the MRI for Low Back Pain?

 

[DrCommonSense]

Anna Rahm, 17, began experiencing back pain without relief. Anna’s parents took her to a chiropractor who suggested that she be taken to a physician so that she could undergo an MRI scan. Anna met with her primary care physician at Southern California Permanente Medical Group and was prescribed steroids.

Anna’s mother requested that Anna receive an MRI in light of her 8 months of back pain. However, the doctor said that she could not authorize the test. Anna consulted a physical medicine physician at the HMO clinic who denied her request for an MRI and instead recommended an epidural injection and exercise.

Anna’s back pain increased despite attempts to treat it with acupuncture.


Anna’s mother then talked to the physical medicine specialist and again made the request for an MRI scan. The physician denied the request and instead referred Anna to physical therapy, which she was forced to discontinue because of her extreme pain.

Two months later, Anna finally underwent an MRI, which revealed an aggressive pelvic mass. She was subsequently diagnosed as having osteosarcoma and underwent chemotherapy and multiple surgeries, including amputation of her right leg and portions of her pelvis and spine.




Umm, she should have gotten millions. Red flags all over the place just reading the above.

Whats the "red flags" again? Persistent nonspecific back pain?

Don't see any evidence there was a rapid need for a lumbar MRI considering cancer is very low on the differential.

Should we order an MRI for a patient with low back pain for >4 months to rule out cancer?

 

[DrCommonSense]

I was not there but i bet this is what happened - the PMR doc was willing to order an MRI if the patient was willing to have an epidural. That is probably the normal "flow" and "pathway" for this particular doc. This is not part of the SCPMG PMR guidelines - so the doc was going counter to his/her own guidelines. When you violate your own guidelines you are sunk.
I want to make another point here - an ESR test is cheap, fast, and would have raised the Dx of cancer immediately in most cases. This is not part of ISIS guidelines but IMHO it should be.
I will now climb off my soapbox, and you all owe me 2 cents.
addendum - I have just read 3 DIFFERENT accounts in the media as to what happened. None of them refer to epidurals. So we really have no idea what went on in the courtroom. This is fake news.

According to the American College of Radiology, an MRI after >3 months of low back pain should only be ordered if there are SIGNIFICANT concern for severe stenosis (radiculopathy, reflex changes, cauda equina, etc) or fevers, weight loss, etc that increases the suspicion of malignancy.

http://www.lni.wa.gov/ClaimsIns/Files/OMD/MedTreat/Imaging/LBchecklist.pdf

Ergo, without any of those signs which are NOT stated in this lawsuit, this guy followed all the "guidelines" I have seen on this issue.

There is no guideline that says its necessary to have an MRI by 6 months, 1 year, 2 years or even longer of nonspecific low back pain. There has been a STRONG emphasis on rehabilitation before even considering an MRI.

 

[Ducttape]

Typically almost all insurance companies say that they will. Over an MRI got nonspecific LBP of > 8 weeks (or so) that had failed conservatives CR therapy including PT, physician directed home exercise, NSAID/muscle relaxant, and lifestyle modification.

I've taken the position of ordering MRI and getting it denied for all but the previously imaged. Insurance company then to "blame".


What worries me more is the fact you guys are reading articles written by litigation attorneys touting the "successes" in their field...


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[bedrock]

Typically almost all insurance companies say that they will. Over an MRI got nonspecific LBP of > 8 weeks (or so) that had failed conservatives CR therapy including PT, physician directed home exercise, NSAID/muscle relaxant, and lifestyle modification.

I've taken the position of ordering MRI and getting it denied for all but the previously imaged. Insurance company then to "blame".

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Agree with this. 8 weeks or more of LBP that failed PT/NSAIDs gets an MRI ordered.

If insurance company denies the MRI, then the insurance company can get sued, not me.

Besides, a non contrast MRI is not that expensive. Way more waste in insurance company/hospital administrators than in a few extra MRIs .

 

[DrCommonSense]

Typically almost all insurance companies say that they will. Over an MRI got nonspecific LBP of > 8 weeks (or so) that had failed conservatives CR therapy including PT, physician directed home exercise, NSAID/muscle relaxant, and lifestyle modification.

I've taken the position of ordering MRI and getting it denied for all but the previously imaged. Insurance company then to "blame".


What worries me more is the fact you guys are reading articles written by litigation attorneys touting the "successes" in their field...


Sent from my iPhone using SDN mobile

The number of huge lawsuits just keeps going up and up. Something to take into mind while practicing medicine.

With most insurance policies covering about 1M/3M, what happens if you get hit with a 10M lawsuit?

Will your personal assets be screwed?

 

[DrCommonSense]

Agree with this. 8 weeks or more of LBP that failed PT/NSAIDs gets an MRI ordered.

If insurance company denies the MRI, then the insurance company can get sued, not me.

Besides, a non contrast MRI is not that expensive. Way more waste in insurance company/hospital administrators than in a few extra MRIs .

Not according to Chou et al. They are saying you are a wasteful doctor who is the scum of the earth and the reason for the high health care costs.

Also, can't you get dinged for ordering too many MRIs from insurances these days?

 

[painfree23]

Agree with this. 8 weeks or more of LBP that failed PT/NSAIDs gets an MRI ordered.

If insurance company denies the MRI, then the insurance company can get sued, not me.

Besides, a non contrast MRI is not that expensive. Way more waste in insurance company/hospital administrators than in a few extra MRIs .

Insurance company gets sued?? Won't u get in trouble for not doing a peer to peer and convincing them enough ??

 

[drusso]

Employed MD's working for a HMO...any questions? They won't lose a night of sleep over this and will keep working until their pension checks start rolling in...

 

[willabeast]

The crucial point given the information presented - IF the patient was offered an epidural, then an MRI should have been ordered.
Reasoning is one only does epidurals for radicular pain that is severe. So if you are offering an ESI and the patient has had > 8 weeks of radicular pain an MRI is needed. If no epidural was offered, and the patient answered negative to all the red flag questions, personally i would have gotten an ESR and wondered a lot about a stress fracture that did not show up on plain film. I would have evaluated the pars with an MRI. But that has nothing to do with guidelines.

 

[willabeast]

Employed MD's working for a HMO...any questions? They won't lose a day of sleep over this and will keep working until their pension checks start rolling in...

hey Drusso i just reported you. ROTFL.

 

[willabeast]

According to the American College of Radiology, an MRI after >3 months of low back pain should only be ordered if there are SIGNIFICANT concern for severe stenosis (radiculopathy, reflex changes, cauda equina, etc) or fevers, weight loss, etc that increases the suspicion of malignancy.

http://www.lni.wa.gov/ClaimsIns/Files/OMD/MedTreat/Imaging/LBchecklist.pdf

Ergo, without any of those signs which are NOT stated in this lawsuit, this guy followed all the "guidelines" I have seen on this issue.

There is no guideline that says its necessary to have an MRI by 6 months, 1 year, 2 years or even longer of nonspecific low back pain. There has been a STRONG emphasis on rehabilitation before even considering an MRI.

OK but then why offer an ESI? (if it was offered).

 

[willabeast]

The number of huge lawsuits just keeps going up and up. Something to take into mind while practicing medicine.

With most insurance policies covering about 1M/3M, what happens if you get hit with a 10M lawsuit?

Will your personal assets be screwed?

This is a good question. Everyone needs an umbrella liability policy. If you do not have one, get one immediately. They are cheap. I think mine covers me for > 5 million dollars, and is 800 dollars a year through state farm. You really need this especially for auto accidents.
//
Personal Liability Umbrella Policies may provide:

• Additional liability protection at a reasonable price
• Protection against personal claims, such as defamation of character, libel, or slander, that may not be covered by your other policies
• Minimum coverage of $1 million, which can be increased in $1 million increments

How can a Personal Liability Umbrella Policy help protect you? 1
Auto


While driving, you change lanes and cause an accident, which results in multiple injuries to passengers of another vehicle.



Home
While cooking, you leave your stove unattended. In addition to damaging your property, the fire also damages your neighbor's property and injures your neighbors. As a result, you may have to pay for any repairs to your neighbor's dwelling in addition to any injury claims. Or, consider that while on your property, a guest slips on your sidewalk or falls from your trampoline. The injured person could file a claim against you.

Boat
While operating your boat, you hit a water skier and cause serious injury.//

 

[DrCommonSense]

The crucial point given the information presented - IF the patient was offered an epidural, then an MRI should have been ordered.
Reasoning is one only does epidurals for radicular pain that is severe. So if you are offering an ESI and the patient has had > 8 weeks of radicular pain an MRI is needed. If no epidural was offered, and the patient answered negative to all the red flag questions, personally i would have gotten an ESR and wondered a lot about a stress fracture that did not show up on plain film. I would have evaluated the pars with an MRI. But that has nothing to do with guidelines.

So all patients that get ESIs need to have MRIs now?

Never knew that was a "guideline" for performing an ESI.

Also where are you getting this 8 week stuff from? I see no guidelines that say an MRI is essential for persistent low back pain.

 

[DrCommonSense]

OK but then why offer an ESI? (if it was offered).

Dunno why he offered it but its not material towards the need for an MRI.

The need for an MRI is independent of the ESI offer and is clearly discussed by the American College of Radiology.

According to their guidelines, a prudent argument can be made that the patient didn't have a convincing need to obtain an MRI rapidly.

 

[Ducttape]

My local insurance plans use eviCore for guidelines.

One of the "red flag" indications reads as below:

"Severe Radicular Pain

All of the following must be present(Initial clinical evaluation required within the last 60 days)

 Severe radicular pain in a specified spinal nerve root distribution (minimum 9/10 on the VAS); and
 Documented significant functional loss at work or at home; and
 Severity of pain unresponsive to a minimum of seven (7) days of physician-directed treatment; and

 Treatment plan includes a transforaminal epidural steroid injection (TFESI) at any level(s) or an interlaminar epidural steroid injection (ILESI) at the cervical or thoracic levels or a plan for urgent/emergent spinal surgery."


Likewise, in the Musculoskeletal portion of the guidelines, one finds this statement:

"An epidural steroid injection is considered medically necessary as an initial trial in an individual with evidence of symptomatic spinal stenosis who meets ALL of the following criteria:
• diagnostic evaluation has ruled out other potential causes of pain
• MRI or CT with or without myelography within the past twelve (12) monthsdemonstrates severe spinal stenosis at the level to be treated
• Significant functional limitations resulting in diminished quality of life andimpaired, age-appropriate activities of daily living
• Failure of at least four (4) weeks of conservative treatment (e.g., exercise, physicalmethods including physical therapy and/or chiropractic care, NSAID’s and/or muscle relaxants)."

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[willabeast]

So all patients that get ESIs need to have MRIs now?

Never knew that was a "guideline" for performing an ESI.

Also where are you getting this 8 week stuff from? I see no guidelines that say an MRI is essential for persistent low back pain.

I never wrote an MRI is essential for LBP. I wrote that you would need an MRI for a radic > 8 weeks (that is not improving) .Should have said 8-12 weeks. Now if you do ESI for low back pain then this would be confusing. I would not do an ESI for low back pain.
Regarding the difference between acute and chronic pain. There are different definitions. some people use 3 months.
//Others apply acute to pain that lasts less than 30 days, chronic to pain of more thansix months duration, and subacute to pain that lasts from one to six months.//
One more thing - if you do not do an MRI before your ESI, how would you know where to place your needle? I understand that was not your question, but you have me wondering now.

 

[Tapspatellas]

Age alone in this case is an indication for MRI.

The insurance companies don't give a crap. They will deny MRI orders for blatant, well documented red flags and make you do a peer-peer with a doc who is confuzzled you even have to talk to them.

 

[vm26]

did she ever have radiographs? Presumably would have seen something if it was an aggressive osteosarcoma...our system is wacky, I read tons of non-indicated L/S mr's on geriatric patients that have multiple MRs in the last few years

 

[Ducttape]

Dr. Maus of Mayo Clinic at least believes MRI should be done before ESI....

https://www.researchgate.net/profil...eroid-Injection.pdf?origin=publication_detail


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[painfree23]

This is a good question. Everyone needs an umbrella liability policy. If you do not have one, get one immediately. They are cheap. I think mine covers me for > 5 million dollars, and is 800 dollars a year through state farm. You really need this especially for auto accidents.
//
Personal Liability Umbrella Policies may provide:

• Additional liability protection at a reasonable price
• Protection against personal claims, such as defamation of character, libel, or slander, that may not be covered by your other policies
• Minimum coverage of $1 million, which can be increased in $1 million increments

How can a Personal Liability Umbrella Policy help protect you? 1
Auto


While driving, you change lanes and cause an accident, which results in multiple injuries to passengers of another vehicle.



Home
While cooking, you leave your stove unattended. In addition to damaging your property, the fire also damages your neighbor's property and injures your neighbors. As a result, you may have to pay for any repairs to your neighbor's dwelling in addition to any injury claims. Or, consider that while on your property, a guest slips on your sidewalk or falls from your trampoline. The injured person could file a claim against you.

Boat
While operating your boat, you hit a water skier and cause serious injury.//

This will cover you for medical lawsuits too?

 

[drpainfree]

This will cover you for medical lawsuits too?

I don't think so

 

[hyperalgesia]

I don't really blame the doctor here. For her entire medical education, she has been hand-fed population-inspired guidelines and now works as a zoo animal trying to bring more customers to the park. This lawsuit rightfully hammers the zoo owners (the HMO) and hopefully they will go out of business. Maybe some local doctors will be able to step in and provide true, individualized medical care.

This case shows how some "guidelines" utterly failed this patient. They didn't fail the population though. Lots of administrators are employed with the money saved off of this one rare statistic that no one will ever report or remember when making policy.

 

[clubdeac]

I never wrote an MRI is essential for LBP. I wrote that you would need an MRI for a radic > 8 weeks (that is not improving) .Should have said 8-12 weeks. Now if you do ESI for low back pain then this would be confusing. I would not do an ESI for low back pain.
Regarding the difference between acute and chronic pain. There are different definitions. some people use 3 months.
//Others apply acute to pain that lasts less than 30 days, chronic to pain of more thansix months duration, and subacute to pain that lasts from one to six months.//
One more thing - if you do not do an MRI before your ESI, how would you know where to place your needle? I understand that was not your question, but you have me wondering now.

Cohen showed that obtaining an MRI before performing an epidural did not change patient outcomes

 

[Dr. Ice]

I practice in a high litigious part of the country and I will not enter the epidural space without an MRI period. Not sure why someone would suggest an epidural for low back pain anyway not to mention in someone 18. What would they be treating discogenic pain? And if so how would they know without an MRI anyway?

 

[DrCommonSense]

I never wrote an MRI is essential for LBP. I wrote that you would need an MRI for a radic > 8 weeks (that is not improving) .Should have said 8-12 weeks. Now if you do ESI for low back pain then this would be confusing. I would not do an ESI for low back pain.
Regarding the difference between acute and chronic pain. There are different definitions. some people use 3 months.
//Others apply acute to pain that lasts less than 30 days, chronic to pain of more thansix months duration, and subacute to pain that lasts from one to six months.//
One more thing - if you do not do an MRI before your ESI, how would you know where to place your needle? I understand that was not your question, but you have me wondering now.

There was no evidence of radiculopathy noted that didn't improve after 8 weeks in that lawsuit. I don't think the patient had radiculopathy considering the area of CA was in the pelvis. It was mostly just plain back pain.

You could order plain Xrays of the back instead of an MRI for the ESI/RFA/etc.

 

[DrCommonSense]

Age alone in this case is an indication for MRI.

The insurance companies don't give a crap. They will deny MRI orders for blatant, well documented red flags and make you do a peer-peer with a doc who is confuzzled you even have to talk to them.

Actually its not according to any guideline.

 

[DrCommonSense]

This will cover you for medical lawsuits too?

Personal umbrella does NOT cover personal assets in medical lawsuits

 

[DrCommonSense]

did she ever have radiographs? Presumably would have seen something if it was an aggressive osteosarcoma...our system is wacky, I read tons of non-indicated L/S mr's on geriatric patients that have multiple MRs in the last few years

Do you order MRIs on all nonspecific low back pain patients that are young? I thought we were supposed to be going away from that according to rodger chou.

 

[DrCommonSense]

I practice in a high litigious part of the country and I will not enter the epidural space without an MRI period. Not sure why someone would suggest an epidural for low back pain anyway not to mention in someone 18. What would they be treating discogenic pain? And if so how would they know without an MRI anyway?

Regardless of the person asking for an LESI or not, that is IRRELEVANT to the lawsuit.

The lawsuit is essentially saying that he should've ordered an MRI within a few months of nonspecific low back pain rather than at 8 months.

According to ALL guidelines from radiological societies, there is ZERO reason to order an MRI quickly in a younger patient with nonspecific low back pain.

If she has severe radiculopathy or weakness in the legs/reflex changes, then you would have a case for him not ordering an MRI being wrong. However, the case clearly shows it was only nonspecific low back pain.

 

[DrCommonSense]

I don't really blame the doctor here. For her entire medical education, she has been hand-fed population-inspired guidelines and now works as a zoo animal trying to bring more customers to the park. This lawsuit rightfully hammers the zoo owners (the HMO) and hopefully they will go out of business. Maybe some local doctors will be able to step in and provide true, individualized medical care.

This case shows how some "guidelines" utterly failed this patient. They didn't fail the population though. Lots of administrators are employed with the money saved off of this one rare statistic that no one will ever report or remember when making policy.

How "rare" is it though? If we practice like the "guidelines" say, most likely we will run into this problem in the future and a potential lawsuit.

I had a 40 something year old patient present with nonspecific ilioinguinal groin pain that was in the ER 3 times whereby he was discharged for "ilioinginal neuralgia". After a few injections, he never improved.

I decided to order a lumbar MRI that found metastatic CA to the spine that was causing this pain. Luckily the insurance didn't fight me.

ER docs, PCP, etc all missed this. VERY EASY TO DO. I would've missed it as well.

 

[emergentmd]

I'm just a family doctor, but 8 months of back pain especially in a teenager seems MRI worthy to my mind

She should have come to the ER. I would have ordered that in a heart beat, day #1. Parents and pt wants it, looks in pain, MRI it is.

 

[DrCommonSense]

She should have come to the ER. I would have ordered that in a heart beat, day #1. Parents and pt wants it, looks in pain, MRI it is.

Cool story bro until the administrators decide you are being "unreasonable" with excess imaging.

Incidentally, here is an ER case of similar nature:

Brain-damaged woman wins $8 million judgment against doctors

Here the ER didn't perform an LP after a normal imaging scan as per ER guidelines. Yet that didn't save the doctor.

Also here is BC/BS of Georgia that is unwilling to pay for "unneeded" ER visits going forward:

BCBS of Georgia to stop covering ED visits it deems unnecessary

Going to be interesting to see how they approach imaging for nonspecific back pain patients and headaches coming into the ER in the future. They might decide ordering all of them MRIs/CTs are "cost ineffective" and ding the physician doing it. So the physician who misses the diagnosis will be exposed to a 10 million dollar lawsuit for the 1/5000 patient that has a hematoma or cancer but will also be dinged for ordering those 5000 CTs/MRIs that are needed to find that one outlier.

The insurance companies will cite some kind of "guideline" stating the imaging was "unnecessary" since it was "nonspecific back pain" or "headaches" which don't warrant an imaging study and will decide to refuse payment.

Ergo, the ER eats the costs. Imagine how the MBAs who run the hospital will think if they get many unpaid for imaging studies as per insurance "guidelines"

Interesting times.

 

[emergentmd]

Hey

Cool story bro until the administrators decide you are being "unreasonable" with excess imaging.

Incidentally, here is an ER case of similar nature:

Brain-damaged woman wins $8 million judgment against doctors

Here the ER didn't perform an LP after a normal imaging scan as per ER guidelines. Yet that didn't save the doctor.

Also here is BC/BS of Georgia that is unwilling to pay for "unneeded" ER visits going forward:

BCBS of Georgia to stop covering ED visits it deems unnecessary

Going to be interesting to see how they approach imaging for nonspecific back pain patients and headaches coming into the ER in the future. They might decide ordering all of them MRIs/CTs are "cost ineffective" and ding the physician doing it. So the physician who misses the diagnosis will be exposed to a 10 million dollar lawsuit for the 1/5000 patient that has a hematoma or cancer but will also be dinged for ordering those 5000 CTs/MRIs that are needed to find that one outlier.

The insurance companies will cite some kind of "guideline" stating the imaging was "unnecessary" since it was "nonspecific back pain" or "headaches" which don't warrant an imaging study and will decide to refuse payment.

Ergo, the ER eats the costs. Imagine how the MBAs who run the hospital will think if they get many unpaid for imaging studies as per insurance "guidelines"

Interesting times.

Hey I just practice medicine how I feel appropriate. I will do stuff I don't think is necessary just to please the O suites but not when it compromises patient care.

If this girl came in the first time and never saw anyone, Of course she doesn't get an MRI. But if she bounced back in intractable pain, and I saw her the 2nd time and the family wanted an MRI....I absolutely would order one even if I get flack from the insurance.

Good aspect of ER medicine is I don't have to get any preapproval crap.

 

[IN2B8R]

The classic damned if you do and damned if you don't....


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[BobBarker]

I don't know what administrator gets upset about excessive imaging. They make a lot of money off of imaging.

 

[Tapspatellas]

Actually its not according to any guideline.

I've always treated it as a red flag. You are right, they don't specifically have it in the most recent imaging guidelines, but still considered a red flag.

Citation:
Consultant. 2013;53(6):436-440

ABSTRACT: A focused history and physical examination directed towards uncovering signs that suggest a serious underlying cause of low back pain are crucial. “Red flags” include pain that lasts more than 6 weeks; pain in persons younger than 18 years or older than 50 years; pain that radiates below the knee; a history of major trauma; constitutional symptoms; atypical pain (eg, that which occurs at night or that is unrelenting); the presence of a severe or rapidly progressive neurologic deficit; urinary and/or fecal incontinence; poor rectal tone; and a history of malignancy. These markers provide a cost-effective means of guiding your selection of laboratory and diagnostic imaging studies.

 

[vm26]

Do you order MRIs on all nonspecific low back pain patients that are young? I thought we were supposed to be going away from that according to rodger chou.

I'm a radiologist so I don't order them, just read them...many don't seem to be indicated, it may be that some patient's demand them, also seems like mid-levels are increasingly ordering them

 

[painfree23]

Personal umbrella does NOT cover personal assets in medical lawsuits

Is there anything that does??

 

[neutro]

if not an MRI, then perhaps an Xray could have been ordered. Often times that will show bony mets.
I will often get an Xray to a) assess anatomy, and b) in conjunction with PT so atleast they have SOME imaging.

From what I recall, Steve Cohen suggests this practice also, i.e. less MRI, more X ray.

So to NOT order an MRI for 8 months low back pain, is negligent. I mean if the patient was otherwise normal, healthy and reasonable, then yes, certainly some sort of imaging is indicated.
Unless that particular physician can tell me 100% of the time where the disk/mass/compression is located on the spine based on physical exam then I suppose that is ok. Which ofcourse all of us know is not possible.

 

[hyperalgesia]

Is there anything that does??

You can just increase your malpractice limits for a higher premium.

It's rare for people to successfully sue beyond medical malpractice limits, whatever they might be. My understanding is that lawyers don't want to waste time on it. Easier to just find another "victim" and go for the insurance limits on that.

 

[DrCommonSense]

Is there anything that does??

nope unless its medical malpractice insurance at higher coverage limits, which increases your risk of lawsuits