Sherry DiPrima, RN Nurse Case Manager received a Cincinnati Insurance referral for a 44 year old male for medical case management to assess vision issues relative to a work related injury of the left eye. He initially was treated at a local ER for corneal abrasions, rust in the cornea and a CT scan was completed which was negative. He was referred the following day for evaluation by a neuro-ophthalmologist and multiple diagnostic tests were ordered.
Over the course of the next six months, Sherry monitored and assessed the injured worker’s multiple visual complaints. Additional testing at each follow up appointment revealed that the injured worker was able to read letters from the eye chart and reading card, but amazingly reported the inability to see! Various tests done over the life of the case alluded to the possibility of unrelated diagnoses; yet some indicated damage resulting from the injury. In addition to the neuro-ophthalmologist, the injured worker was referred to a retinal specialist.
He was eventually referred for a second opinion with the retinal specialist at Will’s Eye. Diagnoses of excessive dilation of the pupil secondary to trauma and confirmation of a deficit of the visual field following testing were noted. Further testing was recommended. By this time, the injured worker presented with changes in his subjective complaints. He was noted over a period of time to become more non-compliant with prescribed medications, and was driving when he had previously reported that he could not. He presented with persisting dilation of the left pupil but did not wear sunglasses or appear to protect his eye in any way aside from wearing a baseball hat. Therefore, as this case remained unresolved, Sherry recommended scheduling an IME as soon as possible at Will’s Eye with a neuro- ophthalmologist.
The interesting piece of this difficult case was that the contact person with the insured was the injured worker’s sister. It was suggested to the adjuster earlier on that the contact person be changed to allow for open lines of communication. When this did not change, it made it especially difficult as we were now attempting to assess whether or not he was instilling drops in the left eye to maintain the persistent dilation of the pupil. There was also one occasion that the sister asked if the injured worker was using any drops which would dilate the pupil.
Arrangements were made with a Dr. Sergott, neuro-ophthalmologist at Will’s Eye for the IME and further testing. One of the big questions posed was whether it appeared that this injured worker could be instilling drops into the affected eye, which the injured worker denied. The report which followed reflected that the injured worker had two problems that were not physiologic in nature and did not represent any type of damage from the work injury. The IME report confirmed that the pupil was pharmacologically dilated, confirming that the injured worker was instilling a dilating drop into his eye to keep the pupil in this condition. The report further noted that this injured worker was in no way disabled and could return to work immediately. “All of his claims and findings are fraudulent in nature.” With this Sherry was able to close her file.
Sherry provided meticulous, persistent, tactful, effective medical case management on this file, resulting in documentation of fraudulent activity by the injured worker and a release to full duty work without restrictions. Due to effective, regular communication with all parties, Sherry was alerted to the issues on this case that just did not make sense. By taking the injured worker out of the area for a very specialized, highly professional opinion, the pieces of the puzzle were able to be put together, resulting in an excellent resolution of this claim.
Not every injured worker intentionally fakes an injury, nor do those who do go to such extreme lengths to imitate symptoms. It takes a thorough knowledge of medical case management and insight to handle these unique types of claims.
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