Winter 2022-23

Diagnostics As a Defining Touchpoint in the Claims Journey

Fast Focus

It’s an early touchpoint that can set the tone of a claim: the timing and accuracy of diagnostic test results can determine the course of an injured worker’s treatment plan, their recovery, and ultimately the associated claim, making it important that timing, quality and availability of these services is on target.

Diagnostics Timing: Who Decides and When?

The timing of when specialized diagnostics tests (such as advanced imaging services like MRI and CT) should optimally occur following the onset of injury is an area where clinical approaches can vary. Some providers take a “wait and see” approach, while others take the position that the sooner a patient is diagnosed, the sooner treatment and a plan for recovery can begin. In reality, the timing of specialized diagnostic testing can be a complex decision that includes individual patient considerations and multiple stakeholders.

Sometimes, speed matters: The ability for the treating physician to create a treatment plan that will effectively guide an injured worker back to health relies on establishing an accurate diagnosis. When the accuracy of that diagnosis in turn relies on findings from advanced imaging services, the efficiency in which these services are ordered and delivered can be important to getting the claim off on the right foot.

Potential Impacts of Delayed Diagnostics Services:

Higher rate of missed appointments

Treatment delays

Exacerbation/worsening of injury

Increased lost-time days

Increased length of stay

Increased downstream costs

Delays in reviewing diagnostic test results have been associated with subsequent delays in medical care and negative outcomes such as prolonged hospital stay and costs.1 Longer periods of wait days (WDs) are also associated with a higher likelihood of missed appointments.2 A retrospective study of more than 40 thousand patients identified a correlation between WDs for scheduled MRI services and missed appointments – meaning that the longer the time period between when a test is ordered and the day of actual service, the more likely the patient will not show up.

Notably, this effect was more pronounced in underrepresented minority populations and patients of low socioeconomic status, signaling the role that timely service delivery can play in helping to address health inequity.2

But the science on when the timing is right continues to evolve. “There are some newer and, in some cases, seemingly conflicting practices,” explains Healthesystems’ clinical expert Tate Rice, PT, DPT, MBA. “It used to be that you shouldn’t conduct an MRI too early because of the swelling. Now, we’re seeing data that says the swelling may actually help produce a better read.

The timing in the literature is not always prescriptive. In general, most physicians will wait at least 2 weeks for a specialized diagnostic test.

Tate Rice, PT, DPT, MBA
Director, Product Management at Healthesystems

“The timing in the literature is not always prescriptive. For example, in the case of subacute or chronic pain perpetrated by a suspected labral tear, ACOEM guidance recommends an MRI 4-6 weeks after the patient has failed non-surgical therapy, such as an NSAID. But for a suspected rotator cuff tear, the guidance isn’t as prescriptive in terms of timing of MRI.”

But generally speaking, Dr. Rice adds, “Most physicians will order an X-ray right away, but wait at least two weeks for a specialized diagnostic test.”

Sometimes, it’s better to wait: In the case of lower back pain (LBP), studies have linked early diagnostics testing to increased costs and service utilization on a claim when a diagnostics test was the initial primary care referral vs physical therapy.

In a retrospective analysis of electronic medical record (EMR) and insurance claims data, LBP-related utilization and costs were compared in patients receiving physical therapy (n=385) as initial primary care referral vs magnetic resonance imaging (MRI; n=377). Overall, average cost per patient over a 12-month period was approximately $4800 higher for the imaging group vs the physical therapy group. An initial referral for MRI rather than physical therapy also increased the odds of surgery, injections, specialist, and emergency department visits.3

Similarly, the Washington State Disability Risk Identification Study found that administering an MRI earlier than recommended guidelines in patients not exhibiting red flags for chronic LBP increases the likelihood of injections or surgery. This practice also increases utilization of outpatient and physical/occupational therapy by approximately 50%.4

“In the case of lower back pain, it is more desirable to start with physical therapy before ordering a diagnostic test” explains Dr. Rice. “In fact, ACOEM guidance advises against diagnostic testing for the majority of lower back pain patients, with some exceptions.”

And while the timing of a diagnostic test order is determined by the treating provider, the claims professional plays a key role in identifying contextual factors that may impact the order.

Stephanie Arkelian, a Senior Director of Product Management at Healthesystems, comments on her early days as an adjuster. “As a claims professional, you need to be able to take what you know about the case and identify whether additional information is required to make an authorization decision. This may mean involving nurse staff, referring the order for utilization review, or leveraging the expertise of diagnostics vendors to help determine if 1) the type of diagnostic test is appropriate for the injury and 2) the timing is appropriate.

As a claims professional, you need to be able to take what you know about the case and identify whether additional information is required.

Stephanie Arkelian
Senior Director of Product Management at Healthesystems

“More seasoned or clinically savvy adjusters recognize these opportunities based on factors related to the injury or circumstances of the case,” Arkelian continues. “However less seasoned adjusters may need training in this area. Taking those different factors together can be as much an art form as it is a science, and having familiarity with the process is invaluable.”

Quality and Accuracy of Reads: Room for Improvement?

Hand-in-hand with getting the timing right is getting the read right. While many diagnostic tests are considered routine in healthcare, the prevalence and impacts of diagnostics test errors is concerning with these errors representing the largest portion of medical malpractice claims and costs, more than surgical or medication errors.5

One significant area of concern is disagreement in the interpretation of test results and diagnosis between different types of providers. One retrospective study of nearly 300 patients found that the diagnosis from an initial primary care referral was discordant to some degree with a specialist’s final diagnosis in nearly 9 out of 10 cases,6 underscoring the value of a second-opinion interpretation of advanced imaging results.7,8

In workers’ compensation populations, where complexity of injury drives higher volume of diagnostics utilization compared with group health populations,9 it follows that this an area where the industry is focused on “getting it right” – from a timing perspective, from a cost perspective, and certainly from an accuracy perspective. Today, there are diagnostic vendors in the workers’ comp space who are offering some innovative solutions and expertise to help with this very challenge.

“Healthesystems is continually assessing the market for vendors that support the areas of quality and value in ancillary medical services,” says Arkelian. “Specific to diagnostics, we’ve seen some standouts in terms of what they are offering to help address concerns around read quality and diagnostic inaccuracies related to advanced imaging services – including models that directly leverage specialized expertise in second-opinion reads.”

Access to Services: Concerns Beyond the Pandemic?

Downstream impacts of the COVID pandemic, including disproportionate workforce attrition in the healthcare segment and global supply chain disruptions, have contributed to or exacerbated challenges in aspects of healthcare delivery well beyond the peak of the pandemic, and this includes diagnostic service fulfillment. Radiologist staffing shortages preexisted the pandemic,10 and this specialty area continues to battle high demand among staffing challenges.11 From a supply chain perspective, new issues continue to arise. Shortages in the contrast agents used in CT scans from GE Healthcare, a primary supplier of these agents, were reported as late as May of 2022, more than 2 years after the start of the pandemic.

Read Out of Stock: Medical Supply Chain Shortages Impacting Workers’ Comp

Even as the healthcare industry continues to battle and overcome these challenges, other, systemic considerations related to access to these services exist, specifically concerning health equity. Both race and socioeconomic factors are tied to inequitable access to high-quality diagnostic services and ultimately high-quality outcomes, due to a combination of environmental, patient-specific, and systemic factors.12 In addition to the earlier commentary on the more prevalent relationship between WDs and missed appointments for MRI among underrepresented populations and low socioeconomic status, another large retrospective analysis identified race and socioeconomic status as independent predictors of risk for imaging missed care opportunities related to MRI or CT services.13

Considerations for Workers’ Comp Medical Programs

The management of diagnostics services within injured worker populations has always been a delicate balancing act. And as we layer on the additional complexity of post-COVID impacts and social determinants of health, there are some questions workers’ compensation medical program managers can be asking:


Does the diagnostics vendor solution I have in place provide me with the network depth and breadth needed to ensure resiliency in a post-COVID healthcare environment?


Am I seeing performance measures that give me confidence that services are being fulfilled efficiently and effectively?


Do I have an analytics solution in place that provides me with the visibility to understand how individual patient factors, such as social determinants of health, tie to utilization of ancillary medical services such as diagnostics?


  1. Ong M-S, Magrabi F, Coiera E. Delay in reviewing test results prolongs hospital length of stay: a retrospective cohort study. BMC Health Serv Res. 2018;18:369.
  2. Daye D, Carrodeguas E, Glover M, et al. Impact of delayed time to advanced imaging on missed appointments across different demographic and socioeconomic factors. J Am Coll Radiol. 2018;15:713-20. doi: 10.1016/j.jacr.2018.01.023.
  3. Fritz JM, Brennan GP, Hunter SJ. Physical therapy or advanced imaging as first management strategy following a new consultation for low back pain in primary care: association with future health care utilization and charges. Health Serv Res. 2015;50(6):1927-40. doi: 10.1111/1475-6773.12301
  4. Graves JM, Fulton-Kehoe D, Jarvik JG, Franklin GM. Health care utilization and costs associated with adherence to clinical practice guidelines for early magnetic resonance imaging among workers with acute occupational low back pain. Health Serv Res. 2014;49:645-65.
  5. Johns Hopkins Medicine. Diagnostic errors more common, costly and harmful than treatment mistakes. April 23, 2013.
  6. Van Such M, Lohr R, Beckman T, Naessens JM. Extent of diagnostic agreement among medical referrals. J Eval Clin Pract. 2017;23:870-4.
  7. Tuite CM, Boros MC, Ruth K. Value of second-opinion interpretation of outside-facility breast imaging studies to a radiology department and cancer center. J Am Coll Radiol. 2022;19:552-60.
  8. Khalilzadeh O, Rahimian M, Batchu V, et al. Effectiveness of second-opinion radiology consultations to reassess the cervical spine CT scans; a study on trauma patients referred to a tertiary-care hospital. Diagn Interv Radiol. 2015 Sep; 21(5): 423–427.
  9. NCCI Research Brief. Workers Compensation and Group Health – Comparing Utilization of Physician Services. September 2021.
  10. American Society of Radiologic Technologists. Radiologic Sciences Staffing and Workplace Survey 2019. September 2019.
  11. Fleishon HB. The Radiology Labor Shortage. ACR Bulletin. February 2022.
  12. Waite S, Scott J, Colombo D. Narrowing the gap: imaging disparities in radiology. Radiol. 2021;299:27-35.
  13. Glover M, Daye D, Khalilzadeh O, et al. Socioeconomic and demographic predictors of missed opportunities to provide advanced imaging services. J Am Coll Radiol. 2017;14;1403-11.


Since 2010, the semi-annual RxInformer clinical journal has been a trusted source of timely information and guidance for workers’ comp payers on how best to manage the care of injured worker claimants and plan for the challenges that lay ahead. The publication is an important part of Healthesystems’ proactive approach to advocating for quality care of injured workers while managing the costs associated with treatment.