A claimant is treated for a neck injury in March, and the file shows nothing more until late June. That gap could point to a resolved injury, a missed referral, or records that haven’t arrived yet.
Adjusters and defense counsel tend to read gaps against two questions: did the incident cause the condition being treated, and what is that treatment worth? So it helps to know what kind of gap you’re looking at, and what else might explain it.
Where Gaps Show Up
The most familiar gap is the delay between the date of loss and the first visit. A claimant who saw a provider the same day presents differently from one whose first appointment came three weeks later. If there’s a reason for the wait, you’ll want it documented.
Gaps also show up in the middle of treatment. Care starts, stops, and picks back up months later. When that happens, it’s fair to ask whether the original complaint had resolved and whether the later visits still tie back to the incident.
Then there’s prior treatment. If the claimant was seeing someone for the same body part a few months before the incident, that says something about whether the condition was already active.
How Long is Too Long?
There’s no set number. Start with the treatment plan. If physical therapy was ordered three times a week, a two-week absence stands out. If the specialist scheduled a follow-up for six weeks out, two weeks is right on schedule.
It’s also worth reading the note from the visit where treatment resumed. Providers often write down why the patient was away.
Make Sure the Records are Complete
Before reading too much into a gap, make sure the records are complete.
Records come in batches from different custodians, often over weeks or months. A stretch that looks significant after the first delivery can disappear when the next one arrives. And some providers never make it into the original request because nobody knew about them.
Here are a few signs that care continued somewhere else:
- A referral to a provider whose records aren’t in the file
- Billing records or EOBs with dates of service the clinical notes don’t cover
- A prescription from someone who appears nowhere else
- An intake form or patient history that lists other treating providers
If you find any of these, a supplemental request is usually the next step, well before anyone puts a number on the claim.
Common Explanations
Plenty of gaps have ordinary explanations. Authorization for the next round of treatment was pending. The claimant started a new job, moved, or lost their provider when the practice closed. When there’s a reason like this, it usually shows up in the notes from the visits just before or after the gap.
It helps to log it early, because the file won’t stay with you. It goes to defense counsel, and often to a nurse reviewer or IME physician after that. If the gap is already noted with its dates and the pages on either side, nobody down the line has to rebuild the chronology to find it.
Seeing the Intervals
Spotting a gap by hand means building the chronology first: pulling dates of service from every provider, putting them in order, and reading the spaces between. On a large file, that’s most of the work.
Compex retrieves the records, and Asabell™, our medical records intelligence platform, organizes the encounters across providers and dates of service into a chronology of care, with evidence citations that reference the supporting medical records. A color-coded timeline shows medical charges relative to the date of loss, so treatment before the incident is easy to pick out. Asabell Case Summary, coming soon, will bring that chronology together across the complete record set.
If building chronologies is eating into your team’s review time, we’d love to show you how Asabell works.
