Dr. Bill Gallagher 2012-12-12 01:17:23
When it comes to reaching a settlement in a personal injury case it is essential to remember the golden rule. The one with the gold makes the rules. With personal injury cases the insurance companies have the money and as such they make the rules with programs like Colossus that help them determine the extent of injuries and their value. For a chiropractor who treats personal injury cases or the attorney who represents them this could be a problem until you learn to play by the rules. Liberator2 is the one EHR program specifically designed for personal injury cases that knows the rules and plays by those rules taking the advantage away from the insurance company. So what do you need to know? GOLDEN RULE #1: Diagnosis it HCFA forms and most billing programs accept four diagnosis codes. As such most doctors include only four codes. This works well to the insurance companies’ advantage as they will only be required to consider those four codes in determining the value of the case. Generalized codes that cover a region fail to address each component and each level of involvement. They do allow everything to fit into the four available spaces on the billing form but they do not force the insurance company to address each component. Using “whiplash” or “soft tissue damage” will actually devalue a claim. Breaking it down to the concussion, loss of enjoyment, duties under duress as well as contusions, spasms, ligament laxity and more at each level insures that they consider each problem at each level in valuating a claim. Using only four diagnosis codes can cut a claim’s value by 80% GOLDEN RULE #2: Document it On the surface there is nothing new here. Whatever the doctor documents is something the attorney can use. What is not written did not happen. It is not enough to have a list of diagnosis codes. Each of these needs to be documented as to the quality, frequency, intensity and more. Once a diagnosis is listed it must be addressed. Diagnosing sprains, concussions or anxiety is appropriate but failing to mention it in SOAP notes or to treat them appropriately effectively tells the insurer that it was not addressed and as such does not need to be considered. The less information available to the insurer the more likely they are to devalue each code. GOLDEN RULE #3: Prove it Failure to prove the extent of injuries is an open door for the insurer to sweep most of your claim out that door. A loss of range of motion needs to be shown in a computerized study. An MRI may show disc involvement but that finding carries more weight when muscle weakness or dermatome involvement can also be demonstrated. Ligament damage, the main underlying cause of soft tissue injuries can be measured with the proper x-rays and CRMA (Computerized Radiographic Mensuration Analysis). When done so a 25-28% impairment rating can be established. GOLDEN RULE #4: Validate it While there is plenty of research showing that in most cases chiropractic is the best course of treatment Colossus has yet to include this knowledge. As such it is important to have a 9 point medical validation review. Such a review will not only validate the findings and treatment but will also provide an impairment rating per AMA guidelines. Having another doctor or the emergency room agreeing that your client suffered injuries is one thing, having an AMA impairment rating is priceless. GOLDEN RULE #5: Demand it There are 43 value drivers and decision points used by insurer’s programs to rate a case and arrive at a settlement offer. Thirty of these come from the doctor’s notes and the other 13 are administrative and legal factors that must be included in a demand letter. If your software program or legal assistant is missing any of these your client is missing out too. Liberator2 is the one system that takes all of these into account and makes the case for you. The same system that will generate a nine page report for each visit will also generate a 12 to 14 page demand letter with room for the attorney to address the 13 legal issues. How well your case does depends on a preponderance of evidence. The more value drivers included the more value. The more decision points met the easier the decision will be. The more supporting proof you can submit, the less chance of a claim being denied.
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