"Overcoming Gaps in Care"

Quickie Consult 1082
Narratives 85 N

From the Desk of Dr. Mark Studin
Academy of Chiropractic

Preamble: Many of the issues I bring to you are very small, yet each issue is just that, an issue. If you take care of the small issues, then you will be able to build and more importantly, focus on the bigger issues...a larger practice and more family time. -Mark Studin 2006

"Speaking the Language of the Lawyer & Take a Quiz"


Dr. Studin: We just sat and spoke for a few minutes. You had something really cool. So, start from the beginning.

Guest Doctor: All right. So, I got this referral from this attorney who just got his client. She was injured about a year and a half ago, low speed accident. She was treated by her chiropractor for about maybe two months. Then they said, I need her because she has pip and they basically said she was fine. Everything was preexisting,

Dr. Studin: that typical bullshit says nothing wrong. Well preexisting.

Guest Doctor: the treating doctor actually wrote a rebuttal. So, me and then the IME doctor wrote a rebuttal to that.

Dr. Studin: And so, did you read the training doctors rebuttal?

Guest Doctor: Yeah.

Dr. Studin: Did it say in writing; I did everything and he's wrong basically.

Guest Doctor: Basically. I mean I attributed; I mean she's 67 years old. Because what happened was it's a doctor she was seeing just maybe four times a year just for maintenance and all of a sudden she got, you know and she was a weightlifter before. But I mean far as causation is clearly it’s trauma.

Dr. Studin: So, but the other issue is do you understand before we even get into what your issues are, why that treating doctor failed? And his argument was, because he argued the facts of the case medically and every doctor is entitled to their opinion even though you might not agree with an IME doctor. Now that IME was ordered by the insurance company or by the lawyer?

Guest Doctor: the insurance company, her own insurance company.

Dr. Studin: his insurance company ordered VMA, his defense lawyer or so I just want to get that clarification. So, at the insurance company hired a doctor and that doctor gave his opinion. So, no matter what this doctor says, no matter what the treating doctor says, the insurance company gets to say that, okay, you're entitled to your opinion, but so is the doctor we hired and we're going to go with that doctor's opinion. And now that doctor really doesn't have a leg to stand on unless he gets in the courtroom and tries to convince a jury. So now the lawyer brings you in, to do what?

Guest Doctor: To see if I can get the case open. Even though there's a huge gap between treatments. She stopped treatment because even though she has good amount of tip, um, the doctor didn't want to carry the liens so the doctor stopped treatment as soon as he found out there's no payment but a year and a half as passed, she still has a lot of pain. She's in paying cash just to help mitigate.

Dr. Studin: And does she, do you have massage records, or do you have receipts from the massage therapist on a continual basis to show the continuing of the care?

Guest Doctor: without gaps? It was sporadic cause she didn't have money to.

Dr. Studin: So, the answer is no. So, who was in extreme pain? I mean, how big was the gap? Is it two weeks, a month, six months?

Guest Doctor: Probably six months. All between the chiropractic care, which was probably like over a year and three months ago, the last time she saw her chiropractor which was a year and three months ago.

Dr. Studin: Who Do you know, that's in a tremendous amount of pain and has that large of a gap in care. The answer is nobody. You can overcome that negative IMA if the doctor does things in that report and triggered him and we're not going to even talk about that right now. Okay, we can overcome that and that we probably can overcome that negative IMA. You can't overcome that gap in care. How did you know that patient who was previously a weight lifter try to go back to weightlifting and hurt herself again.

How do you know she didn't this niche and hurt herself? The only way you can overcome that gap in care is if you have treatment records. Was she self-treated? where she went for massage and you have records from the massage therapists or even cancelled checks, even receipts if she paid cash, um, pharmacy receipts that she, you know, purchasing Ibuprofen or Aleve or whatever. She takes over the counter over and over and over and she self-medicated if she kept a log of stretching and exercise and some kind of demonstrable evidence that there really has not been a gap in care because of finances, She's been treating, she's been self-treating, walk. By the same token, did she have this lawyer from the beginning or just now?

Guest Doctor: Just now. because their first lawyer sat on it and didn't do it.

Dr. Studin: So, she did have a lawyer from the beginning. So therefore, the lawyer did not inform her that she does have pips still on the table if she needs it and that she should be fighting to get that pips extended. She got bad advice.

Guest Doctor: Yeah. right. And, and she felt misrepresented by that lawyer because it wasn't really, you know, I guess it was a low speed impact and not the thing. And the lawyer just kind of dropped the balls, the junior attorney at a bigger law firm. So, you know, she just found this other law firm that I work with.

Dr. Studin: It's in my opinion that you cannot overcome that gap in care. Her only recourse is against the lawyer who didn't represent her properly. That's not your argument. I think that the current lawyer you're working with, I wouldn't put my reputation on the line, that this person that I'm going to try to overcome this issue for this, for this patient, but they were too large of gaps in care to be able to causally related because the first thing of defense lawyer is going to say appropriately is how did you know she didn't try to lift something?

How do you know she didn't have a fall? Another accident. There were months and months of gaps in care. Who is the reasonable world has this much pain and problem and goes two or three or four months without treatment? Unless you can have, and what I would say to the city attorney, listen, I can help you if I get receipts from a massage therapist on a regular basis. I get notes from a massage therapist. I get cancelled checks that you paid the massage therapist. I get receipts that you've been buying Advil or Aleve over the counter on a continual basis. I have to show a continuity of care between them and now, other than that, there's no way we can overcome those gaps in care. And I can't say, with any degree of medical certainty that she didn't do something else in the intervening time.

I mean, if she's in this much pain, if I did another MRI and I saw, you know, inflammation, I could say, well, you know, that was a recent problem, but you know, does she want to pay $1,000 for an MRI? You know, these are all the different obstacles that we have and I can help you, but only with that demonstrative evidence. Other than that, I can't say she didn't, as I said a moment ago, false lift, lift something in that and it's too large a gap in care.

Guest Doctor: So let's say she does have some receipts and I know she did some massage and she mentioned it. I can call her again. You know, how can we proceed from there?

Dr. Studin: then you just do a PIMA, evaluate the patient just like you would any other PIMA, but you have to account for 18 months. You have to account for all 18 months of what she did in the timeline. If you cannot account for that, and usually it's two weeks, but you know what, even if you stretch it to three or four weeks, that's okay. I'd be okay with that. But if you're going more than a month and someone's in that much pain, I wouldn't, I wouldn't put my reputation on the line, even to piss this lawyer walked through with you. You're going to set yourself up for failure for the future.

You're going to be known as it, you know, it was a plaintiff whore, I feel, say and do anything to win the case. And that's not the reputation you want.

Guest Doctor: Right. So, can I say, I mean not going to match or the patient, but just say, patient stated she has not had any other injuries or causalities. I would cause her aggravation of her symptom apology, you know, in these past few months, um, her pain just gotten worse. Um, and by evidence of also, she has no medical records prior to the MBA, any acute treatment. And the doctor even knows that, you know, and the IME was really skewed, and it sends data. It was attributing her pain as a chronic pain, even though there's no evidence of any acute treatment to…

Dr. Studin: you're taking the patient's word. The jails are full of people who said, I did not rob the bank. I didn't pull the trigger. I didn't, you know, I didn't hit the person. Everyone says that. Okay, so, but where's your evidence? Well, bullshit. A reasonable jury would never believe person who said, Oh, well I'm in so much agony and all of a sudden, six months later, they haven't done anything in six months. Oh, I did a lot. I took all these drugs over the counter. I went to some massage. Where're the bills? Where's the receipts? Right. There's proof. Show me. Did she change her job?

Guest Doctor: She lost her job. She lost her job because she was a recruiter, where basically she was in so much pain, she couldn't stand, you know, talk to your clients. Now she's taking a minimum wage jobs as a result, you know, she lost her job as a fact and due to the pain that she can’t stand for x amount of hours at a time.

Dr. Studin: Some of those in that much pain and I really get no healthcare for a year and a half. Sorry. It's just, it doesn't pass the sniff test.

Guest Doctor: Yeah, I know she did a couple of massages. That's where she says, I mean I can call her back and see what kind of receipts she got or any type of a proof.

Dr. Studin: You might want to discuss this with the lawyer and let him do it. Why are you going to waste your time to try to make the case for a lawyer when you're not going to get a nickel out of it?

Guest Doctor: Yeah. So how about you said self-care, over the counter medication and

Dr. Studin: show me receipts, something, we talked about that, that's got to be demonstrably

Guest Doctor: and how about self-exercise? How do you demonstrate that or prove that the patient would likely say, okay, I did it.

Dr. Studin: I tell my patients to keep an exercise log. And there were certain services where patients can actually go online and they could document their exercises. And an exercise log is huge, but this is overcoming a gap in care. I can tell you right now, you're not going to, this is a case, the lawyers not going to win and you're not going to get paid. You're just not going to overcome it. It's too bad. You could give me all the, you can give me all the bullshit reasons you want. At the end of the day, a reasonable jury will not believe a person who just says, oh, I went in to take cash from massage therapy. And then in a lot I don't have any receipts. Then I went and paid cash for all these drugs I took. I don't have any receipts. I did exercise every single day. I was in agony. I didn't keep a record of anything. Okay. And I haven't seen anybody in 18 months other than that. Now that I have a new lawyer, all of a sudden, I'm going to see a doctor because I want to make money in my case.

I don't want to be redundant because we're just going to keep going in circles but talk to the lawyer and take it from there. If you have any more questions, call me back.

Guest Doctor: Okay. Sounds good. Thanks. Bye.

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