Academy of Chiropractic

Quickie Consult 1124
Lawyers and Medical 78 L

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

"Conversation with Lawyers or Arguing Ligament Laxity"


Dr Studin: Could you please say again what we talked about a moment ago? So that we could set the groundwork of what we need to do.

Guest Doctor: I was just commenting on having been in the planets person that injury a field for many years, that the problem I encounter is when speaking to insurance company adjusters, they seem to believe that when an orthopedic surgeon says something, it's the holy grail. And it's true. Whereas when a chiropractic physician says something, they go, well, that's only a chiropractor.

Dr Studin: So let's handle that issue up front. So, when you have to understand and control, and again, you've been through my presentation and Dr Rowan's you understand a little bit where I'm coming from. So appreciate the fact that I presented over a quarter of a million attorneys and my career in including pretty much every attorney represented by every carrier along with, thousands of claims adjusters. I've been inside the insurance industry and they have consultants like me, but on their side who sit and just create templated macros and talking points to talk to people like you. So the issue is the carriers do not want chiropractor's involved in cases costing too much money, which is why in the year 2000, when Allstate hired computer science corporation, they retooled the Colossus Algorithm. And part of that is saying, Oh, you only have a chiropractor because the carriers want you to go to the Ortho and neurosurgeons, in the beginning, they did that by inducing you by in settlement to give a little bit more money to Ortho, by getting the plaintiff's community to shift the population injured away from current practice initially to the medical specialists. And the reason they do that is a neurosurgeon for instance, their malpractice is between 363 and 600,000 a year. A orthopedic surgeon as a tick below that with a chiropractic malpractice is 2000 to 2,500 a year. So when we spend an hour with the patient documenting, they'll spend 12 minutes and document very little. It's either a surgical lesion or a nonsurgical lesion. And the carriers love that because when it feeds into the Colossus Algorithm, there's 1100 value drivers that the surgeons don't have time and we'll go out of business if they document everything. So with that understanding, you also have to realize that in the contemporary practice of law, you have four paradigms of practice. One is settlement, that's your lowest yield. You're dealing with the claims rep and their mantra, oh, you only have a Chiro. That's their mantra because the carriers are still trying to shift the populace and patients away from Chiro to Ortho, neuro and neurosurgeons because it limits the amount that they can document And by the way, the verification of that is look at your settlement offers 10 years ago versus today. 10 years ago, they were $20,000/$30,000/$40,000 and today there are 2/3/4 thousand, 5 thousand dollars. The numbers are spiraling downward with mobile offers as a result of shifting to the Ortho, neuro and neurosurgeon. But they still say that same thing and the plaintiff's community has drank the cool aid from the carriers and become the carriers cash cow. But your lowest yields is the first paradigm at practice of law. And that is claims reps. You're dealing with a pure colossus algorithm with no leeway. Your second level, which you go up a little bit more in value is when you get to the supervisor those claims reps and you get a little bit more money out to ensure that every diagnosis is being considered, all the documents are being answered. And then you do a little bit better. Now, when you deal with the right doctor and the Colossus Algorithm all it does is pulls out words and phrases from reports if very nondiscriminatory. Now, there were certain things like when you deal with laxity of ligament, that they do want to see the medical provider on there for the simple reason that it's worth so much that they want to knock that out of the box because they know chiropractors, especially the ones that have advanced training, put that in there more often and not the medical folks. So you've got to ensure that you've got some of those things validated by medicine. So your second paradigm is your claims supervisor. Then what you want your third level of practice is when you get out of the claims rep and you put it to suit. Now it's been assigned to an attorney. Now you're arguing policy values. Even though the opposing attorney will say, well, I don't have authority to put a number two and I got to go back to the claims are up. The attorney has a tremendous amount of leverage to say, listen, I can take this to trial, but it's going to cost a lot of money. Your fourth practices now trial the fourth, which is usually your highest level of reimbursement. If you have all your ducks in a row, and when you're dealing with connective tissue disorders, what state farm wants you to call Soft tissue, the minor impacts soft tissue that's what they're trying to convince you that's worth nothing. So a case in point was in Hartford, one of our doctors, his daughter was in an accident about two years ago, the initial offer to the attorney she got hit by a rear ended by a truck. And the trucker originally lied to the police and said she was at fault. But, Geico, which is I believe is the carrier offered $4,000 nuisance value. Her only positive findings was lax of the ligament. So the lawyer just wanted to take the money. And the doctor said, are you out of your mind? This is my daughter. I understand that she's going to have problems the rest of her life. And the argued with the attorney, he made the attorney call me, I educated the attorney on that issue. So the lawyer went back and put in the sue and the claims rep, the supervisor, the opposing lawyer, and got $30,000 offer, literally within three or four days. He said, I want to take it. The chiropractors who's the father of the daughter said, there's no way in hell. You show them the impairment level, a week after that they walked away with $145,000. So, they understand this, but you have to determine on what level you want to go at. So you can't drink their Cool aid when they say only a Chiro. Well, I have a doctor care practice, here's his credentials, here's the findings, but it's like saying it's only a medical doctor when you're dealing with a general GP or an orthopedic surgeon, my doctor is highly credential. Please let me send you a CV over and then we'll have another conversation. If you want to stay at the adjuster level or you want to get to the supervisor or you want to put it to suit and now negotiate with the opposing counsel, you will yield different results depending upon what level of practice you choose for each of your clients. What's the second issue?

Guest Doctor: Well, I'm reviewing a particular case now where the local chiropractic physician having found a on the basis of the supine metrics to report a ligament laxity has converted the whole person permanent partial disability to approximately a 71% regional cervical permanent partial disability fees. 25 to 71. The insurance company hired a records review orthopedic surgeon who probably isn't even familiar with ligament laxity and said at most it's a 4% permanent partial disability and that the chiropractic physicians interpretation of the AMA guidelines fifth edition to result in a 71% cervical regional disability is vastly overstated to the point of being ridiculous. And it's only at best a 4%. So he's, the orthopedic surgeon is wedded to his belief, I believe that when it's a ligaments injury or as they call soft tissue injury that at most it's a four or five, 6% permanent partial disability and they just don't employ those tables from the AMA guidelines, which allow for that conversion to a regional from whole person and a for those large numbers. They just see it, It's a different a worldview.

Dr Studin: It's not a different worldview. It's business, right? this is all about leverage and being a trial attorney, so you understand leverage better than anyone. And you went to lose a case based upon leverage. It's just that simple. The answer to that is that okay, dear claims examiner, and again, you've got to get to the supervisor at this level or put it to sue. Dear whoever, I appreciate your orthopedic surgeons position however, we look at the measurement from spine metrics and Dr Peiser, a Harvard trained neuroradiologist who's been published over a hundred times. He's showing that the bone slipped five millimeters, or if it's angular deviation greater than 11 degrees on page 545 of the AMA guides, it says a five millimeter slippage It's 25 to 28% whole person impairment. This is not about my chiropractor physician's opinion. This is not about your orthopedic surgeons opinions. This is about a Harvard trained already radiologist taking a ruler, measuring the bones, positional. This is about the American Medical Association guys devotion from family fifth edition, page 545 saying when a bonus slipped that far, it has damaged the ligament. therefore you have a diagnosis of ligament and it's saying there's a 25 to 28% whole person impairment. On page 242 of that same book, it says you can convert a whole person to a regional impairment, which is 71%. However, in the state of Connecticut as usual and customary to convert that it's a whole person versus regional. So I appreciate your 71% argument really based upon not understanding impairment ratings, but the chiropractics position I'm working with is qualified, to render impairment ratings and through the University of Bridgeport College of Chiropractic, through Chiropractic Academia, a federally recognized chiropractic institution to render impairment ratings. He's been highly trained in that and perhaps your orthopedic surgeon has no credentials as impairment rating is not part of their basic training, nor do I see evidence in a CV requested of any course and impairment rating. So therefore, I am not arguing what my doctor said versus what your doctor said. I'm simply looking at how much of bone shifted, but that's reported by and what that is value that in the book, unless you choose to say that the 50 medical schools that contributed to the AMA guides are wrong Then this person has a 25 to 28% whole person impairment and we need to move forward as such, period.

Guest Doctor: My case that I'm referring to isn't suit and I think I'm going to send them a letter. It's simply referring to those tables and those pages in the AMA guidelines. It's a political issue. It's a scientific issue.

Dr Studin: If there's one step you're missing. You're still allowing the argument that it's their orthopedic surgeon versus your chiropractor. It's not, it's simply the Harvard trained radiologists were rendered this finding, showing the Bone slip, which can be measured with a ruler of which we're planning to demonstrably show in the courtroom and here's what it says. So it's not about my Chiro versus your work. You want to get rid of their leverage.

Guest Doctor: well a factoring in the issue of a preexisting versus accident caused, is it reasonable to argue that no one has ligament laxity in the absence of trauma and that it could not have been a preexisting?

Dr Studin: well, that's part of the equation, and the answer to that is: Is there bone spurs at that level? Because if there is a bone spur, that means the problem has been there for a minimum of six months or longer. If there's no degenerative joint disease, if there's no bone spur, then in fact you know it's fresh. If there is no model changes, if you have an MRI, it will also show that there is no bone edema, so it's relatively fresh. Those are the things you have to factor in as well. You could also look at disc height. If the disc is thinned, that's all. If the disc is type preserved, then it's new. So when you're looking at age dating, whether it be a herniated disc or lax to the ligaments, these are the things that the doctor with you understands how to document as well. And you can ask for an addendum report on age dating this laxity of ligament. You should have to pull those physiological mechanisms. And again, it's about leverage and you've got the policy limits on the table. You now know what's been done on policy issues on this type of scenario and the doctor you with knows who I'm talking about can chit chat with them and you'd get the doctor and get some information, but you've got it determine what the policy limits are. And then you've got to determine what you can we go for the whole policy because the ligament and here, here's the other issue.

Guest Doctor: This is very helpful and it broadens my ability to argue this to the a carrier's attorney and adjusted. My last question is, after you've determined as ligament laxity , you converted it to the regional permanent partial disability. You have adequate presentation with regard to age dating. The particularly individual whose report I'm reviewing at this time as a young man approximately 30 years of age and he's reasonably active, but he has these periodic continuing episodes of severe flare ups. So he has some good days where his pain levels are 2 on a scale of zero to 10. Then he handles these episodes every couple of weeks or so where the pain shoots to an 8. So I want to be able to argue that given his documented ligament laxity and the severe documented AMA guidelines, permanent partial disability, that this individual a will reasonably deteriorate. And that as he ages, he will develop arthritis. And The capacity will diminish because right now his functional capacity is decent. He goes to work every day. He has a wife, he has a couple of kids, but he has these flare ups. What I would assume given this level of PPD, a permanent disability that is functional capacity with most likely deteriorate. He will develop arthritic changes at these levels and he will have a future which is clouded with pain and functional loss. Given the trauma that he's experienced.

Dr Studin: you articulated that extremely well, but there's two corrections that I would make. One, I would not argue or regional impairment. I just only comments on the whole person impairment because that's what the courts are used to seeing. Even though you can articulate why it was done regionally. Number two, there were two words. Wolff's law, which was coined by Julius Wilson, the 1850s, which says when there's aberrant pressure on a bone the bone will remodel cold arthritis. When you have ligament damage, which is connective tissue, stop using the word soft tissue. Your client has a connective tissue pathology and the ligament over stretches and impairs because of wound repairs. It wound repairs with a cheaper grade of tissue. Ligaments are made up of two types of tissues. Collagen and Elastin. Collagen is very durable. Elastin is elastic. That's where the word comes from. But when do you have a ligament damage it doesn't heal, it wounds repairs with only Collagen and it doesn't have the ability to lay down Elastin again, that's a cheaper great of tissue? It's like cutting into a steak and seeing grizzle. That's what it looks like, it doesn't have the pliability in the movement, so therefore the joint, will have other too much play in it or restriction in it either way it's going to be anyone position over time starting at six months, you're going to start seeing a little bit of bone remodeling. But over time as you put it appropriately and articulated it well will have arthritic degeneration that could not, should not, Might, but they will, especially if there's lacks of the ligament over time and it's not crystal ball stuff, this person is going to have future disabilities. It's not even a question at this level because the connective tissue has been destroyed and wound repairs with the chief of greatest tissue and the doctor you're with has the research article to verify that and prove it. And we talked about it when I lecture. So that's really the argument when you look at disability. Disabled and it will start expressing itself over a period of time and get worse. It's not even a question. It will occur. Mr. Jones is going to have significant future disabilities, whether it's an five years, eight years, 10 years, everyone degenerate at a different time upon their level of activity, their occupation, what they're doing. But it's going to, and it's going to affect them for the rest of his life. And if you want to have a snapshot of what it kind of look like, go look at some of the people in the nursing homes walking in walkers leaning over his spine is going to lose it the ability to hold itself upright. How it'll affect him and how significantly it will be significant, but it's a matter of time. And this is about Mr. Jones. I'm not giving you out of a population of a hundred this is the average. This is my patients is going to happen to him.

Guest Doctor: well that answers my questions with regard to this case. That's very helpful. I thank you. 

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