Academy of Chiropractic Personal Injury & Primary Spine Care Program
Quickie Consult 98
Retrospective Review Results "A Cause for $Big$ Concern
A doctor I was expert for over the last year just settled amicably with the insurance company because I pressured the lawyer into settling the case and not fighting it. The reason I recommended settlement is that the doctor, although he responsibly cared for the patient, helped the patient and had testimonials from his patients to prove this, made a few simple omissions in his paperwork. These omissions, if brought out in trial, would be fatal for the case and cost the doctor significantly more than settling.
First, a little background; I took on this case as expert for the defense, although I had precious little time to devote to it, understanding that it would take me countless hours to dissect every chart and there were over 70 cases. I did so to learn the insurance company’s tactics by seeing their internal paperwork through subpoenas on the case.
What I saw at first appalled me due to the blatant lies of the carrier’s expert, but then intrigued me by the leverage those lies gained in court. Those falsehoods were perpetrated by a credentialed chiropractor, who in turn gained the carrier's lawyers more latitude in court by getting the judge to allow them to look deeper and create a story that sounded plausible, but wasn’t true. In the legal world, perception is critical in prevailing in the absence of hard facts on either side. Every case has circumstances that are swayed by perception and no hard facts because no one goes through life documenting every facet of their life; it’s not what we do, nor should it be.
The carrier’s expert claimed to have reviewed every note on every case the doctor had treated for that carrier over a 5-year period and concluded that not one service was deemed necessary based upon accepted chiropractic standards. NOT ONE in over 70 cases. Here is the tough part; this doctor was very diligent and correctly evaluated his patients every 30-45 days, recommending care based upon his findings. The doctor utilized computer-generated SOAP notes and had a SOAP for every visit.
The doctor had also voluntarily hired a compliance company 2-3 years prior to this and got a clean report, indicating he was in compliance. The carrier attempted to render complaints against the doctor through the state licensure board in order to discredit the doctor’s work. The board, on 2 separate occasions, cleared the doctor as being compliant based upon his work and the report of the independent auditor he hired. Thus far, everything sounds like this doctor did his homework, dotting his “i’s” and crossing his “t’s.”
Here is where everything went wrong. The doctor treated, on most visits, the full spine and billed accordingly, based upon the actual care rendered. Again, good…but…in the doctor’s evaluation and treatment orders he did not diagnose every area treated on many of the patients. Now…the doctor rendered the care, billed for what he did…and I strongly recommended that he not fight the case and settle. Why? You cannot treat what you do not diagnose and you cannot bill for what you do not create a treatment order for.
The second issue is that he took x-rays on most of his patients and again, rendered no treatment orders in writing for those x-rays. Did he take the x-rays? Yes. Did the patient need the x-rays? Yes. Were there orders for them?. NO!
I had the doctor’s lawyer speak to a healthcare lawyer that I work with who has defended these cases for over 5000 doctors over the course of his career and today still defends these types of cases on a daily basis. The recommendation: Settle for what you can or face potential criminal charges for insurance fraud. In addition, the carrier was seeking RICO charges that carry treble damages.
The doctor settled the case for ONLY $125,000 and forfeited his current accounts receivable with the carrier. This is a solo practitioner with a very modest practice. This does not include the $100,000 in legal bills. He got away cheap. If he fought, it would have cost him over $700,000.
Why did he get away so cheap? His notes were actually very good, he had an independent audit that put the state board’s ruling on his side and the credentials of his expert, me, who claimed that the carrier’s expert was grossly inaccurate, all of which were strong support for him. As a result, the carrier chose to take their lumps with only a small amount of money and walk. This is a small amount of money for the carriers. This consult will be the focus of a future article in a national publication in the fall, but I wanted you to get the information first.
This is why I have been haranguing you to fax me your records to 661-843-1062. Your documentation is the key to keeping your hard-earned money. The carriers are coming to an office near you; perhaps it will be your office. They might not come today. Maybe it will be 5 years from now, just like the doctor I defended.
As a note, one doctor recently had a major insurance company come into his office…a very, very, very busy practice with numerous doctors. 2 special investigators spent an entire day with portable scanners and copied every page of every file for that carrier. They are looking because this would be a big money maker if he wasn’t prepared.
Remember the 6 P’s. Proper Planning Prevents Piss Poor Performance.