Guest guest Posted June 7, 2003 Report Share Posted June 7, 2003 Hi Lilijoy, Yes this seems to be the trend. I just had an IME review from a neurologist who tore apart me, my chartnotes and my patient. He BS'd on about how " you can only palpate the piriforims rectally " and more blah, blah, blah,...needless to say we went to court and we won. The attorney kick the S*** out of the IME. Don't let the IME's get you down. If you do your job well, and your patient's attorney does his/her job well, then you should have no problem. As far as your job is concerned, I would be as well informed on MVAs as possible. There are some things that have been working quite well for me. 1) Go to DeShaw's seminar on MVA stuff. It's worth it!!!! 2) Get Arthur Croft's book " Whiplash Injuries " it has all the science including the accepted guidelines for treatment/diagnosis. 3) Get the book " Medical Proof of Whiplash " it is a big binder that costs about $80.00. It gives all the science you could ever need including all the abstracts and references great for preparing/going to court/deposition. It also comes with a CD Rom that contains all the text AND a power point presentation AND graphics for you to use in court/narrative writing. It also has yearly updates for purchase. I have been dilligently studying this stuff, because I'm tired of insurance companies, IME's, other " experts " , and junk science. The only way to fight back is to know more than them. As far as charting is concerned, I would be happy to share what we do at our clinic if you would like to come visit. We are on NW (very close to you, I think). The last thing I would mention is talk to Drs. Freeman, DeShaw, Steve DeShaw, Dan , and Don Ferrante. They have helped me more than I ever could say... Sincerely, Terreri, DC yucky IME's > > I just received a letter from an insurance company with a copy of the > results on my patient's IME. > The physician concluded that the patient's motor vehicle accident > injuries should have been " resolved " > by the time the patient had sought out treatment at my office (2 months > after the accident.) > > This is the second time this spring that a patient who has been under > my care for less > that six-eight months has had a completely meaningless IME. I can > count on one hand the amount of IME's I've had over the past 8 years. > > I d not over treat or put patients on top heavy treatment plans. If > anything I under treat and always use another expert if there is any > question > about diagnosis or prognosis. > > In both cases the patients were African American. I do not know if > the adjustors are trying to find people who perhaps might not > readily fight back. > > > In both cases the patients were referred to me by attorneys. > > I feel like the insurance companies are out for a blood sport right now. > > Is there any thoughts or helpful advice re charting, etc which would > help? > > Thanks, > > Lilijoy Rothstein,D.C. > 2525 NW Lovejoy SUite 404 > Portland, Oregon 97210. > (503)294-1235 > > > > OregonDCs rules: > 1. Keep correspondence professional; the purpose of the listserve is to foster communication and collegiality. No personal attacks on listserve members will be tolerated. > 2. Always sign your e-mails with your first and last name. > 3. The listserve is not secure; your e-mail could end up anywhere. However, it is against the rules of the listserve to copy, print, forward, or otherwise distribute correspondence written by another member without his or her consent, unless all personal identifiers have been removed. > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 7, 2003 Report Share Posted June 7, 2003 I also forgot to mention Dr. Pfieffer's work. His seminar covers ALL aspects of charting MVAs and he shows a ton of exam stuff, including techniques. He has an amazing chart note system that is beyond comprehensive. You can use some or all of it. We are still sorting through his stuff. I just wanted to make sure I didn't leave him out - his stuff is great also!!! Matt Terreri, DC yucky IME's > > I just received a letter from an insurance company with a copy of the > results on my patient's IME. > The physician concluded that the patient's motor vehicle accident > injuries should have been " resolved " > by the time the patient had sought out treatment at my office (2 months > after the accident.) > > This is the second time this spring that a patient who has been under > my care for less > that six-eight months has had a completely meaningless IME. I can > count on one hand the amount of IME's I've had over the past 8 years. > > I d not over treat or put patients on top heavy treatment plans. If > anything I under treat and always use another expert if there is any > question > about diagnosis or prognosis. > > In both cases the patients were African American. I do not know if > the adjustors are trying to find people who perhaps might not > readily fight back. > > > In both cases the patients were referred to me by attorneys. > > I feel like the insurance companies are out for a blood sport right now. > > Is there any thoughts or helpful advice re charting, etc which would > help? > > Thanks, > > Lilijoy Rothstein,D.C. > 2525 NW Lovejoy SUite 404 > Portland, Oregon 97210. > (503)294-1235 > > > > OregonDCs rules: > 1. Keep correspondence professional; the purpose of the listserve is to foster communication and collegiality. No personal attacks on listserve members will be tolerated. > 2. Always sign your e-mails with your first and last name. > 3. The listserve is not secure; your e-mail could end up anywhere. However, it is against the rules of the listserve to copy, print, forward, or otherwise distribute correspondence written by another member without his or her consent, unless all personal identifiers have been removed. > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 8, 2003 Report Share Posted June 8, 2003 Hi Lilijoy, There is no question that insurers are attempting to save money by paying less on claims (rather than making it in investments). This strategy has prompted a variety of tactics, including paying out exorbitant fees to providers who will say what they are paid to say. There is nothing "independent" about an IME in the setting you describe; you can call them a CME (compulsory medical exam) or DME (defense medical exam). There are many jurisdictions that do not allow the use of the term "independent" to describe these exams. I just gave a lecture at the American Psychiatric Association annual meeting two weeks ago on this topic (see the article below). The proclamations by your DME provider are epidemiologic in nature, and have nothing to do with a clinical examination. There is no data that allows a practitioner to examine a patient, ignore the findings of the examination, and determine that they "should not have been hurt, and therefore weren't." Statistically, people shouldn't die in plane crashes, yet it would be ludicrous for a pathologist to claim that a decedent isn't dead because he or she had a low risk of dying in a plane crash. This is precisely what your DME has done, however, and this knowledge allows you to illustrate to a judge or a jury just how idiotic such a claim really is. The claim has nothing to do with your patient, and is theoretically derived from the general population. They are, in fact, speculation about the epidemiology of crash related injuries. A sharp attorney can keep such claims from a jury with a Daubert evidentiary hearing, since this would require the DME to show that his or her scientific (not clinical) opinions have been subjected to peer review, have a known rate of error, and are generally accepted in the relevant discipline (which is actually trauma epidemiology, a field the provider is not trained in). The opinions would never pass muster under such criteria. If the judge lets them in, then a good attorney can have a field day on cross examination, making the provider look like a horse's patoot. D Freeman Mailing address: 1230 Liberty Street NESalem, Oregon 97303ph 503 586-0127cell 503 871-0715 Defense or Compulsory Medical Exams; Some Considerations By Freeman PhD, DC, MPH The potential for fraud in healthcare by healthcare providers is readily recognized in all aspects of society. The high fees charged by doctors for their services regardless of outcome is frequently the source of humor, derision, and anger. The reason for this potential for fraud is what is known in the business of healthcare finance as the "agent relationship;" the individual who profits from the sale of the service is also the arbiter of necessity of the service. The patient is informed that they need a lumbar fusion, hysterectomy, root canal, or 35 chiropractic adjustments by the neurosurgeon, gynecologist, endodontist, or chiropractor, respectively. For this reason, the doctor-patient relationship amounts to a leap of faith on the part of the patient that they are being sold services that are truly necessary for their condition. This leads to a fiduciary as well as ethical obligation on the part of the healthcare provider to the patient; the doctor is obliged to provide services that are appropriate for the patient's condition in both quality and quantity. This responsibility is enforced by peer review groups and licensing boards, which curbs potential abuse. How then, does the independent medical examiner fit into the scheme of appropriate and necessary healthcare? Their purpose is to review the propriety of a specific treatment for a particular condition of an individual patient, usually for the third party providing reimbursement (usually an insurer), who in turn has a fiduciary responsibility to the patient to pay for treatment that is considered reasonable and necessary. The agent relationship for the provider of the IME is entirely different than for the healthcare provider. The IME provider has no ethical or fiduciary responsibility to the patient, and has only to answer to the insurer who has requested the IME. The reimbursement rate for the IME is usually set in advance, so that there is no opportunity for the IME provider to enhance recovery from an individual IME. Future work for the IME provider, however, is more likely if the insurer client is satisfied with the results of the IME. Satisfaction for the insurer with the results of the IME is more likely if it is a cost effective alternative to reimbursing for treatment without question. Therefore, there is a financial incentive for the IME provider to determine that the treatment in question is unrelated to a condition for which the insurer is responsible. Thus the agent relationship for the IME provider to the insurer requires a leap of faith on the insurer's part that the report of the IME is an accurate characterization of the needs of the patient and the propriety of the treatment. There is no apparent fiduciary or ethical responsibility on the part of the IME provider to provide an accurate picture of the patient's condition or treatment, other than the personal ethics of the individual IME provider. There are generally no peer review or licensing board disciplinary consequences if the IME provider chooses to serve only their own financial needs in the performance of the IME. Such an arrangement invites abuse. The IME situation that encourages the greatest amount of abuse is the defense medical evaluation. The DME occurs in liability litigation where the defending insurer or attorney representing the insurer is not attempting to determine the necessity of treatment, but rather sets out to prove that either or both the treatment and condition allegedly related to the litigation is not the responsibility of the defending insurer. This situation most frequently arises in motor vehicle crash-related injuries. The DME provider is asked to give the defending attorney evidence that will help with a legal defense of the allegation that the treatment and injuries in question are related to the crash in question. There are no consequences for the DME provider for giving a less than truthful assessment of the situation; one that benefits the defending insurer and the DME provider. This arrangement not only invites abuse, it encourages it. It is important to note that not all DME providers abuse their position, however, it is equally important to note that there is no disincentive for such abuse. The purpose of this discussion is to present the scientific weaknesses inherent in the self-serving DME or IME opinion, one that embraces junk science as its core (I define junk science as the use of scientific terms and formulae applied inappropriately for the express purpose of lending credence to an opinion that is clearly lacking in validity). The following are the primary scientific and logical transgressions of such opinions that invalidate them: The use of risk retrospectively Example: "Ms. presents with clear evidence of a herniated disc. The risk of such an injury following the crash in question is minimal, therefore I find it highly unlikely that Ms. sustained any injury beyond a mild muscle strain in the subject crash." Discussion: Risk is a statistically-derived tool that is used prospectively to determine to probable proportion of a population that will experience an outcome. A correct use of risk is as follows: "one out of three people who sustain a whiplash injury and seek treatment will have some degree of residual neck pain 33 months post crash." An incorrect use of risk would be "three people sustained a whiplash injury 33 months prior, therefore at least one but not two of them now have neck pain." Why is this wrong? Why doesn't 10 coin tosses result in heads every other toss? Because of the effects of random variation. Since it is unknown how random variation will affect an individual outcome until after an event, the only valid measure of the outcome is the measure of the outcome, and not the probability of the outcome. In the case of an injury following a crash, the measure of the outcome is the evaluation of the injury by a qualified and competent practitioner. Injury risk is inconsequential, and not to be considered after the fact. The most absurd, yet appropriate example of this particular type of junk science is to use the statistic that risk of death in a plane crash in 1 in 1,000,000, and therefore so unlikely that it could not have occurred in the case in question. The use of an average as a range Example: "The average recovery time for whiplash is 8 weeks, therefore the first 8 weeks of Ms. ' treatment was reasonable and necessary, but all subsequent treatment was not." Discussion: The average of a data set is a measure of the central tendency of that data set. It does not imply the range of the data set in any way. For example, the statement that the weight of an average US citizen is 165 lbs. does not rule out a 100, 250, or 800 lb. person. Likewise, regardless of the average recovery time, it is the range of recovery time that is of importance. As an average is a measure of the middle of the bell curve, using it as a cutoff point only correctly defines about half of the population. As discussed above, random variation dictates that an individual outcome can land anywhere on a distribution curve, from 50th percentile to 99.9th percentile. The actual outcome is determined by real determinants of the patient's condition, such as history and evaluation. The use of an average obviously implies advanced scientific knowledge of the epidemiology of the condition, yet invariably, it is fabricated from the examiner's experience. This is a classic example of junk science. Misuse and misinterpretation of the biomedical literature Example: "It is clearly indicated in the literature that chronic pain following whiplash is non-pathologic, and thus no treatment is indicated for such conditions." Discussion: The literature is frequently cited as a source of information by which the examiner can state that the patient in question does not have an injury associated with a particular crash, however, extrapolating the literature to an individual not specifically described in the literature is flawed on the same bases stated under #2. Thus, even if the above statement was true (it is not) it does not rule out that fact that an individual patient can have a pathologic response to a whiplash injury. The only way to account for random variation is to examine the facts of the case on their own merits. Additionally, most frequently the DME and IME-cited literature is selectively read, ignoring the majority of papers that contradict opinions expressed by the authors of the particular paper. Just as frequently, the papers are mis-read, mis-quoted, or not read at all, and the opinion is unrelated to paper cited. Another popular ruse is to use the expression "the literature shows that..." without giving any specific cites, usually because none exist. Many cites are actually based on abstracts of papers that have not been read in their entirety. Setting a standard of care based on an individual opinion Example: "Such conditions do not typically require care for more than a few weeks" Discussion: The appropriate duration of type of treatment, regardless of guidelines, is a case-by-case determination that is made by practitioners on a daily basis. How long a particular individual will need treatment cannot be determined until the individual has recovered or the treatment ceases to be effective. Average values are not appropriate in determining the outcome of a real event, as discussed under #2. Most particularly, the personal opinion of a reviewing practitioner versus the treating practitioner regarding the quantity or type of treatment required for a particular condition is an open invitation for abuse of the position by the reviewer. As there are no ethical constraints preventing the reviewer from disallowing treatment (it is simply personal clinical opinion), and there are considerable financial incentives for doing so, I do not believe that this is a workable method for determining the reasonableness of treatment. Recommendations: IME and DME examiners should be held to the same ethical standards as practitioners. Peer review and disciplinary action from examining boards should be available to monitor the practices of IME/DME providers. The financial incentive combined with lack of ethical constraints inherent in the IME/DME system must be recognized and freely discussed by licensing boards and other regulatory agencies. The use of junk science methodology by the IME and DME to deny treatment and remuneration for injury, particularly given the lack of ethical constraints on such practices, should be viewed as an act of unprofessional conduct, in precisely the same manner that overcharging and overtreating a patient would be viewed, since both are financially motivated. Reasonableness of treatment remains an important problem for all parties. An unbiased, well trained group of providers who do not provide IME/DME services should be formed by the regulatory boards to provide treatment review. Their work product should be standardized and open to statistical review. -----Original Message-----From: Lilijoy Rothstein [mailto:joyous@...]Sent: Saturday, June 07, 2003 5:30 PM Subject: yucky IME's I just received a letter from an insurance company with a copy of the results on my patient's IME.The physician concluded that the patient's motor vehicle accident injuries should have been "resolved"by the time the patient had sought out treatment at my office (2 months after the accident.) This is the second time this spring that a patient who has been under my care for lessthat six-eight months has had a completely meaningless IME. I can count on one hand the amount of IME's I've had over the past 8 years.I d not over treat or put patients on top heavy treatment plans. If anything I under treat and always use another expert if there is any questionabout diagnosis or prognosis.In both cases the patients were African American. I do not know if the adjustors are trying to find people who perhaps might notreadily fight back.In both cases the patients were referred to me by attorneys.I feel like the insurance companies are out for a blood sport right now.Is there any thoughts or helpful advice re charting, etc which would help?Thanks,Lilijoy Rothstein,D.C.2525 NW Lovejoy SUite 404Portland, Oregon 97210.(503)294-1235OregonDCs rules:1. Keep correspondence professional; the purpose of the listserve is to foster communication and collegiality. No personal attacks on listserve members will be tolerated.2. Always sign your e-mails with your first and last name.3. The listserve is not secure; your e-mail could end up anywhere. However, it is against the rules of the listserve to copy, print, forward, or otherwise distribute correspondence written by another member without his or her consent, unless all personal identifiers have been removed. Quote Link to comment Share on other sites More sharing options...
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