Guest guest Posted October 11, 2011 Report Share Posted October 11, 2011 You need an attorney…… Bob W. Pfeiffer, D.C., D.A.B.C.O.Lee Pfeiffer, R.N., B.S.46 N.E. Mt. Hebron Dr. (no USPS mail)P.O. Box 606 Pendleton, OR 97801drbob@...leernbs@...541-276-2550 All people smile in the same language From: [mailto: ] On Behalf Of drjohansen@...Sent: Tuesday, October 11, 2011 5:08 PM Subject: PIP IME-apportionment? Just got a letter from Safeco that lends a new twist to the IME scam.Our patient (DOI 12/31/10) was IME'd by Courogen MD orthopedic surgeon on Oct 1,2011. Dr C says since my patient has preexisting fibromyalgia and DJD, therefore only the first 90 days(Jan-March) of tx are covered 100%, then 90 days at 50% (April-June 2011), and after that all her problems were due to preexisting...they are denying all bills after 7/1/11-based on a 10/1 exam! they expect to be reimbursed at settlement for all bills paid after 7/1/11and 50% April-June. We provided regular reexam and outcome assessments.Doubt if Dr Couragen read them however. Patient received the IME report and was told she could share the report with us if she wished.Comments? R Johansen D.C. PC,DABCOChiropractic Life Center12762 SE Stark StreetPortland Oregon 97233Voice 5032557746,Fax 5032550818____________________________________________________________Penny Stock Jumping 3000%Sign up to the #1 voted penny stock newsletter for free today!AwesomePennyStocks.com Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 12, 2011 Report Share Posted October 12, 2011 Comments? A bunch of junk. This is absolutely insane. The IME system needs a change. ph Medlin D.C. From: drjohansen@... Sent: Tuesday, October 11, 2011 5:08 PM Subject: PIP IME-apportionment? Just got a letter from Safeco that lends a new twist to the IME scam. Our patient (DOI 12/31/10) was IME'd by Courogen MD orthopedic surgeon on Oct 1,2011. Dr C says since my patient has preexisting fibromyalgia and DJD, therefore only the first 90 days(Jan-March) of tx are covered 100%, then 90 days at 50% (April-June 2011), and after that all her problems were due to preexisting...they are denying all bills after 7/1/11-based on a 10/1 exam! they expect to be reimbursed at settlement for all bills paid after 7/1/11and 50% April-June. We provided regular reexam and outcome assessments.Doubt if Dr Couragen read them however. Patient received the IME report and was told she could share the report with us if she wished. Comments? R Johansen D.C. PC,DABCOChiropractic Life Center12762 SE Stark StreetPortland Oregon 97233Voice 5032557746,Fax 5032550818____________________________________________________________Penny Stock Jumping 3000%Sign up to the #1 voted penny stock newsletter for free today!AwesomePennyStocks.com Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 12, 2011 Report Share Posted October 12, 2011 I would recommend referring to the reality that the preexisting fibromyalgia and DJD are in fact complicating risk factors that lower the consumer’s threshold for injury and will prolong their response to curative care and as such places their current condition in a Cat. III or IV condition as per the OPUG OBCE guidelines with a Cat. III possibly taking up to six months of conservative care to bring them back (if even possible) to their pre-injury status and a Cat. IV up to 12 months…. Vern Saboe DC FACO From: [mailto: ] On Behalf Of ph MedlinSent: Wednesday, October 12, 2011 8:34 AM ; drjohansen@...Subject: Re: PIP IME-apportionment? Comments? A bunch of junk. This is absolutely insane. The IME system needs a change. ph Medlin D.C. From: drjohansen@... Sent: Tuesday, October 11, 2011 5:08 PM Subject: PIP IME-apportionment? Just got a letter from Safeco that lends a new twist to the IME scam.Our patient (DOI 12/31/10) was IME'd by Courogen MD orthopedic surgeon on Oct 1,2011. Dr C says since my patient has preexisting fibromyalgia and DJD, therefore only the first 90 days(Jan-March) of tx are covered 100%, then 90 days at 50% (April-June 2011), and after that all her problems were due to preexisting...they are denying all bills after 7/1/11-based on a 10/1 exam! they expect to be reimbursed at settlement for all bills paid after 7/1/11and 50% April-June. We provided regular reexam and outcome assessments.Doubt if Dr Couragen read them however. Patient received the IME report and was told she could share the report with us if she wished.Comments? R Johansen D.C. PC,DABCOChiropractic Life Center12762 SE Stark StreetPortland Oregon 97233Voice 5032557746,Fax 5032550818____________________________________________________________Penny Stock Jumping 3000%Sign up to the #1 voted penny stock newsletter for free today!AwesomePennyStocks.com Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 12, 2011 Report Share Posted October 12, 2011 Ron, Sounds like she had a preexisting condition. Were you treating her for that problem prior to the MVA? If so, her status just prior to the MVA and the frequency and extent of treatment provided to her before the accident would be determinants in the apportionment calculations. If she had on ongoing problem up to the time of the MVA, I think the ortho’s apportionment scheme is liberal. Have you ever apportioned your treatment between 2 or more contributing conditions? There is a good apportionment protocol in the UWS protocols and pathways which is available through the UWS website, www.uws.edu. J. Burke, DC, DABCO Associate Professor University of Western States Gresham Integrated Care 1304 NW Civic Drive Gresham, Oregon 97030 503-512-1040 Email: mburke@... “The greatest obstacle to discovery is not ignorance - it is the illusion of knowledge.” - Boorstin Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 13, 2011 Report Share Posted October 13, 2011 In response to Vern, fibromyalgia and DJD could be factors that complicate recovery from accident related injuries, but the issue Ron brought up concerns apportionment, which no one seems to have considered. IF the patient had preexisting conditions AND IF she was receiving treatment for them prior to the MVA, then to what extent is the treatment subsequent to the MVA made necessary by that accident, and to what extent would the patient have received treatment anyway had she not been injured in the accident? That is the question that must be answered. The orthopedic surgeon who examined the patient gave a reasonable and, as I said, liberal opinion about apportionment. Regarding Dr. Medlin’s statement that “the IME system needs a change,” well, in fact, there is no “IME system” when it comes to personal injury claims. There is a well-defined IME system in workers’ compensation. In PIP, the right of the patient’s auto insurance carrier to send the patient for an IME is defined in the patient’s auto insurance policy. In other words, it is a contractual obligation between the patient and his/her insurer. It’s a trade off. On the one hand, the insured can seek treatment for covered conditions from any licensed healthcare provider. On the other hand, the insurance company can send the insured to a doctor of their choice for a medical evaluation. Another aspect of IMEs in auto accidents is defined by tort laws. For example, if you have a patient who was injured and is suing the party who caused the accident, that party’s insurer ( the “bodily inury” or BI carrier) will defend that person in the suit brought by your patient. Your patient may be required to submit to an IME requested by the BI insurer before the case can go forward to arbitration or trial. (Sometimes the BI insurer will get a medical record review in lieu of the IME.) So, in summary, PIP IMEs are governed by contracts between insurance companies and insureds. BI IMEs are governed by tort law. What part of the “system” would you like to change, Dr. Medlin, and how do you propose doing so? J. Burke, DC, DABCO Associate Professor University of Western States Gresham Integrated Care 1304 NW Civic Drive Gresham, Oregon 97030 503-512-1040 Email: mburke@... “The greatest obstacle to discovery is not ignorance - it is the illusion of knowledge.” - Boorstin The opinions expressed in this email message are those of the sender. They are not endorsed by nor necessarily represent the University of Western States. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 13, 2011 Report Share Posted October 13, 2011 All, I talked to our patient recently(majority of tx was provided by my associate so I wasn't familiar with the history) and there was PT for a preexisting condition concluding two weeks before the DOI. I can see the Ortho's reasoning for the apportionment,and although I don't like the outcome of the IME,can understand the logic. Looks likely the case will head to PIP arbitration, where evidence will be judged by a panel of lawyers... R Johansen D.C. PC,DABCOChiropractic Life Center12762 SE Stark StreetPortland Oregon 97233Voice 5032557746,Fax 5032550818----- Re: PIP IME-apportionment?Date: Thu, 13 Oct 2011 15:40:45 +0000 In response to Vern, fibromyalgia and DJD could be factors that complicate recovery from accident related injuries, but the issue Ron brought up concerns apportionment, which no one seems to have considered. IF the patient had preexisting conditions AND IF she was receiving treatment for them prior to the MVA, then to what extent is the treatment subsequent to the MVA made necessary by that accident, and to what extent would the patient have received treatment anyway had she not been injured in the accident? That is the question that must be answered. The orthopedic surgeon who examined the patient gave a reasonable and, as I said, liberal opinion about apportionment. Regarding Dr. Medlin’s statement that “the IME system needs a change,” well, in fact, there is no “IME system” when it comes to personal injury claims. There is a well-defined IME system in workers’ compensation. In PIP, the right of the patient’s auto insurance carrier to send the patient for an IME is defined in the patient’s auto insurance policy. In other words, it is a contractual obligation between the patient and his/her insurer. It’s a trade off. On the one hand, the insured can seek treatment for covered conditions from any licensed healthcare provider. On the other hand, the insurance company can send the insured to a doctor of their choice for a medical evaluation. Another aspect of IMEs in auto accidents is defined by tort laws. For example, if you have a patient who was injured and is suing the party who caused the accident, that party’s insurer ( the “bodily inury” or BI carrier) will defend that person in the suit brought by your patient. Your patient may be required to submit to an IME requested by the BI insurer before the case can go forward to arbitration or trial. (Sometimes the BI insurer will get a medical record review in lieu of the IME.) So, in summary, PIP IMEs are governed by contracts between insurance companies and insureds. BI IMEs are governed by tort law. What part of the “system” would you like to change, Dr. Medlin, and how do you propose doing so? J. Burke, DC, DABCO Associate Professor University of Western States Gresham Integrated Care 1304 NW Civic Drive Gresham, Oregon 97030 503-512-1040 Email: mburke@... “The greatest obstacle to discovery is not ignorance - it is the illusion of knowledge.” - Boorstin The opinions expressed in this email message are those of the sender. They are not endorsed by nor necessarily represent the University of Western States. ____________________________________________________________57-Year-Old Mom Looks 25Mom Reveals $5 Wrinkle Trick That Has Angered Doctors!ConsumerLifestyles.org Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 13, 2011 Report Share Posted October 13, 2011 First off let me say that we see a lot of Work Comp and PIP. The % of PIP IME’s to WC requests far exceeds WC in our office. By the way, we don’t get IME requests that often frankly. Your support for the IME system--because aside from you explaining the law there is indeed a system to it--is a bit curious. Those of us who’s practices see a lot of PIP certainly see some absolute atrocities in the process (system) in which these IME’s are not only performed, but requested. Undoubtedly there are at times an IME that is requested that is reasonable, but more often than not the request and the result of the exam and report leave the patient and the managing doctor dumbfounded. I would personally eliminate parts of the exam that are completely arbitrary: An IME doctor looking at a case 6 months into treatment (a doctor who mind you has never laid eyes on the patient in the beginning nor many times has read the treating doctors reports) who decides “ahhh, yea, this patient has reached MMI at hmm, 2 months ago...everything else is due to pre-existing conditions or what have you.†If they wish to stop any tx following that examination, that may be justified fine, but to go back and say a patient was MMI weeks or months before the IME exam took place is absolute NONSENSE. I think there should also be clearer definitions as to when and why an IME should be ordered. Again the system is very arbitrary in this regard and there is no predicting it. A patient progressing well with great documentation and attending all appointments gets an IME 6 weeks into treatment, a patient exhibiting the opposite in attending appointments and progress etc. sometimes to our amazement never IME’d. I would also like the examinations to exhibit a more fair result. What I mean by that is that the OVERWHELMING result of an IME exam is the discontinuation of care. Some parity in the system would be nice. In addition, we have noticed that the likelihood of an IME exam is highly correlated to the specific adjuster running the case. Again, this goes back to having clear definitions as to when and why the order is made. How on earth can this be a fair process when you have a Rouge Adjuster with an itchy finger. We have one we deal with who is extremely rude. We have had it out with her. Unfortunately she’s been an adjuster on a few cases in the past year. ALL WERE IME’D.. and we keep great records, updates etc.. Finally, I’d like there to be an actual feasible rebuttal or response. In other words, there should be some recourse or second opinion. Currently when the ax of the IME falls, its over. Ridiculous. If it wasn’t so early , and I wasn’t between patients I could undoubtedly think of more and be able to provide a way in which to accomplish some fairness. ph Medlin D.C. From: Burke Sent: Thursday, October 13, 2011 8:40 AM mailto: Subject: Re: PIP IME-apportionment? In response to Vern, fibromyalgia and DJD could be factors that complicate recovery from accident related injuries, but the issue Ron brought up concerns apportionment, which no one seems to have considered. IF the patient had preexisting conditions AND IF she was receiving treatment for them prior to the MVA, then to what extent is the treatment subsequent to the MVA made necessary by that accident, and to what extent would the patient have received treatment anyway had she not been injured in the accident? That is the question that must be answered. The orthopedic surgeon who examined the patient gave a reasonable and, as I said, liberal opinion about apportionment. Regarding Dr. Medlin’s statement that “the IME system needs a change,†well, in fact, there is no “IME system†when it comes to personal injury claims. There is a well-defined IME system in workers’ compensation. In PIP, the right of the patient’s auto insurance carrier to send the patient for an IME is defined in the patient’s auto insurance policy. In other words, it is a contractual obligation between the patient and his/her insurer. It’s a trade off. On the one hand, the insured can seek treatment for covered conditions from any licensed healthcare provider. On the other hand, the insurance company can send the insured to a doctor of their choice for a medical evaluation. Another aspect of IMEs in auto accidents is defined by tort laws. For example, if you have a patient who was injured and is suing the party who caused the accident, that party’s insurer ( the “bodily inury†or BI carrier) will defend that person in the suit brought by your patient. Your patient may be required to submit to an IME requested by the BI insurer before the case can go forward to arbitration or trial. (Sometimes the BI insurer will get a medical record review in lieu of the IME.) So, in summary, PIP IMEs are governed by contracts between insurance companies and insureds. BI IMEs are governed by tort law. What part of the “system†would you like to change, Dr. Medlin, and how do you propose doing so? J. Burke, DC, DABCO Associate Professor University of Western States Gresham Integrated Care 1304 NW Civic Drive Gresham, Oregon 97030 503-512-1040 Email: mburke@... “The greatest obstacle to discovery is not ignorance - it is the illusion of knowledge.†- Boorstin The opinions expressed in this email message are those of the sender. They are not endorsed by nor necessarily represent the University of Western States. Quote Link to comment Share on other sites More sharing options...
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