The good, the bad and the ugly of personal injury documents when dealing with patients, coding, and various documentation
By adopting the best documentation practices, you can establish yourself as the go-to chiropractor for treating personal injury (PI) patients and limit your struggles with lien patients and their attorneys when dealing with personal injury documents.
Let’s dive into a few of the good, as well as the bad and the ugly, of documentation in PI. Of course, before implementing any of my opinions here, make sure to first check with your local health care attorney and other professionals and specialists for advice.
Do: Tie together notes, treatment and diagnostic codes
Attorneys, adjusters, judges and juries understand stories better than they understand numbers and medical jargon. This is why your own documentation can either help or hurt a trial attorney’s case. If you tell a great story in your notes, attorneys can use this to get bigger settlement results.
Your notes and personal injury documents should paint the picture of the patient’s “life before” compared to “life after” the PI incident, which is shared to you by the patient during your medical evaluations and treatment, and by the patient’s reaction to your treatment protocol. Traditionally, the story includes struggles with normal activities such as eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet.
To help the attorney tell a great story through your notes, document the answers to questions such as:
- To what extent have your injuries made you rely on the help of others as compared to before the accident?
- What emotional or mental health changes have you experienced with your work, regular daily activities or hobbies?
- How have your injuries changed your energy, fatigue or stress levels, or your interest in maintaining your usual activities?
- How have the injuries changed your normal family and other important social relationships?
- To what extent have you experienced increased fear, anger, frustration, irritation, isolation or sadness?
- What changes in appetite, sleeping patterns or sexual activity have occurred?
Consider, for instance, one doctor, who noted that the patient’s husband had to dress his wife, put on her makeup and take off her makeup because she could not raise her arms. The attorney was able to use her embarrassment, as well as the removal of her joy of caring for her appearance, as evidence that the injury eroded the patient’s self-worth. This story is worth more than simply noting that the patient cannot raise her arms.
That said, be sure the treatment, and the codes for the treatment, are a match to the notes. Be aware that when coded optimally, some codes, such as those reserved for traumas, can elevate a personal injury case to an adjuster. Other codes, such as sprains and strains, can hurt the case valuation, given how adjusters use software intentionally designed to attack coding methods.
Be sure, too, that you never upcode. Some chiropractors reserve certain codes for PI patients, assuming that the case will settle and the provider’s bill will be reduced. When you apply different codes to two people with the same injury yet assign only the PI cases with the additional codes (and higher treatment costs), you put the entire case in jeopardy, along with your license. After all, adjusters and savvy defense attorneys will dive into your coding and payment histories and eat your bills for dinner any chance they get.
Do: Have a strong lien or letter of protection among your personal injury documents
The cornerstone of a great PI practice is a rock-solid lien agreement or letter of protection (LOP). The best lien agreements/LOPs should:
- Be signed not only by the patient, but also by all attorneys on the case. By signing a contractual lien agreement or LOP, the attorney can be imputed with a fiduciary duty to protect your financial interest in most states.
- State that the patient owes the full charges regardless of the case outcome. Whereas a PI attorney is paid on a contingency fee basis, your pay is not contingent upon the case’s outcome. The lien/LOP should say as much.
- Specify that you have priority claim to any MedPay or PIP issued specifically on your bill, and that the payment will be turned over to you immediately, and in full, without attorney’s fees being deducted. MedPay and PIP are coverages issued by auto policies, paid out regardless of who is at fault, so they do not require any significant involvement, if any, of an attorney.
- Note that if a reduction is being requested, the attorney agrees to provide in writing the full intended disbursement listing of all settlement proceeds from all sources. You need full transparency to decide if and how much to reduce the bill.
Do: Send GFEs and interim bills throughout treatment
Per the No Surprises Act, you are required by law to provide good-faith estimates (GFEs) in advance of care to uninsured and self-pay patients so they aren’t later “surprised” by your bill and can seek alternatives if they dislike your pricing. Comply with this law, even if you think it does not apply to your patient. The law is in flux, and attorneys will use noncompliance as an opportunity to reduce your bills.
Provide your patient with a GFE at the beginning of care, and interim bills throughout treatment to both the attorney and the patient. This way, if an attorney makes a post-settlement complaint about your bills, you can argue that the attorney and patient were given multiple opportunities to communicate with you prior to settlement. The attorney’s failure to do so is evidence that there is no actual or viable issue.
Don’t: Diagram accidents
If you (or your patient) attempt to diagram accidents, you can create liability issues.
Neither of you is an accident reconstructionist. What the patient described to the insurer likely doesn’t match exactly what you or your patient diagram. You also run the danger of appearing biased when your best value is as a neutral observer.
Don’t: Allow patients to list pain scales and circle pain areas without your presence
Too many practices ask patients to complete forms in the lobby without providing any instruction or real understanding. The patient might then indicate that everything hurts at a 10 on the pain scale. Other patients miss key areas or underrate their pain because they want to seem tough.
In either case, this is a disaster for your patient’s claim or lawsuit.
Have your patients fill out key forms in your presence. You can take notes for the storytelling documentation and explain the difference between a 5 and a 10.
Accuracy is key in PI. After all, your personal injury documents will be reviewed by attorneys, adjusters, judges, juries and even your own patient. Be mindful of what you say, how you record it and how everything is tied together: your diagnosis, codes, notes, plan and actual treatment.
Don’t: Fail to support your fees as reasonable
Nothing will come under more scrutiny in PI than the reasonableness of your fees and charges. Unfortunately, your fees will likely be attacked even when they are reasonable, purely as a tactic.
You can nip this in the bud by establishing the propriety of your treatment and the reasonableness of your fees from the outset. The more you can support your fees, the more likely you are able to: 1) help the attorney defend your fees to the insurance adjuster; and 2) take the wind out of an attorney who tries to later argue that your bills aren’t reasonable.
The best resources for establishing that your fees are reasonable include databases of industry coding, billing and reimbursements; billing services; organizations; and experts who conduct their own provider surveys or compile fee information based on the billing services they provide. A number of services can help you. For example, there are a number of aggregators like FAIR Health Consumer (fairhealthconsumer.org) and Context Health (context4healthcare.com) that allow you to compare actual pricing with the average pricing data these services and others have compiled by specialty, zip code and treatment code.
Another method is simply assembling past examples of full payment of your full bills, being sure to redact identifying information.
The best practices include:
- Giving a fee comparison to your patient during the first meeting.
- Sending a fee comparison to the attorney. A good attorney can, in turn, use the fee comparison and any other bill support with the insurance adjuster, who is always looking to reduce your bill entitlement. By supplying this supportive documentation, you become a hero to the attorney and your patient.
- Updating your fee support electronic file as you constantly gather full-pay examples as well as anything else that supports your charges for use or reference as you need.
Embrace the good and avoid the bad and the ugly in personal injury by adopting best documentation practices.
MICHAEL COATES is a national authority on personal injury medical lien recovery and the founder of PIMadeEasy.com, which educates, coaches and trains medical providers and their staff to accelerate their success in personal injury. If you have questions, please reach out to Michael and his community thorough his free Facebook group, PI Made Easy Insiders, at Facebook.com/groups/pimadeeasy.
