Ask the Docs
How to Spot a Personal Injury Predator
By Dr. Jonathan Chung of Keystone Chiropractic
- The famously dirty personal injury industry
- When profit leads to failed patient care
- How to spot predatory practices
Personal injury (PI) is a famously dirty industry. When people think about PI, you usually think about ambulance chasing attorneys taking up local billboards, radio, and television commercials. In a state like Florida where just the act of a car crash can make you eligible for $2500 of personal injury protection at minimum, and many eligible for $10,000 of coverage from their insurance company, it has opened the door for many avenues of scams and unscrupulous activity.
Common fraud activity includes people paid to stage accidents, forced referrals from tow truck companies, enticing victims with cash payments to go to certain clinics, and more.
Attorneys get a bad rap (some of them deserve it), but when it comes to your health after an accident it may be the doctor you choose that could be the biggest threat to your health and your money.
When Profit Leads to Failed Patient Care
While attorneys get most of the blame for a corrupt delivery system, unethical practices by healthcare providers have contributed to the problem.
There is an unspoken trust between medical providers and the public to always practice with the best interests of the patient in mind. While doctors will try their best to insulate themselves from getting too involved with the business side of medicine, the personal injury business has made it difficult to practice strictly based on clinical findings.
Health providers face pressure from patients and attorneys to help build a case for larger settlements. New doctors have large student debts to pay on top of trying to support their families. No one is trying to harm the patient, but it’s easy to see how money can muddy the waters of patient care.
So many patients are subjected to unnecessary imaging and procedures because of pressure from attorneys and patients to pad the medical bills and build a case for lawsuit. MRI’s are so widely prescribed for personal injury cases because the findings can show greater injury despite the fact that the correlation between imaging findings and pain are surprisingly weak.
In some cases, offices and facilities have become places that exclusively see injured patients for the sake of billing thousands of dollars from insurance with little regard for appropriate management. Their only goal is to increase their billing as high as possible until the injury benefits are exhausted, and the patient is released from care regardless of whether they received the care they need.
This not only robs patients of benefits that may provide them with appropriate care from other providers, but it also causes take money out of the pocket of consumers as insurance premiums rise to pay for these unethical practices.
So what’s a person supposed to do? Here are some thoughts:
- Ask About the Expected Services and Fees Involved: When patients have the expectation that insurance will be paying for their services, they rarely ask about what services will be performed and the cost of these services.This might be okay if you have private insurance, but in capped payment systems like personal injury protection, doctors may be prescribing the same tests and procedures for all patients to get the bill to rise as fast as possible.Transparency in costs helps to control spending. If you knew that your x-rays were going to cost $500 of your own money, you’re a lot less likely to get it done unless you felt like it was necessary.If a doctor or staff is elusive about their fees and services saying things like “Oh don’t worry about that, your insurance will cover it.” Then press them on it. You will eventually get the explanation for their billing, and see if what they say and do actually matches up.Treat your insurance dollars like they are your own dollars, because when benefits start to run out and you’re not better, you may ultimately end up paying yourself.
- Check Your EOB’s and Your Statements: Insurance companies will send you an explanation of benefits to show patients what was billed for and what they paid for those services.In shady practices, you may see billing for services you’ve never received before. Patients who have never had an ultrasound machine touch them will see ultrasound in their billing. Patients who do a few arm circles may see a bill showing that 30 minutes of exercise is on the bill.This is a crime, and it’s called fraudulent billing, or just fraud for short. In the most extreme cases, you may see dates of service billed for days you know that you were never in the office.
- Are You Getting the Same 3 things Done over and over with no results?: Doctors who care about their clinical outcomes will design treatment plans based on your specific injury and how well you are responding to care.A sign that you are in an injury mill type practice is if you are being scheduled for the same treatments multiple times per week with no regard for how you are responding to care. This usually looks like getting electric stimulation and ultrasound placed on you by staff, a chiropractor manipulating your spine, and some vague recommendations for exercises. This is done 3-5x per week and the treatment doesn’t change despite the fact that you don’t feel any better, and sometimes continue to feel worse. Good practice is to triage your case based on the severity of your injuries. If you have a severe acute injury, you may need medical management from patches, meds, or injections so that you can feel functional as you go towards physical rehabilitation. Good practice also involves getting you to an appropriate specialist if you are not improving in a timely manner.When offices are not paying attention to whether the patient is getting better from their treatment, then it is a sign that they are trying to max out your benefits as quickly as possible.
- Are you being coerced into seeing certain doctors?: Patients are always in control over what doctor they wish to see. If you have a comfort level with a certain doctor, then you always have the ability to find out if that doctor accepts personal injury claims.Some PIP schemes are set up to funnel patients into specific doctors’ offices for reasons that are not about helping the patient. At times people can be pushed into these offices by attorneys or patient runners saying they have to see a certain doctor for the purposes of the case. Some schemes will even go out and give patients financial compensation to go to specific offices which is outrageously illegal.This is a sign that there is an illegal kickback system involved that is built to just get maximum reimbursement from the PIP system.
Predatory PIP Practices Hurt Us All
So what’s the big deal if a practice is trying to max out your insurance money? After all, if you as a patient aren’t paying the bill then why should you care?
The truth is that these types of practices hurt us all. It hurts attorneys who are trying to build a business ethically in a dirty system that will spend more to get an advantage. It hurts doctors who treat patients for the best clinical outcome who may see insurance reimbursement go down to combat fraud.
Most of all, it hurts us all as people who want to trust attorneys, doctors, and the insurance company. As a doctor, you’ll usually expect me to trash insurance companies for cutting payments, but in terms of PIP many times it’s just a response to fraudulent or unethical billing practices. Insurance companies raise premiums on us all when fraud gets out of hand, and in some cases, it makes it really hard to get insured at a reasonable rate after an accident lawsuit.
I have no sympathy for a multi-billion dollar industry, but I can certainly see why the system is built the way it is when I observe some of the scams that are run by people that are supposed to be the gatekeepers of patient health.
This industry may be too far beyond repair and reform, but maybe it can get a little bit cleaner when patients are informed enough to call it out.