auto accident claims: the influence of colossus on...
TRANSCRIPT
Auto Accident Claims: The Influence
of Colossus on Recoveries Guidance for Counsel on Insurance Adjustment Software to Maximize Settlement Offers
Today’s faculty features:
1pm Eastern | 12pm Central | 11am Mountain | 10am Pacific
The audio portion of the conference may be accessed via the telephone or by using your computer's
speakers. Please refer to the instructions emailed to registrants for additional information. If you
have any questions, please contact Customer Service at 1-800-926-7926 ext. 10.
THURSDAY, NOVEMBER 29, 2012
Presenting a live 90-minute webinar with interactive Q&A
Matthew J. DeGaetano, Certified Colossus Consultant, Personal Injury Institute, Lewisville, Texas
Steven M. Gursten, Attorney, Michigan Auto Law, Farmington Hills, Mich.
Tips for Optimal Quality
Sound Quality
If you are listening via your computer speakers, please note that the quality of
your sound will vary depending on the speed and quality of your internet
connection.
If the sound quality is not satisfactory and you are listening via your computer
speakers, you may listen via the phone: dial 1-866-869-6667 and enter your PIN
when prompted. Otherwise, please send us a chat or e-mail
[email protected] immediately so we can address the problem.
If you dialed in and have any difficulties during the call, press *0 for assistance.
Viewing Quality
To maximize your screen, press the F11 key on your keyboard. To exit full screen,
press the F11 key again.
Continuing Education Credits
For CLE purposes, please let us know how many people are listening at your
location by completing each of the following steps:
• Close the notification box
• In the chat box, type (1) your company name and (2) the number of
attendees at your location
• Click the SEND button beside the box
FOR LIVE EVENT ONLY
Program Materials
If you have not printed the conference materials for this program, please
complete the following steps:
• Click on the + sign next to “Conference Materials” in the middle of the left-
hand column on your screen.
• Click on the tab labeled “Handouts” that appears, and there you will see a
PDF of the slides for today's program.
• Double click on the PDF and a separate page will open.
• Print the slides by clicking on the printer icon.
Computer Software Program used by Insurance Companies
The adjuster enters information about the claim into the program
The program accesses over 10,720 rules or value drivers to evaluate over 750 injuries
The program computes a settlement figure that is consistent with the severity of the patient’s injury
7
Colossus arrives at an
evaluation by assigning
points to value drivers
associated with each
injury.
9
The actual assignment of points
is determined by each individual
insurer.
They become the
baseline data by which all injury
values are arrived at.
10
Each insurer has the
ability
to manipulate this point
assignment and database
any time it wishes.
11
Some of the “value
drivers” have multipliers
as well.
These multipliers
add significant points to
each “value driver”.
13
The mathematical equation
consists of the following
components, which must be
indicated in the medical records
and be specifically stated in the
demand from the attorney
14
What Caused The Cultural Change In the
Insurance Industry?
•The Insurance Industry claim handling
culture went through a major
transformation during the mid 1990’s
adopting the opinions and advice of
McKinsey Consulting.
15
THE MEDICAL COMMUNITY ENVIRONMENT
• This was accomplished by each individual insurer
in conjunction with McKinsey Consulting (Arthur
Anderson or Accenture as it is currently known,
also contributed to some insurers’ transformation)
through the creation and implementation of the
McKinsey “Business Process Improvement” (BPI)
culture. This transformation of claim culture is
evident in the McKinsey documents Allstate has
produced in other cases across the country.
16
Soft Tissue Injuries
• The current industry percentage of these claims which
would involve “soft tissue” injuries varies between 85 and
90 percent. The most common treating facility or
practitioner sought for the treatment of “soft tissue”
injuries is Chiropractic. The current industry percentage
of Chiropractic involvement in these types of claims is as
high as 95%. Most of the injured parties have either
PIP/MPC benefits available to pay for the treatment. A
very significant number of the injured parties also have
either third party claims against an insured negligent
tortfeasor or a first party claim under their UM/UIM
(Uninsured Motorist/Underinsured Motorist) coverages.
17
THE CONTINUUM COMPANY
• At about the same time, an Australia based computer
software company creates Colossus.
• Designed to evaluate claims based on:
- Injuries
- Treatment Specifics
- Symptomology
- Future need for Treatment
- Impairments and Disabilities
18
COMPUTER SCIENCE CORPORATION
• Licensed Colossus from the Australian Firm (Continuum
Company)
• CSC offered it to the insurance industry as a way of
reducing claim payouts
• McKinsey approved the venture and was retained by each
of the insurers to calibrate the values of Colossus.
• Calibration was performed by Arthur Anderson or A.K.A.
as Accenture
19
How Can The Artificial Intelligence
Affect Your Office?
•Colossus & National Insurance Crime
Bureau (NICB)
•They use this system for all doctors
prior accidents, questionable cases,
referrals, tax ID’s, SS#, looking for
patterns
23
Colossus
• The Colossus equation is designed to
establish:
Economic Damages or Special Damages –
Medical Bills & Loss of Income
Non – Economic Damages or General
Damages – Pain & Suffering
What does this mean?
24
UNTIL THE LATE 1980’S
• Most claims were settled for 3-5 times the special damages
For example:
- $5000 in specials settled at $15000
25
Colossus
• Therefore each INJURY MUST BE IDENTIFIED BY A
QUALIFIED DOCTOR
Example: If the patient had a sternum injury at
the ER and it does treating facility does not
recognize or diagnose that injury the claims
representative is barred from imputing that
additional injury.
The result would have an impact on the final
value of the claim.
26
66% savings “The case reserve in 1990 for a soft tissue injury
liability claim was approximately $15,800.00 The
case reserve for the same type of injury in 2001
was $5,800.00. This reduction in the claim
severity was a direct result of the process and
programs such as “MIST”, Minor Impact and “No
Damage / No Injury”. This $10,000.00 savings per
claim has a direct impact on profits realized from
the claims department”.
• This is the amount of dollars set aside by the insurer in anticipating the amount to paid on
this type claim at settlement. The figure is based on a three year historical severity realized
by the insurer.
• Fowler vs. State Farm Mutual Automobile Insurance Company, Hawaii; The United States
District Court For the District of Hawaii; Civil No. CV07 00071 SPK/KSC;
27
66% savings
Considering that State Farm Claim Vice
President (Fowler vs. State Farm) recently stated
in a deposition. State Farm experiences 15,000
claims per day. It might be an eye opening
exercise to have some economist actually
extrapolate the direct and indirect economic
impact on the public over the last fifteen years.
• This is the amount of dollars set aside by the insurer in anticipating the amount to paid on
this type claim at settlement. The figure is based on a three year historical severity realized
by the insurer.
• Fowler vs. State Farm Mutual Automobile Insurance Company, Hawaii; The United States
District Court For the District of Hawaii; Civil No. CV07 00071 SPK/KSC;
28
THE ARTIFICIAL INTELLIGENCE OF
COLOSSUS
• Begins with database profiling
- Chiropractors
- Medical Doctors
- Patients
29
DOCTORS HAVE BEEN DATABASED
• If Colossus devalued most of your cases last year because:
- You look poor notes
- Failed to refer for a second opinion
- Used the wrong terminology
- Used the wrong prognosis
- Did not objectify your findings with diagnostics
- Did not monitor clinical progression with Outcomes Assessments
- Did not use active care procedures • Then…………
30
UNDERSTANDING IS THE KEY
If Attorneys, Medical Doctors, Chiropractors understand
Colossus and work within its framework, then Colossus
can be beat.
We can win the whole pot even though we are holding a
bad hand
31
The Entire Case Is Calculated
From The Treating Physicians
Records And Protocols.
Attorney Demand Packages Are
Obsolete!
32
What Are Our Clinical Tools
•Flexion / Extension Views
•Lateral Flexion Open Mouth
•Digital Motion X-Ray
•Proton Density MRI ( Upper Cervical
Studies )
•AMA Guides For Permanent
Impairment
33
Soft Tissue Injuries and the Attack by
the Insurance Companies
• Most Chiropractors treat Soft Tissue Injuries
• Our office looks at ALL ANATOMICAL STRUCTURES.
“CONNECTIVE TISSUE”
• 95 % of all Soft Tissue cases are treated by Chiropractors
34
All Injuries Must Be Identified
• Contusions all other body parts
• Sprain/Strain all other body parts
• Fracture all other body parts
• Dislocation all other body parts
• Ligament injuries – usually associated with joints
• Laceration all other body parts
• Penetrating wounds all other body parts
• Crush wounds all other body parts
• Amputation all other body parts
• Concussion
• Lastly, dental injuries
35
All Injuries Must Be Identified
• Sprain/Strain cervical, thoracic and/or lumbar
• Subluxation
• Prolapse cervical, thoracic and/or lumbar
• Bulge cervical, thoracic and/or lumbar
• Herniation cervical, thoracic and/or lumbar
• Dislocation cervical, thoracic and/or lumbar
• Fracture cervical, thoracic and/or lumbar
• Superficial Injuries all other body parts
36
Do You Know The Four IV Phases Of
Whiplash?
The s-shaped curve, with hyperextension
of the lower segments and flexion of the
upper segments. This is one of the chief
points of injury and occurs before the
head strikes the head restraint. Adapted
from Ono et al.
37
UNDERSTANDING THE
EQUATION
• No human intuitive abilities
• Depends on the input of the claim handler alone
• Garbage In – Garbage Out
39
IN THE ABSENSE OF COMMUNICATION,
THE PATIENT IS THE VICTIM
• We need to speak the language of Colossus
- Symptoms
- Diagnosis
- Treatment
- Prognosis
- Additional Factors
- Impairment
40
Permanent Impairment
• Permanent Impairment is defined with the following
factors
• A medical condition resulting from trauma or work related
disease or illness
• A deviation from normal function of a body part or organ
system
• Something the body or body part can no longer perform
normally
41
How does permanent impairment
differ from Disability ?
• Disability is how the impairment affects and
changes the person’s ability to perform, social, or
employment demands
• Impairment is a medical assessment
• Disability is a non-medical assessment
NOTE: Colossus is not capable of establishing an impairment rating,
only a qualified medical physicians can assess impairment ratings.
42
Colossus
•Colossus is NOT capable of assessing
brain damage
•The only head injury impairments,
which may be entered into colossus
are related to sight, hearing,
equilibrium, air passage, or
mastication (TMJ)
43
Colossus
• Colossus Applies General Damage Compensation For
Impairments Based On The Following:
• The Body Part Or System Impaired
The Degree (Amount) Of The Impairment Assigned By
The Medical Examiner
Impairment Ratings Must Be Part AMA (American
Medical Association) 6th Edition For NOW…
Law Suit Pending
44
Injuries Diagnosed & Treated
•Minimum Competency To treat PI
Patients
•The Doctors Ability to
Address Each & Every
Injury
45
PROPER AND COMPLETE DIAGNOSIS
• The Initial Records Must Reflect ALL Complaints
Of The Patient
• The Examination Should Indicate All Injuries
Related To Each Complaint
• Colossus Is Structured To Recognize Only The
Diagnosed Injuries Found In The Records
46
DIAGNOSE ALL INJURIES
SEPARATELY!!!!!!
• If the shoulder is included as a separate injury
then the colossus program would allow additional
treatment for the shoulder.
• Although radiating pain increases the value of the
case, it does not increase it as much as
diagnosing the symptom as a separate injury.
47
CPT Codes
• Using forms that contains CPT codes is huge for
your case for 2 reasons. It helps the office biller
work more quickly AND helps the Colossus data
entry person work more quickly to settle the
claim.
Keeping good medical records makes the claim
adjuster and all attorneys’ jobs easier because
they have all the “facts” to know what injuries
were diagnosed.
48
Intake and Management
Forms
• Attorney Intake Form
• DUD and LOE Worksheets
• Physician Intake/Discharge Form
• Physician Request Form
• Common Injury Code Sheet
• Supplemental HCFA Form
• Body Shop Questionnaire
49
DOCUMENTATION OF ALL SYMPTOMS
• After the injuries (diagnosis) are inputted,
colossus asks a series of questions associated
with each injury.
• The corresponding input adds individual value
amounts to the claims general damage range.
50
IMPORTANT SYMPTOMS
• Loss of range of motion
• Headaches
• Spasms
• Dizziness
• Visual disturbance
• Radiating pain
• Anxiety (must be treated)
• TMJ
• Stiffness
51
SYMPTOM DURATION
• It is not necessary to acknowledge the symptom
on each date of treatment
• However, the entire duration of the symptom
should be reflected in the chart notes.
52
PRE – EXISTING CONDITIONS
• If a plaintiff has a pre-existing condition, Colossus will place a higher value on the claim
• An asymptomatic condition with no treatment in the past 24 months.
• Even a condition that was symptomatic there is a need for clinical discussion.
53
TREATMENT DELAY AND/OR
TREATMENT GAPS
• Any delay in seeking treatment or any gaps
in the treatment regimen must be
substantially explained in the records.
• Either of these situations unexplained would
result in decreasing the weight of the
treatment duration.
54
THE PROGNOSIS
NEVER MENTION THE TERM MMI FOR WHOLE BODY
ONLY EACH BODY PART AFFECTED
• Resolution Undetermined – No Value
• No Complaints, No Further Treatment -
• Complaint, No Further Treatment -
• Complaint, Further Treatment -
• Complaint, Guarded Prognosis -
55
ADDITIONAL FACTORS
• There are three additional factors which have
significant weighted affected on the general
damage portion of a claim.
- Duties Under Duress
- Loss of Enjoyment of Life
56
In summary . . .
•Firms need to be proactive
•Medical and Chiropractic institutions do not train doctors to manage personal injury clinically or case manage wise.
57
In summary . . .
Go to www.Colossusinfo.Net
For your Complimentary
Colossus Guide
&
Colossus Firm Assessment
58
Dr. Matthew J. DeGaetano Certified Colossus Consultant
Personal Injury Institute
363 West Main Street
Lewisville, TX 75057
http://www.personalinjuryinstitute.com/
Steven M. Gursten Attorney
Michigan Auto Law
30101 Northwestern Highway
Farmington Hills, MI 48334
http://www.michiganautolaw.com/