OVERLOOKED ACCIDENT INJURY

We will introduce the most overlooked Threshold injuries among auto accident victims, with discussions about why they are missed, how to determine who is a candidate to suffer these injuries and provide a reporting of the appropriate tests and diagnostics that can be used to detect them.

SPINAL INSTABILITY DUE TO LIGAMENT TEAR IS REPORTED TO OCCUR IN 65% OF VEHICULAR COLLISIONS

Open Orthop Journal. 2014; 8: 326–345. Published online 2014 Oct

In auto accidents, injuries occur during the first 10 milliseconds. This suddenness overcomes the elastic strength of the ligament. As the ligament stretches to the point of tearing, it reaches a physiologic extent where it cannot return to its original shape.

This internal disruption is a TEAR of the ligament and is followed by complete structural or functional failure of the ligament.

Spinal Disorders 1992;5:390-397

Spinal Instability From Torn Ligaments Is Missed Because It Cannot Be Seen By The Human Eye.

When the patient has tested positive for one of the highest rated spinal injury types as recognized by strict criteria of the AMA Guides for diagnosing this injury referred to as “Alteration Of Motion Segment Integrity” (AOMSI), evidence-based data should be submitted as many adjusters have not heard of AOMSI or the AMA criteria to accurately diagnose this injury.

One reason may be that the diagnostic test for this injury has not been available until a few years ago.

According to a former Superintendent of Insurance at All State, James Mathis, the diagnosis of AOMSI (Ligament Laxity) assigns a case settlement reserve value of $66,000.

People with a MTBI may have many emotional and behavioral effects. That’s because our brain controls the way we act and feel. An injury to the brain — usually an injury to the frontal lobe — causes changes in emotion and behavior. The life changes that happen after a MTBI, also affects how people act and feel. People with a MTBI may have changes in self-esteem.

Symptoms include but are not limited to…frustration, increased anger/aggressiveness, impulsivity or difficulties in self-control, faulty or poor judgment with decreased ability to initiate conversation or activity, repetitive behaviors, less effective social skills, changes in sexual behaviors, impaired self-awareness about how MTBI impacts him/herself and others. Emotional effects may include: increased anxiety & depression.

Concussion Induces A Barrage Of Ionic, Metabolic, And Physiologic Events And Manifests In A Composite Of Symptoms Affecting A Patient’s Physical, Cognitive And Emotional States, And His Or Her Sleep Cycle. Any One Of Which Can Be Fleeting Or Long-Term In Duration.

“Compared to other proteins that have been measured in (MTBI’s) mild traumatic brain injuries, BDNF, (brain-derived neurotrophic factor) does a much better job of predicting outcomes’’. Blood tests are now being used to measure BDNF and detect MTBI’s.

[Frederick Korley, M.D., Ph.D., an assistant professor of emergency medicine at the Johns Hopkins University School of Medicine and first author of the new paper].

DIFFUSION TENSOR IMAGING (DTI) has been shown to be sensitive enough to detect brain injury from diffuse axonal injury with more sensitivity than MRI or CT.

When the brain is directly impacted, bruising or tearing on the outer most tissue of the brain is shown in the grey matter and is easily observable on MRI and CT. However, the tissue destruction and changes from DIFFUSE AXONAL INJURY, arising from a high speed velocity can tear or damage the axons of the brain and can be seen in the white matter AND is clearly best shown by DTI.

In the cervical spine, the arteries pass through small openings (foramen) in the vertebra. Accidents cause spinal instability, where the vertebra are thrown out of position or subluxated or dislocated where the vertebra cause partial occlusion of up to 30% of accident cases in at least one vertebral artery resulting in a blood-flow loss to the brain.

Symptoms of blood flow loss do not produce typical symptoms. Here is a list of clinical signs that evaluators look for after an auto accident. .

THIS INJURY IS OVERLOOKED BECAUSE OF 3 FACTORS:

1. Most evaluators fail to ask if impact forces are oblique or if the head is turned during impact (as looking into the rear-view mirror) and subsequently miss this neck vertebra fracture.
2. It takes 2 months to reveal this injury and most x-rays are taken at the emergency room or soon after the accident, consequently causing this fracture to be overlooked. It is classified as a “Derangement fracture”, similar to a compression fracture which takes time to develop.
3. It requires special x-ray analysis and 35 degree, cephalad tube-tilt positioning which most doctors and radiologists are not familiar with.

Uncinate Process Fracture of Neck Vertebra From Oblique G-Forces

The x-ray must be taken after 2 months and must be positioned in a special way to show the uncinate process. This requires special tube positioning at an angle of 35 degrees of cephalad tube tilt positioned 10.5 inches closer to the patient than normal. Most practitioners are not familiar with this special tube positioning.

During auto accidents, a neurologic syndrome following injury of the spinal sympathetic nerves of the neck results from pinching on the cervical chain ganglia of nerves by the adjacent vertebrae.

Chain Ganglia Injury -or- Cervical Sympathetic Syndrome is a pathological condition that is characterized by a host of cranial symptoms, such as headaches, abnormal functions of the eyes and the ears, and psychological and mental disorders.

This syndrome usually appears after physical injuries to the neck seen in cervical acceleration/deceleration car wrecks that cause instability of the spine where vertebra are forced out of position and press against the delicate bundles of nerves that run close to the spine along the entire spinal column.

This syndrome usually appears after auto accident produces physical injuries to the neck.

We are showing different threshold injuries as a result of spinal instablility that is causally related to common low speed vehicular collisions and that are often overlooked. This is to inform plaintiffs providers and representatives to conduct concierge triage injury intake Questionnaires and perform clinical evaluations geared towards identifying and diagnosing all the medical sequelae of injury.

BRANCHES OF THE CERVICAL CHAIN GANGLIA LEAD TO MANY PARTS AND ORGANS OF THE BODY AS:

Eye /Skin / Heart / Larynx / Pharynx / Pineal gland / Carotid body / Sweat glands / Erector muscles / Vestibular system / Blood vessels of the skin.

This injury exceeds psychosocial reasons for chronic pain and is further explained by kinesthetic information being routed directly to the EYE and BALANCE control areas of the brainstem.

Today’s medical-legal community better understands and accepts the oftentimes perplexing, multi-faceted nature of auto related cervical acceleration/deceleration (CAD) associated disorders. However, many insurers don’t - and many providers miss injury types.

Diagnosing Cervical Chain Ganglia ongoing symptoms – whether physical or psychological – starts with awareness utilizing “Best Practice” custom Concierge Injury Intake Triage Questionnaire targeting these symptoms.

Traffic accidents Have Become The Leading Cause of Post-traumatic Stress Syndrome (PTSS) & Disorder (PTSD)…since the Vietnam war

Diagnosing Stress, Anxiety & Emotional Disorders starts with awareness utilizing “Best Practice” custom Concierge Injury Intake Triage Questionnaire targeting these symptoms.

Criteria for Rating Impairment for Auto & Pain Related Sleep Disorders

Reduced daytime alertness that reduces the quality of the individuals performance at work, or interferes with social or interpersonal relationships, or decision making or other loss of normal activities of daily living: should be assessed by the AMA Guides, Chapter 13, Pg. 317, Table 13-4 - Criteria for Rating Impairment for Sleep Disorders.

SLEEP DISORDERS become especially common when people are in pain from accidents. Problems can range from difficulty falling asleep to difficulty staying asleep; in turn causing heightened pain, anxiety and worsening sleep.

Impairments from sleep disorders relate to; the nervous system, cognitive abilities, behavioral and emotional factors or relate to irritability or depression.

50% of people report sleep difficulties Interfere with their DUD, & LOE.

Diagnosing Sleep Disorders starts with awareness utilizing “Best Practice” custom Concierge Injury Intake Triage Questionnaire targeting these symptoms.

AWARENESS IS A KEY FACTOR IN DIAGNOSING OVERLOOKED INJURIES

Most providers are trained in the physical injuries seen in auto accidents however, as demonstrated by the percentage of overlooked injuries as shown in this report, many physicians are unaware of injury severity types and miss many injury thresholds.

A comprehensive injury intake triage questionnaire is unquestionably the best practice when seeking to uncover all the multi-faceted injury severity types seen in accidents, even at low speeds.

REPRESENTING CAR ACCIDENT CLIENTS?
DON’T MISS THESE LONG TERM CONSEQUENCES

We have demonstrated how Injury Severity Thresholds are routinely excluded from medical discovery damaging the injured and the claim, and we now introduce other important factors that affect the injury claim as well.

Many attorneys and providers are unaware of the difference that examination levels and Triage Intake Questionnaires have on the valuation of an injury claim. However, the insurance companies have created a precise method to determine case valuation using “Decision Points” with a Decision Point formula (described below) and the provider may not be optimizing medical discovery or documentation as revealed by the following factors as well as the errors in overlooking injuries described earlier in these pages.

As far back as 1992, insures have used software’s as Colossus to determine claim valuation based on their set of “Decision Points”. Today there are 80 different versions of software’s used by all insurers and 67,880 Decision Points of which the insurers do their best to keep secret.

Aaron DeShaw, ESQ, DC;

“Plaintiffs’ lawyers are frequently unaware of what decision points are treated as significant by Colossus”

Look for a Personal Injury Provider Who uses the “Injury Model” Examination and Includes the Decision Points on Personal Injury Cases

Most Electronic Medical Record systems are based on the Center for Medicare Service Guides or “CMS” Guides. Insurance claims require additional and complex medical documentation that is not fully addressed in CMS Guideline Exam Levels and comprises such areas as:

• “Case Maximizers”
• “Value Drivers”
• “Prolonged Modifiers”
• 67,880 “Decision Points”

NOTICE: Missing Medical Decision Points = Missing Settlement Valuation.

This becomes evident when you take into consideration the following formula insurers use for determining settlement valuation as:

The Decision Point to Dollar Translation Percentage Multiplier Formula

It is apparent that the formula (above) the insurers use to determine settlement valuation is based on Decision Points and that missing Decision Points = missing settlement valuation.

You may Contact one of our national provides to receive a checklist of the 25 decision point sections of a bodily injury claim to compare to the number of decision point sections represented by your provider and that are included in your demand.

If your provider is using the CPT code 99203 or 99204 to represent the level of examination for the assessment of your injured clients, you may want to be aware that in Chapter 12 of the Medicare Manual, the 99204 Exam is named:

• 99204 -IPPE – Initial Preventive Physical Examination – Welcome to Medicare Visit

The members of the National Providers Accident Council conduct a 1191M Level Injury Model Examination named:

• 1191M - Impairment Rating By Attending Physician, Standard, 1-3 Body Areas, Performed At MMI

The 1191M level examination is designed as an “Injury Model” for cases that may require litigation and therefore subsequent Whole Person Impairment (WPI) rating while operating at “Best Practice” to diagnose and represent the Injury Severity Thresholds, rate impairments, include Decision Points and utilize Table formatting for valuation.

Since the introduction of the personal injury “Business Process Index” (BPI), insurers now require TABLE Formatting of Whole Person Impairments.

Insurers have different requirements involving diagnosis and medical determinations, represented by 25 sections of a bodily injury claim and they require WPI to be displayed in Table formatting (next page top).

Just as there are different levels of assessments and examinations that plaintiffs’ providers can perform, insurers call upon their doctors referred to as IME=Independent Medical Examiners to contain costs.

Insurance Companies’ Use “RUBBER STAMP,” “RISK MANAGEMENT,” and “STACKING THE DECK” tactics to lower settlement valuation.

The Question Is:

• By whose standard is it determined whose opinion carries the greater weight?

The Answer Is:

• An Independent Medical Validation (IMV) performed by a disinterested 3rd party, is used to confirm the accuracy and conformity to facts and show evidence-based data to counter the varying medical opinions of the Independent Medical Examination (IME). This eliminates common litigation obstacles and reverses low-settlement valuations in a Colossus injury claim!

The primary role of the IME is to provide impartial, unbiased medical opinion to “clarify” medical restrictions and limitations.

However:

• ...the IME evaluator is hired and paid for by the defense insurer, making it impossible for the IME to provide an impartial, unbiased opinion. Instead, they will side with the source of their paycheck.

The result is the IME is nothing more than a “risk management” tool that “rubber stamps” a future decision to deny the claim. It is nothing more than a ploy to “stack the deck,” where adjusters and IMEs dispute, deny, discount, and defend low-settlement valuation. www.badfaithinsurance.org/reference/HL/0090a.pdf

IME Physicians Do Not Appear Concerned with the Insured’s Medical Well-Being.

The IME physicians have a clearly defined agenda and strategy to assist the insurance company with what appears to be credible, objective medical opinion contrary to that of the primary care (treating) physician.

IME Examinations are one of many “risk” activities used by the insurer to attack the credibility of the claimant and their primary care providers.

On the contrary, the process known as Independent Medical Validation, or IMV, [Not IME], is truly impartial and unbiased. Its purpose is to provide administrative, legal, and medical validation to:

• Meet court-accepted evidentiary burdens of proof of regulatory requirements for process controls
• Assure with the highest probability that medical services, impairment rating, and treatment determinations meet specifications, have uniform quality, and establish the preponderance of evidence
• Win the Greater Weight Challenges

IMV vs IME: The Quality System (QS) of Regulation defines Independent Medical Validation (IMV) as:

• “...establishing by objective evidence that a medical process consistently produces a result or end product, meeting its predetermined specifications, stating how validation will be conducted, including evaluation parameters and what constitutes acceptable test results.” Cain v. Bain,709 S.W.2d 175 (Tex. 1986)

The process of IMV is being used successfully by plaintiff attorneys to counter insurance company adjusters’ and doctors’ varying opinions and reverse and prevent low-settlement valuations.

Insurance Companies Can Be Successfully Challenged At Their Own Game!

FACT: Insurance companies refer injured parties to their own IME doctors to dispute claim factors.

NOW: Plaintiff attorneys can counter unfair opinions, tactics and low-settlement valuations by referring clients for the process of IMV.

This is highly effective and often the only chance to reverse low-settlement valuations. Contact the National Providers Accident council for a directory of providers who can arrange an IMV for your undervalued claims.

Validation Instead of Exploitation

Do NOT accept the opinions, disputes, and denials of a potentially prejudiced insurance adjuster or IME doctor. Their primary goal is to exploit the situation to minimize the claim to the insurer’s advantage.
There are doctors in your community who can provide an (IMV) to confirm the accuracy and conformity of facts and evidence-based data. Their professional opinion can overcome disputes and common litigation obstacles and they can help successfully reverse low-settlement valuations in auto accident Colossus claims.

The IMV process can be effectively used to eliminate the following challenges:

• Low and unreasonable settlement valuation
• Varying and/or opposing medical opinions
• Medical evaluators’ inability to reach agreement about injury severity types
• Adjusters and IMEs disputes and denials of claim factors
• Physicians inability to differentiate one type of impairment from another
• Clinical findings that are not obvious
• Blaming pre-existing conditions or prior accidents as the cause of current injuries
• Stating NO DAMAGE= NO INJURY when crash speeds are not sufficient to produce property damage
• Clinical findings that are not obvious

The IMV Process Is More POWERFUL than Adjusters’ and IMEs’ Claims

It’s true that insurance companies have a lot of power behind them. Their teams of IME’s and adjusters set the bar high. Fortunately, the IMV process is more powerful. It provides demonstrable evidence to prevent adjusters and IME’s from disputing, denying, and discounting claim factors and tendering low-settlement valuations.

Contact the National Providers Accident Council for a directory of providers who can arrange an IMV when your claims are undervalued.

Contact a provider for a copy of one of our 7 medical-legal books, as shown on the following page, to prevent & reverse IME bullies from undervaluing injury claims.

Overthrowing Unfair, Unrealistic, Low and/or False Adjuster Determinations
The IMV process is powerful enough to counter the unfair claims made by adjusters. Adjuster’s and IME’s fear any foundation for rebuttal.

Please Note: The process of Independent Medical Validation provides Medical Determination with Memorandum Of Points, Statements of Undisputed Facts, Declarations, Exhibits, and Authorities, intended to present evidentiary burdens of proof in admissible format to establish preponderance, eliminate varying medical opinions and show the Great Weight of the evidence to overcome challenges.

One of the purposes of the IMV is to produce enough evidence-based data from one side to create a belief that its version is more likely true than not.

• If IMV evidence-based data comes under dispute, such dispute must show that the finding is so against the great weight and preponderance of the evidence as to be clearly wrong and manifestly unjust and against authorities.

Our Providers are trained in this environment and engage Zeusclaim, a seamless electronic medical record system designed for bodily injury claim assessment to exchanges complex medical data, interface and input-added valuation into a Colossus claim and the other 79 claims settlement software programs used by the insurance industry.
Plaintiff’s attorneys’ are NOT bound by the evidence and opinions of IMEs and claims adjusters! You have another option!

Unfair claims settlement practice acts are brought to life when adjusters do the following;

• Manipulate the Trauma Line
• Drag the Injury Severity Point
• Reduce the Severity to Non-Rate Action Plan
• Benchmark the Tuning Bias
• Redesign the Core Claim Process
• Second-guess Professional Medical Opinion

...These represent six (6) of the twelve (12) Unfair Claim Settlement Practice Acts.

Contact A Provider For A Copy Of This Book

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