A S A Shock cking ng Pro roblem m In Pers rsonal al Injury; y; A formula commercial insurers use to determine claim value is based on the above listed Decision Point factors and is named the: “Decision Point To Dollar Translation Percentage Multiplier ” 28
Points Convert Into Dollars The Decision Points convert into settlement dollar valuation according to each insurers own rate. 29
Missing Points = Missing $$$ 30
Missing Valuation When Decision Points are missing in the medical records, values for those factors are missing from the claim. Claim factors and physician reimbursement is challenged, denied or disputed and the injured party receives a lower settlement valuation. 31
Difference Physician record systems are based on Government, Center For Medicare Services (CMS) Guidelines designed for treating average patient conditions and do not apply to personal injury patient care or record documentation leaving a need among injury treating physicians unfulfilled. 32
So Solu luti tion on To solve the complexity of commercial insurer Decision Point guidelines that are missing from the doctors government guidelines, one company named CASE, worked within and across organizational boundaries to create ZEUS, a personal injury specific medical software to counter Colossus. 33
Law awye yer r an and Co Colo loss ssus s Exp xper ert t Aa Aaro ron DeS eShaw haw: “ only a minority of lawyers and doctors have a clue what’s going on” SURVEYS SHOW 80% OF DECISION POINTS ARE FOUND MISSING IN THE AVERAGE MEDICAL SYSTEM 34
Zeus was created with “Computer Aided Decision Making” - a Decision Support System (DSS) - an adaptive and evolving information system that presents very suitable information when approaching numerous and various medical evaluation, acceptable treatment planning and control problems that are often complex and complicated in a commercial insurance environment that differs from and are not part of government guidelines. Particular emphasis is put on real-time DSS with advanced solutions such as mixed knowledge systems, that combine Decision Point medical assessment methods with the prospects of using Ambient Intelligence concept DSS in an injury and commercial insurer/colossus environment. 35
The physician is a participant in the medical discovery process, who can now critically analyze Colossus/ commercial insurer guidelines and Decision Points to communicate new Colossus knowledge in a variety of ways (both collaboratively with the computer aided decision making ability and individually), communicate what has been learned and access references and tools appropriate for the medical documentation and representation tasks and to show his findings have greater believability. 36
This automated ‘Decision Support System’ ( DSS) will search, tag and extract commercial/Colossus Decision Points and formulate them in the correct language, format and sequence to interface and input value into the commercial insurer claim. 37
Karen Greig, ESQ. in Bellevue, Wash., …who's litigated dozens of bodily injury suits against Allstate says: "There's something sinister and surreal about a computer becoming the arbiter of the value of human life" "You can't negotiate with a computer." 38
Plaintiff Attorneys Agree “ Various Elements Of The Software’s Operate In A Systematic Way to Deny Policyholders Legitimate Benefits” 39
Plaintiff Disadvantage ...since Colossus guidelines are not available to the public, it puts plaintiffs at a severe disadvantage. 40
Since 2004, …All State has been ignoring a Superior Court order to release the 10,720 power points that comprise Colossus guidelines known as: “Decision Points” & “ Value Drivers” …the very same points from which they determine settlement value. They claim their Decision Point Guidelines are proprietary and they elect their right to “Civil Disrespect”. 41
FINE Allstate Agreed to Pay a Ten Million Dollar ($10,000,000.00) Regulatory Settlement. 42
“CCPR HARMS PUBLIC INTEREST” SUPREME COURT RULING CCPR HARMFUL TO PUBLIC • Washington State Bar Assn. v. • Allstate’s Practice of Law under Great Western Union Federal CCPR Harms the Public Interest. Sav. and Loan Ass’n ., 91 Wn.2d 48, 54-55, 586 P.2d 870 (1978). The Supreme Court believes CCPR gives a competitive edge that goes beyond expense control in reducing claims costs. 43
• Consumer Federation Of America … released it's report citing court documents that reveal; “insurer's utilization of claims evaluation software's result in huge and questionable insurer claims’ savings ” 44
The Report Stated; …“computer claims software’s utilized by 95% of the nation’s largest insurance companies, can be manipulated to produce unjustifiably low injury payments to consumers and tens of millions of dollars in illegitimate ‘savings’ for insurers.” 45
The Report Also Stated: …”unfortunately, these companies violate their obligation to deliver fair claims’ payments to their own policyholders on a huge scale, in order to increase profits.” 46
And finally: …”most of the nation’s top insurers use “Claim’s Handling Software’s” in ways that put millions of American consumers at risk of not getting the claims payments that they paid for with their premiums”. 47
We Practice In A World Of Improper Claims Tactics, Driven By Computers And Decision Point Guidelines 48
Decision Points …The set of factors for which Colossus determines a range of values that convert into settlement dollars using a formula . Decision points are the points by which Decisions are made regards value 49
RE RECAP AP:The Formula To Convert “Decision Points” Into Settlement Dollars Is: “Point to Dollar Translation Percentage Multiplier” Formula! 50
RE RECAP AP:Decision Points that Determine Value • 10,720 “Decision Points” • 14,357 “Value Drivers” • 27,125 “Severity Drivers” • 26,350 “Standard Multipliers” • 33 “Liability Drivers” • 15 “Additional Increase Multipliers” • 78,597 Decision Point Variances • PLUS: • Injury Severity Points • Case Maximizers • Prolonged Modifiers 51
Since …these decision points are not well known by either the legal profession nor are they not found in the government guidelines used by the medical community. This makes it difficult to represent the full value of the injury without the appropriate medical-legal software. 52
80% 0% Of Of The De Decision ision Poin ints ts Ar Are Miss Mi ssin ing g In The Avera rage ge De Dema mand 53
Mi Miss ssin ing g De Decision ision Poin ints ts Equal ual Mi Miss ssin ing g Settl ttlement ement Do Dolla lars 54
Understanding that missing “Decision Points” cause missing settlement value. 55
How It Works To use these claim settlement software’s as Colossus, an adjuster inputs the “Decision Points” and “Value Drivers” about a claim and Colossus calculates a range of values for the claim's worth. 56
Original programmers at CSC, …Report Colossus was set up to calculate GENERAL DAMAGE CATEGORIES based upon Decision Point Guidelines in: Administrative Economic and Legal Areas 57
Original programmers at CSC …Report Colossus was also set up to calculate GENERAL MEDICAL INJURY (non-economic) damages based upon four (4) medical decision point corners of a claim. 58
1. Injury Severity Points 2. Duties Under Duress 3. Loss Of Enjoyment 4. % Whole Person Impairment 59
Assessing Medical Claim Value Injury Types:………………………..25% value Duties under Duress:…………….25% value Loss Of Enjoyment:……………….25% value % Whole Person Impairment:..25% value 100% value 60
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#1 Injury Severity Points Injuries are represented by diagnoses. Colossus requires double digit diagnoses represented by ICD Codes. Average # of diagnosis = 4 HCFA form = room for 4 diagnoses 1 st area of missing Decision Points and missing value therefore is the diagnoses = 25% value 63
Las Vegas Attorney Steven Burris Reports …" When it comes to discussing the damages issues re injuries, the lawyer must stick to the four corners of the medical records documents. 1. Injury Severity Points 2. Duties Under Duress 3. Loss of Enjoyment 4. % Whole Person Impairment If it is not in the medical records, it doesn't count. Stupid rule, but that's apparently how it's done." 64
Therefore the physician is the single most important aspect of a Colossus case and data contained within the doctor’s chart notes, [not narrative] are the only source of information that adjustors are allowed to derive decision points from to enter into Colossus. 65
Aaron DeShaw, ESQ “It’s no secret that many plaintiffs' attorneys believe there is nothing that can be done to prevent unfair settlements unless they involve major injuries”. DeShaw points out that this is NOT the case as soft tissue injuries meet the “Serious Injury Threshold”. 66
1. MTBI = Closed Head Injuries 2. Sensory Loss 3. Motor Loss /weakness 4. Range Of Motion Loss 5. Diminished Deep Tendon Responses 6. Disc (Disorder/Derangement) 7. Ligament Laxity (728.4 Loss of Segment Integrity/AOMSI) 8. Radiculopathies 9. Fractures (Vertebral Body, Uncinate Process) 10. Spondylolisthesis 11. Stenosis 67
#2 % Whole Person Impairment The evaluator must identify the involved body; Parts • Systems and • Functions • …The evaluator must list: AMA Guide Edition • Chapter and • Table • …used to make the WPI Determination. 68
Colossus Uses 5th Edition AMA Guides All claims should be assessed for whole person impairment according to 5 th edition guides. 69
Attorney Aaron DeShaw: "While the legal profession has historically used narrative-style demand letters to convey claims, much of the information provided in medical or legal narrative style demand letters has no value in Colossus. Adjusters look almost entirely to the medical records for the decision points that input value required by Colossus. 70
Attorney Aaron DeShaw: Only a minority of lawyers and doctors have a clue what's going on. Attorneys need to convey data about the claim using TABLE format ”. 71
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SO, HOW CAN WE PREVENT OR REDUCE IMPROPER, LOW VALUATION ? 73
2 Main Factors All settlement claims will be devalued due to the use of the insurance company’s software’s and Business Process Improvement (BPI) culture, however settling a claim favorably without trial is dependent upon two main factors: 1 ). The physician’s ability to chart the medical decision points so they input value into Colossus and 2). The attorneys specific mirroring , formatting and sequencing of the decision points in the demand letter 74
Strict Requirements of Adjuster “The claims handling software’s themselves make a lot of demands on adjusters, requiring them to enter scores of information. You have to have a good medical record of what the injury is" …says Mr. Smith of American National Property and Casualty Co. 75
Peripherals "Any injury can have many peripherals attached to it. Colossus is very good at finding out what kind of injuries are actually present. But the doctor has to be able to search, tag and extract the Decision Points and is unable to do so with his standard government record system. 76
The more information an adjuster inputs, the more accurate Colossus' calculation becomes ”. Now you can understand how injury claim case settlement value reserve is lost. Missing Decision Points = Missing Settlement Valuation Physicians who use standard medical record systems miss up to 805 OF THE Decision Points 77
What To Include In Demand Because Colossus asks many specific questions about claims factors, you need to know what is being asked, what is being valued, what is missing and what to include in the medical file and in your demand. 78
Decision Points Normally Included In The Average Demand: Summary of Claim Background Damages Facts and faults of Accident - Liability Injuries and Treatment Economic factors (property damage, lost wages, etc). Medical Expenses – current and future Administrative & Legal Decision Points Past Medical History Evaluation, Summary, settlement demand and supporting documents 79
Colossus Expert & Attorney Aaron Deshaw DeShaw says: “ Plaintiffs' lawyers are frequently unaware of what other decision points & value drivers are treated as significant by Colossus”. 80
Value Drivers That Should Be Included In Every Demand: In response to the data contained in both the medical chart notes and the demand, Colossus will then bring up “drop - down” screens seeking additional information. 81
Colossus Questions Here are some of the medical “pop - up” questions Colossus will ask when seeking data. 82
As we review the following list, compare how many Administrative Legal Economic and Medical Decision Points are included and how many are omitted in both your medical experts chart notes and also in your demand. www.demandsthatcommand.com 83
Points To Be Included In Demand Medical Decision Points Administrative Decision Points Legal Decision Points Economic Decision Points Value Drivers Injury Severity Points Case Maximizers Prolonged Modifiers Standard Multipliers Additional Increase Multipliers Liability Drivers Injury Drivers Mileage Drivers Undisputed Statements Of Fact Points Of Memorandum Evidentiary Burdens Of Proof & Authorities Declarations To Establish Preponderance 84
Points To Be Included In Demand Medical History Medical Office Records with Laboratory Tests, Special Tests, Diagnostic Procedures Hospital Records Records From Client Records From Other Sources Explanations For Delay In Seeking Care (72 Hrs) Explanations For Gaps In Treatment (5 Days) Medical Validation Letter – 2 nd opinion from independent 3 rd medical party 85
Functional Physical Examination Injury Types (ICD’s) [25% value of claim] Symptoms (Documented) Laboratory Tests Special Tests ( CRMA/UPFX ) Diagnostic Procedures Specialist’s Evaluation Diagnoses (Double Digits) Complaints – (intensity, frequency, type, radiation, further effects) Duties Under Duress [25% value of claim] Loss Of Enjoyment [25% value of claim] Treatment Stability of Each Medical Condition Static Conditions 86
Medical Determination of Future Treatment Prognosis Overall Prognosis Each Body Area Future Treatment Plan Number of Future Visits (On stable injuries) Future Treatment Duration and Time Lines MMI For Each Body Part % Whole Person Impairment with Medical Validation Letter. [25% value of claim] Evidentiary burdens of proof showing soft tissue injuries meet “Serious Injury Thresholds” Diagnostic Related Estimates (DRE’s) Diagnosis Based Injuries (DBI’s) Spine Impairment Summary Specific Disorders Of The Spine Whole Person Impairment 87
Monetary Factors Administrative and legal costs Damages Current Medical Costs RMP of Future Medical Costs With Full Probability Scale Economic Expenses & Loses Property Damage & any additional losses Vehicle Repair Costs Car Rental Expenses Mileage calculated @52 cents per mile Current Income Loss Future Income Loss Supportive Statements of Costs & Losses 88
ATTORNEY OUTLINE/ CHECKLIST FOR DEMAND LETTER Attorney Demand Letter Attorney Use this checklist to 1. Medical History tag and extract 2. Medical Office records 3. Hospital Records 4. Records From Other Source decision points and 5. Records From Client 6. Explain Delay in Seeking value drivers to be Care 7. Explain Gaps in Treatment 8. Physical Examination included in the 9. Injuries (ICD-9 codes) 10.Symptoms (Documented) demand to input 11.Laboratory Tests 12.Special Tests value into Colossus 13.Diagnostic Procedures 14. Specialist’s Evaluation 15.Medical Validation & Demandsthatcommand.com Determination Letter 16.Diagnoses(double digits) 89
ATTORNEY OUTLINE/ CHECKLIST FOR DEMAND LETTER “Claim Finalization and Demand Letter” Attorney Demand Letter Attorney 17. Complaints – have to be 28.MMI For Each Body Part 29.% Whole Person Impairment rated according to; (Provided by MD Utilizing intensity, frequency, 5 th Edition AMA Guidelines type, radiation, further or with a Medical Validation Letter as effects a 2 nd Opinion from an MD) 18.Duties Under Duress 30.Monetary Damages 19.Loss Of Enjoyment • Current Medical Costs • 20.Treatment Future Medical Costs and Probability 21.Stability of Medical • Economic Loses Condition • Property Damage & any 22.Medical Determination of additional losses • Future Treatment Vehicle Repair Costs • Car Rental Expenses 23.Prognosis Overall • Mileage calculated @52 24.Prognosis Each Body Area cents per mile 25.Future Treatment Plan • Current Income Loss 26.Number of Future Visits • Future Income Loss • Supportive Statements (if Not Stable) of Costs & Losses 27. Future Treatment Duration and Time Line 90
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SOFT TISSUE INJURY LIABILITY CASE CLAIM RESERVE 2004 was $15,800 2015 is $5,800 92
Start Speaking In Their Code Language! To Prevent the insurance companies “software’s” de-valuing your case, cite all applicable Decision Points and formulate your demand using the correct language, terminology, format and sequence to interface with the insurance companies' ‘Decision Point” claims handling software’s. 93
ZEUS VS COLOSSUS We recommend physicians use Zeusclaim to tag and extract the medical decision points to INPUT ADDED VALUE into Colossus! 94
ZEUS VS COLOSSUS We recommend plaintiff attorneys use Zeusdemand which will assemble the medical points for you and then tag and extract the remaining administrative, legal and economic decision points to INPUT VALUE into Colossus! 95
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