Considering Medical Provider Performance in Bodily Injury Evaluations


Sometimes treatment doesn’t get anywhere…should you pay?


Individuals making claims for personal injuries regularly support their claims with medical records which show significant levels of treatment that produce little to no improvement. How many times would you go to a doctor if you said your pain was 7-8 on a scale of 10 and you weren’t getting any better? Put another way, how many times would you take your car back to the same mechanic if he wasn’t fixing the problem that caused it to break down repeatedly? Yet, every day, bodily injury adjusters avoid or bypass answering this question.

These situations don’t seem to pass the insanity test:

The definition of insanity….Doing the same thing over and over expecting a different result.

Challenging a doctor’s performance has always been seen as taboo to those who are not doctors. But does it really have to come to that? Can’t a medical provider’s performance serve as a basis to determine whether treatment was reasonable?

Cigna healthcare certainly thinks so. They recently announced that they would be paying for a new heart medication – Entresto – from pharmaceutical giant Novartis based on how the drug performs. Cigna Senior Vice President Christopher Bradbury had this to say…. “Outcomes-based contracts require that prescription medicines perform in the real world at least as well as they did during clinical trials and are a valuable tool for improving health and managing costs.” In other words, if the drug doesn’t work for a patient you should not expect us to blindly pay for it.

There are three ways to apply this to medical treatment received for personal injuries sustained in an accident

Determine if the treatment actually works

Theory about how various medical devices or approaches to treatment should work aren’t enough. The treatment either helps restore function or it doesn’t. There is a significant amount of research and a growing number of professional organizations that use evidence to assess which treatments work and which don’t. You can find plenty of research through this U.S. Government website: www.guideline.gov.

Learn how to track patient improvement

You don’t have to leave it to the expert to see whether the treatment was working. Medical providers are expected to document both subjective  and objective measures.

Subjective measures include pain scales. While many think that pain scales themselves are questionable, it seems more questionable when the number provided by the patient lies on the “excruciating” end of the spectrum, but treatment remains unchanged.

Objective measures include range of motion and patient strength. This tells them whether they are really helping the patient. For most cases, improvement should start to be seen very quickly (within a few visits). If it isn’t, this begins to sound a lot like the mechanic I mentioned above….

Learn how to spot a scam

As a patient with a 7-8 reading on the visual analog pain scale, I would not have normal strength or range of motion. Neither would you. Or Superman, for that matter. So why does this conflict exist so frequently? More importantly, why are adjusters not spotting it and challenging treatment based upon this?

Expertise Matters

Treatment – the cost of it, how long it lasted, etc. – forms the primary basis for evaluating an injury. Developing the expertise to spot the types of issues mentioned in this blog form the foundation for an effective claims operation. This is why we tie development of these skills so tightly to the way our processes and technology function. You should, too.

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