Using Your Coding Practices to Attract Personal Injury Cases and Bill Defense

A segment of personal injury attorneys are competent, value medical providers, and, as a norm, pay 100 percent of reasonable chiropractic bills. These attorneys are looking for competent chiropractors who refer to specialists when medically indicated and conduct their billing in a way that is reasonable, supportable, and defensible at deposition or trial.

Of course, the less scrupulous attorneys are out there, too. These attorneys seek to pay you less, regardless of your care, your value in the recovery, or your reasonable billing practices.

In the world of personal injury, you will need to deal with both.

So how do you cross the bridge from working with good personal injury attorneys (who value your services and pay your full bill) while also recovering proper payments from those not-so-scrupulous attorneys who want to put financial burdens on the backs of the medical providers? That bridge includes several building materials to make it strong and durable. 

Those building blocks include: 1) setting reasonable fees that are supportable; and 2) coding properly for the nuances of personal injury

Setting and Supporting Reasonable Fees

Your ability to attract the best attorneys so that you can collect 100 percent of your bill (at least 80 percent of the time) starts by establishing a process for demonstrating that you charge reasonable fees. That might sound easy, but the biggest contention area in medical lien recovery generally isn’t your treatment; it’s the amount of your bill.

In a personal injury case, nothing will come under more scrutiny than the reasonableness of your fees and charges. Indeed, even if your fees are lower than the competition’s fees, your fees will likely be attacked, purely as a tactic. If an insurance adjustor or an attorney on the defense side can find a way to demonstrate some problem in your fees, you can bet they will!

And there’s a trickle-down effect at play. If the insurance adjuster or defense attorney manages to demonstrate that your fees are “unreasonable,” then the patient’s attorney will use that to attack your bill and pay you less so that more money can stay in their client’s pocket. The buck keeps getting passed, and that buck keeps getting smaller each time it does.

When you establish the propriety of your treatment and the reasonableness of your fees from the outset, with plenty of support, you accomplish two important things:

1. You can help the patient attorney defend your fees to the defense’s insurance adjuster or attorney; and
2. You can take the wind out of an attorney who tries to argue that your bills aren’t reasonable down the road. After all, if the patient attorney defended your bills to the insurance adjuster, it will be hard for them to turn around and claim that your bills are unreasonable when it is time to pay up!

Reasonableness is based upon a number of factors, such as:

• Your area(s) of healthcare specialization.
• The geographical location where the services are rendered.
• The personalized treatment plan, including the range and types of procedures and specialized care you provide.
• Whether the treatment was medically necessary.
• The actual time spent administering the treatment.
• The application of proper treatment codes.
• Your credentials and level of training.

Various sources can be used to evaluate your fees, such as UCR (usual, customary, reasonable) publications, or an online source, such as FAIR Health Consumer (www.fairhealthconsumer.org) or others. Chances are, you will find that a lot—and maybe most or all—of your current fees are less than what UCR, Fair Health, and other sources would designate as average fees for the codes you use.

The best practice in personal injury is this: Do your own research to ensure that your fees are reasonable. Then, during patient intake, give the patient these four things:

1. A copy of your fee schedule.
2. A good faith estimate per the No Surprises Act.
3. A fee comparison that shows your rates as they measure against UCR or FAIR Health fees.
4. A lien or letter of protection that protects you far more than I suspect your current lien or the usual letter of protection from an attorney does (it matters).

Retain proof the patient received these four documents, and, of course, that the attorney signs your lien, and then send this same set to the patient’s attorney, who needs to also sign the lien or issue you that (enhanced) letter of protection, depending upon your state.

Monthly thereafter, send the patient and the patient attorney interim billing statements so they have ongoing notice and time to speak up if any issue is presented (and if they remain silent that’s to your advantage). Upon discharge, send them both a discharge (final) billing statement. Be able to prove transmission and receipt of these documents for your own protection.

By following these best practices, you’ll communicate that the not-so-scrupulous attorneys need to shape up. You will also be a hero to the patient attorneys who want medical providers with a strong understanding of personal injury in their corner.

Coding & Documentation

And what about coding? Using improper codes can bring down the value of the personal injury case in the adjuster’s eyes. It can also give the patient attorney a headache, and you don’t want to be the cause of an attorney’s headache. After all, the attorney wants to be able to rely on you, the medical provider, to know and understand how your coding practices can impact a case.

Here are a few things to consider for coding in PI.

1. More is not better. Using a laundry list of codes can make it seem like you are padding your bills. Diagnose all injured body areas, of course, and then treat those that fall within your expertise. Do not go on a Where’s Waldo hunt looking for obscure codes that you can apply. Instead, apply the right codes, and move on.
   
   • Never, ever upcode. If you apply additional codes to PI patients to pad the bill, you open your bill to attack. Worse, you may be guilty of medical billing fraud.
2. Remember that your job is to do what is medically necessary. You may have used some modalities early on that simply are no longer necessary. For instance, did you apply a hot pack when the patient first limped into your office? That hot pack was likely medically necessary, but the patient can apply their own hot packs in future visits. Did you timely refer out to imaging or a specialist as soon as medically indicated? Delays in PI are attackable inactions.
3. Consider the use of trauma and trauma-related language. From a legal perspective, trauma is the name of the personal injury game, leading to higher “pain and suffering” awards. It can elevate the value of a personal injury case.
4. Consider, too, the reasonableness of your per-visit fees. Your fees-per-code might be reasonable, but is your total per-visit charge also reasonable? If you are applying too many codes with an associated price tag, you might be accused of padding your bills.
5. Document, document, document. Documentation in most medical practices is sorely lacking. In PI, that can be a case killer. Your documentation should tell the story of the patient’s health before and after the PI incident, and how the incident impacted that patient’s life through their activities of daily living (ADLs). Your documentation needs to tie in and support your diagnosis, treatment, and billing. Proper and thorough documentation is a key area of coding properly, especially in personal injury. (And while you are at it, check out this article on storytelling documentation, the best practice for keeping powerful SOAP notes to help patient attorneys.) 
   

A Couple of Don’ts

Here are a couple of do nots related to documentation:

1. Never diagram accidents, and never ask your patients to diagram accidents. Neither you nor your patient are an accident reconstructionist. What your patient described to you might not be the same as what the patient described to the attorney or an adjuster, so your diagram might hurt the case. A savvy adjuster or defense attorney will use any reason they can find to not pay, so the diagram you keep might create a liability or causation issue when none existed before.
2. Do not use pain scales that the patient identified alone, confused as to how to approach this area. Pain scales are horribly subjective. One patient might think a stiff neck is unbearable and mark her pain as “very severe” (a “10”). Another patient with the same injury might think, “Well, I suppose getting tortured would be more painful, and I don’t want to come across as a baby, so I’d say this is mild” (a “3”). Again, keep in mind that the defense will look for holes, so never ask a patient to identify their pain on a pain scale unless you are there to explain the rating system, answer questions, and guide them through the process.

At the end of the day, attracting the best attorneys boils down to this: taking care of your patient, setting reasonable fees that are supportable, and using proper coding that is supported by thorough documentation. When you know what a patient attorney is up against—namely, the Big Bad Wolf of Insurance—you can shift your behavior so that you make life a lot easier for the best patient attorneys and keep them on your side, sending you a steady stream of referrals. In the process, you will also find you have also set yourself up to properly defend the attacks by less scrupulous attorneys looking to pay you less, just because they can (or want to).