The Other White Meat

For the past year, this column has dealt with the workers' compensation arena, paying little attention to "the other white meat," or better stated, the other popular revenue stream for the treating practioner, personal injury.

Personal injury (PI) pertains to injuries other than those occurring in the work place in which liability for the injury is either accepted or litigated, i.e. auto accidents, slips and falls, or on premises liability. Injuries of this nature typically involve some form of negligence on the part of a person or company necessitating treatment of injuries and compensation for those injuries in the form of pain and suffering; wage loss; impairment or disability; future medical; or even loss of consortium. In some instances, employees who sustain an injury during their course of employment may have an overlapping liability with a third-party necessitating a civil action (e.g., suffering an automobile accident while delivering a pizza for Pizza Hut).

The insured's choice of treating physician/s may initially focus on traditional medicine or physical therapy unless the injured has been a patient of yours prior to the event. As either the primary treating physician or the one chosen to work under prescription, fees remain consistent with your usual and customary charges, contrary to reports that "med pay" has no ceiling or cap and that in this market, you can get "what you are worth." Not so! More about fees in a moment.

Patients often enter this personal injury game with attorney representation before choosing a physician. During the course of retaining their attorney, patients often relinquish control over payment or distribution of monies to the treating physician. Counsel then channels all reports and billings from the treating physician through their office staff, collecting the "med-pay" from the patient's own automobile insurance carrier. Since the patient signed a power of attorney, counsel has every right to perform this task. The problem arises when this same attorney begins to distribute the funds after your patient completes treatment. Remarkably, there is not enough money to go around, so the attorney of record asks all the doctors, "even myself," to take a cut or reduction, usually by one-third.

Because you agreed at the beginning of the case to treat the patient on a lien (in workers' compensation it's called a green lien; in this case, just an attorney lien) in essence, choosing not to collect payment from private or automobile insurance sources, the patient's counsel now has tremendous power to negotiate with you, often finding fault with your billing, records or reasonableness of care, despite the fact he/she may have given you assurances that your lien would be honored or sent you the case in the first place.

This scenario can only happen if you: 1) agree to payment on a lien basis praying that the case will settle soon and at full value of services provided; and 2) don't counsel your patient to not sign a power of attorney.

Medical coverage on an automobile policy pays in addition to any private insurance policy unless the latter has a subrogation clause or the ability for the private carrier to get reimbursed. These monies need not go to any attorney, but there is an exception: if the med-pay is from the other party (the party responsible for the injury, not the patient's own carrier), no payments of bills will be made until the patient is released from care and a settlement reached with the injured or his/her counsel. The attorney is in the way again!

The questions are: Should I treat a PI case? Absolutely!

How do I avoid these pitfalls you discussed? Try the following:

1. Develop a good working relationship with several attorneys you would like to receive referrals from. Find out their policies on power of attorney, and obtain the names of other physicians they refer to. Often a call to these other physicians will give you a good profile on the character and business practices of the attorney.
2. I have brought up the issue of fees before, so here is the simplest solution to billing PI charges. Use the CPT codes charging your "usual and customary" fees. Remember, you can only have one fee schedule in an office unless you are billing for contract care. One rule of thumb is to establish fees based on the OMFS (official medical fee schedule) used for billing workers' compensation patients. Workers' compensation fees are basically set at the 80th percentile of usual and customary charges for similar services in the state per specialty, so adding 20% would give you a reasonable baseline for PI billing. Make sure the code numbers are applicable for nonindustrial services.
3. Keep pristine records of all treatments rendered carefully, noting any remissions or exacerbations. History of injury or etiology of complaints is critical to the foundational issue of treatment. Failure to document will surely compromise your position that all charges are reasonable and reimbursable. This is the one sure area attorneys and carriers will focus on to reduce the value of your treatment. Poor history, failure to record levels of pain by location and intensity, and the absence of accepted Western diagnostic protocols to establish a treating diagnosis will cost you dearly.

Remember: if you're thinking of changing your diet to include "the other white meat," choose your restaurant carefully. Always keep in mind the well-being of the patient, not losing sight of the fundamental issue of overhead management. Uncollected liens are not redeemable at your local store, and landlords have little sense of humor around the first of the month. Although a full waiting room is very satisfying and rewarding, it will soon be filled with other physicians' patients after you lose your lease.

Sound a little bleak? Probably, but knowledge is power and control over your bottom line is your patient's guarantee that you will continue to be able to provide quality services. Remember that the patient is paramount in this treating module. Awareness of the pitfalls of reimbursement will insure compliance of your treatment plan and proper compensation of your services.

Watch for seminars dealing with your role as the primary treating physician in PI. In the greater Los Angeles area, the Southern California Trial Lawyers Association, USC Extension and several private law firms offer complete and ethical programs deserving of your attention.