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Shaw Chiropractic
A Medical-Legal Newsletter for Personal Injury Attorneys
by Dr. Steven W. Shaw

What do you do when the adjustor says...

As difficult as times have become over the past several years I still believe that a personal injury practice is a desirable practice for both physicians and attorneys. Sure, insurance companies don’t want to settle cases and settlement offers are ridiculously low. Medical and chiropractic bills are constantly being discounted by carriers with claims of over utilization or unnecessary care. Does this mean that the end is near? Hardly, I believe it means that we had better pick our fights and stand up for our patients and clients. What has really changed is that we are all much more accountable to justify the care we give as physicians and the demands you make as lawyers. We need to be reasonable with treatment and not let the adjustors or defense council beat us down with unjustifiable and sometimes unscrupulous accusations. This newsletter will address the commonly used tactics by adjustors to discount the value of the file.

The first thing which needs to be realized is that not all cases are worth the big bucks. If a patient enters my office with $175 dollars in property damage from an accident in a parking lot which occurred 9 months ago and no treatment to date my first thought is "How can I help this patient and not appear unreasonable?". Can a patient be injured in this type of injury? Of course, and I could site all kinds of research about low velocity impacts and the mass of the cars and laws of physics but lets be reasonable. No one, especially an adjustor, is going to believe that the above described scenario will result in a 10% impairment with the need for $5,000 in medical specials and 2 months out of work. Why is it that some doctors and lawyers try to make a killing on every single case? Perhaps because it is tough out there some feel need to optimize value on every file. Personally, I believe that you the lawyer and I the doctor need to tell our patient and client the reality of the world as it exists today. Let them know that you will do your best to represent them but they need to set reasonable expectations. If you loose a client its probably a client who would have been disenchanted regardless of the outcome. However, if the client understands the potential outcome of their case it can be moved quickly with little stress on the part of the doctor, lawyer or client.

Now for the other side of the story. A patient is severely injured and the time line of care is reasonable. Medical bills follow a typical rehabilitation program resulting in $2,000-$3,000 in expenses. The patient cannot work and is left with a permanency. The adjustor still does not want to be reasonable. Their job is to save money and they are trained to have an answer to every argument they put forward. Some adjustors have gone so far recently to slander lawyers and doctors suggesting that impropriety exists. Enough is enough. While I don’t expect to be paid for unreasonable care I do expect to be judged for the work I do. Recently, some adjustors have become so bad that it is time to become proactive and make a stand. Below are some of the recent comments that have come back to me with my recommended responses?

Adjustor: The treatment was all chiropractic so the case has no value or less value.

Answer: Sure the treatment was all chiropractic but the diagnosis and mechanism of injury are consistent with one another. Further, the bills were within usual, customary and reasonable guidelines for the type of injuries sustained and the program of care was within established rehabilitative guidelines. Would you rather have had indefinite physical therapy care which is more expensive and proven not to be as effective?

Adjustor: It was only a soft tissue injury

Answer: Only soft tissue? You realize a brain injury is only a soft tissue injury? How about a spinal cord injury or a shoulder dislocation? If a football player has an ACL tear it could end his career. But it’s only a soft tissue injury. For some reason "soft tissue" has earned a bad reputation. Soft tissues of the body include muscles, tendons, ligaments, fat, nerves and all other connective tissue. When healed there is always disorganized scar tissue replacement of damaged soft tissue. This is always associated with contractures and adhesions to adjacent healthy tissue. While the treatment allows for improved healing it rarely if ever allows for complete restoration of the pre-existing soft tissue. Think of an ankle inversion sprain. Once you have had the soft tissues stretch beyond their viscoelastic range the ankle is prone towards repeated injury. Now apply this to the spine. A much more complex joint that protects extraordinarily sensitive nerve tissue. The potential complications are mind boggling. Don’t tell me it was only a soft tissue injury.

Adjustor: Its just another Dr. Shaw case. He treats all your (Hispanic) accident cases.

Answer: Not true although many of my clients choose to use Dr. Shaw’s offices. Keep in mind that Dr. Shaw has offices all over the state. Dr. Shaw has seven chiropractic physicians on staff with two board certified chiropractic orthopedists and six locations. Also, the Shaw Chiropractic offices have chosen to only treat traumatic musculoskeletal injuries so naturally they are involved in many of my personal injury claims. His offices are sensitive to the needs of the traumatically injured patients and they accommodate people of many different cultures. In fact, their staff speak fluent Spanish, Portuguese, Italian, Polish and French. Dr. Shaw speaks publicly on musculoskeletal injuries and because of his advertising and public relations efforts is a well recognized figure in the Hispanic communities of Connecticut . He was recently recognized by the Latino Community and was awarded the Latino Community Service Award.

Furthermore, I personally know that Dr. Shaw requires all his staff physicians to regularly participate in postgraduate education related to injury management and I have found Dr. Shaw and his associates to be objective and reasonable in their case management. I can’t say that about other chiropractic offices with which other of my clients have treated. I feel confident that my clients are treated properly and appropriately when Dr. Shaw is involved in the case management

Adjustor: 5%!!! Everyone gets 5% from a chiropractor.

Answer: I disagree. I have had many cases, more than I care to, that have not had ratings from Dr. Shaw. Unfortunately, the only time you and I need to negotiate is when a rating exists and therefore from your perspective all patients are rated. Take it from me because I have seen both kinds of cases. The reason I like Dr. Shaw’s reports is because he is reputable and he can document and support his opinions. In fact, I have found that the ratings given by Dr. Shaw are reliable and reproducible when referenced to the AMA Guides to the Evaluation of Permanent Impairment. I have never seen unexpected impairments unless there are circumstances which Dr. Shaw can support. Shaw Chiropractic physicians always do inclinometric assessments for objectivity and reference the Guides. Further, I have found that Dr. Shaw often reduces the allowable rating because the patient and the rating just don’t seem to fit. So your argument that all patients get a 5% is not supported by my experience with their office.

Adjustor: The patient was over treated to inflate the value of the case.

Answer: My client is dammed either way. If the bills are too low the injuries are not significant. If they are too high the care was too much. Let me tell you about appropriate care as defined by the medical and rehabilitative experts. In a typical moderate impact injury without complications active acute care will range from 2-4 weeks at a frequency of 3-5 visits per week. Subacute care or rehabilitative care will last for an additional 8-12 weeks at a decreasing frequency of 1-3 visits per week. This should be followed by a clinical trial of withdrawal from care and monthly or bimonthly checkups to assure medical stability. The total visits should range from 18-35 visits with bills in the range of $1,500- $3,500. Clearly, the treating physician or therapist should dictate reports and notes documenting the need for care which is administered and I have reviewed the notes on this client and everything seems appropriate. In fact, the doctor seemed to be somewhat conservative. Have you read the notes and reports?

Adjustor: If your client was so badly injured why didn’t he have an MRI or CT scan or consult an orthopedic surgeon or neurosurgeon?

Answer: That is exactly the question I asked Dr. Shaw and his answer made sense to me. He said that since the patient had soft tissue injuries without neurologic complications an MRI or CT scan would have only added cost to the care and not have altered the conservative management. With regard to the orthopedic referral he stated that he regularly refers patients for extremity complaints. For spinal complaints without spinal cord or nerve root symptoms orthopedic and neurosurgical referral are often not very helpful since these specialists are surgeons. In the absence of surgical indications there is no need for surgical consult. He stated the best suited doctors for these type of injuries are conservative musculoskeletal physicians such as chiropractors or physiatrists.

There are many more comments and answers but space is limited. Having never negotiated a settlement for a patient my responses may seem trite but from my perspective necessary. If an adjustor has his/her mind made up there is nothing you can say or do to change matters. If you do have an adjustor with an open ear perhaps these suggestions may make the difference between going to court and settling a case for full value.

Its time to pick our fights. Nobody wants to waste time in court unnecessarily but when push comes to shove something needs to be done. In my offices we have started picking files which represent rock solid cases from a treatment perspective. If you find that you have a case that you want to pursue to its end then we are here for you. Jury verdicts have not been very promising but that is because we have not chosen the battle. Its time for lawyers to argue some cases and show the system that soft tissue claims can be very real.

Topics for future newsletters are becoming increasingly difficult to pick. I would like some feedback from those of you who read the newsletter. How about research review, basic anatomy and physiology, diagnostics, mechanism of injury, accident reconstruction, soft tissue repair, glossary of medical terms, etc. If you want the information I will find it for you. Your input will be helpful. Call me at 860-522-2225 or write to our office at one of the below addresses.