Other “indicators of fraud” include that a claimant is represented by an attorney; that a claimant’s injuries are subjective; that the insured had a pre-existing injury or health problem; that the insured’s car was new; and that the insured’s car was old. The presence of any two indicators in a claim pushes it into the fraud funnel.


The fraud funnel has excreted billions of dollars into the pockets of insurers over the past 20 years. Its biggest moneymaker though, has been using accusations of fraud to undermine the credibility of chiropractors, who are the doctors most often providing treatment to auto accident patients across the country.


This idea is obviously no new thing (recall the AMA’s Committee on Quackery). The major auto insurers, however, have turned attacking chiropractors into huge profits.


once identifies a “pattern” revealing that most patients receive similar diagnoses and treatments in similar durations.1


This “newly discovered


pattern” demonstrates that the doctor was not rendering care based on the individualized needs of patients, but rather on a “predetermined treatment protocol” designed to maximize billing and defraud the insurance company. The subsequent fraud lawsuit demands repayment of every dollar ever paid to the doctor.


But left with only good doctors to accuse of fraud, insurers needed more than just their invented indicators to support the pretense.


Beginning on the east coast in the early 2000s and spreading slowly west since, major auto insurers have been filing massive fraud lawsuits alleging RICO conspiracies and worse against chiropractic practices in major metropolitan areas. The initial targets were the fly-by-night clinics and mills clearly propped up to milk the tort system rather than provide quality, needed care. But there are only so many of these bad actors available to sue.


Fraud lawsuits are about generating headlines and creating a perception of rampant fraud occurring in bodily injury claims in the major cities. The net value of these headlines to the insurance industry is measured in the tens of billions of dollars, which has only created an insatiable appetite for more.


But left with only good doctors to accuse of fraud, insurers needed more than just their invented indicators to support the pretense.


Thus was born the accusation of fraud based on “predetermined treatment.” “Predetermined Treatment”


Consider just the last ten auto accident patients you treated. How many of them received an adjustment? An examination? Massage? Therapeutic exercises? Ultrasound? How many had a diagnosis of neck or back pain? Could you say that the treatment of 80% or more of just these ten patients included most of these treatments and diagnoses? Now consider all of the patients you have treated over the past seven years. Would the percentages be that much different? If your practice is like most which regularly treat patients injured in automobile crashes, the treatments you have provided and diagnoses you have made over time will have been consistently similar for all patients.


Over the past several years, as they have ranged farther and wider for chiropractors to attack, insurers have invented “predetermined treatment” as the basis for accusations of fraud. The claim is that treatment looks reasonable and necessary in individual claims, which is why it was paid when the bills for treatment were submitted. But after many years of receiving bills and records from a particular chiropractor, some enterprising SIU adjuster looking over many files at


To defend yourself against a lawsuit alleging “predetermined treatment” of hundreds of past patients, you will incur hundreds of thousands of dollars in legal and expert witness fees attempting to justify the treatment you provided for each patient. While the case is pending, the insurer will withhold payment on every bill you submit. If you want to avoid the crippling expense and severe emotional trauma of years of litigation, the insurer will settle for pennies on the dollar of what they claim as damages, but you will have to agree never to bill that insurance company again, and never support the injuries of a patient making a claim against that insurer. Either way, your practice, your relationships with your spouse, kids, friends, co-workers, and employees, will be decimated.


But the result is meaningless for the insurance company. Their goal is achieved with the headline they get merely by suing you.


Protect Yourself


Certain steps can be taken to protect yourself from the fraud funnel. First, make your records more detailed. Tell the story of your treatment and its reasoning. You can protect yourself by creating detailed records which prevent anyone from undermining the credibility of your care.


Second, understand that insurance adjusters see you as nothing more than an indicator of fraud. Do not make the mistake of providing them access to your office or your business records or any other documents to which they are not immediately entitled by the terms of your patient’s authorization. You cannot convince them to respect you. To them, you are nothing more than a ledger entry.


Finally, never offer a statement to an insurer without counsel. The insurer’s only purposes are to get information which they can use to characterize you as a fraud and/or deny payment for your services. They will employ questioning that you are not prepared for and may respond to inaccurately. You cannot retract a statement made under oath, so protect yourself with counsel who understands the purpose of every such inquiry.


Don’t Let Yourself Be the Next Headline


Every doctor I have represented around the country who has been falsely accused of fraud has said the same thing to me: “I never thought this could happen to me.” They all believed their honest professionalism protected them. It does not, nor will yours protect you.


Understanding that your mere existence makes you a target is your best defense against becoming the next headline.


1 How and why doctors get singled out for such retrospective reconsideration is a much broader subject.


Plexus


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