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Over the years, we have had many requests for holding our seminar twice a year. So, we thought we would give it a try. Utah's Best Chiropractic Spring Seminar will be on Thursday, May 22, 2003, 8:00 a.m.-5:00 p.m. at the Salt Lake Community College Miller Campus.
The cost will be $40 per person which includes a continental breakfast, lunch, snack, drinks and handouts. Look for more info in upcoming issues.
Published in Neuroradiology 44(7):617-24,202
Our aim was to characterize and classify structural changes in the afar ligaments in the late stage of whiplash injuries by use of a new MRI protocol, and to evaluate the reliability and the validity of this classification. We studied 92 whiplash injured and 30 uninjured individuals who underwent proton density weighted MRI of the craniovertebral junction in three orthogonal planes. Changes in the alar ligaments (grades 0-3) based on the ration between the high signal area and the total cross-sectional area were rated twice at a 4 month interval, independently by three radiologists. Inter - and infra observer statistics were calculated by ordinary and weighted kappa . Cases classified differently were reviewed to identify potential causes for disagreement. The alar ligaments were satisfactorily demonstrated in all cases (244 ligaments in 122 individuals). The lesions, 2-9 years after the injury, varied from small high-signal spots to high signal throughout the cross sectional area. Signal was highest near the condylar insertion in 82 of 94 ligaments, indicating a lesion near that insertion, and near the dental insertion in eight, indicating a medial lesion. No grade 2 or 3 lesion was found in the control group. At least two observers assigned the same grade to 214 ligaments (87.7%) on the second occasion. In 30 ligaments (12.2%) this agreement was not obtained. Pair-wise inter observer agreement (weighted kappa ) was fair to moderate (0.31-0.54) in the first grading, improving to moderate (0.49-0.57) in the second . Intra observer agreement (weighted kappa ) was moderate to good (0.43-0.70). Whiplash trauma can cause permanent damage to the afar ligaments, which can be shown by high-resolution proton density-weighted MRI. Reliability of classification of alar ligament lesions needs to be improved.
The authors of this study report that the standard approach to MRI, as concems the alar ligaments, is diagnostically inadequate. The T1-weighted image gives poor contrast resolution while the T2-weighted image provides inadequate discrimination between ligament, bone, and soft tissues because of its low signal-to-noise ratio. Thus they used the proton-density weighted sequence and discovered that a significant proportion of their whiplash group subjects had areas of high signal intensity, indicating ligamentous lesion. These were not found among the control group subjects, who were matched for age and sex.
There are a few special things to consider when looking at this paper and, in fact, I have e-mailed the lead author with a few questions of my own. The term "whiplash" was not defined, operationally, by the authors. Some authors include virtually any form of neck or cervical spine injury under this term, whereas others, such as myself, tend to use the term to indicate a rear impact crash vector - an important consideration since we have demonstrated that the acceleration to the head (which can injure alar ligaments among other things) can be as much as 4 times higher in a rear vs. frontal crash, all other variables held constant. Moreover, the epidemiological and clinical literature support a significantly worse outcome for rear impact crash injuries compared to frontal and side impact crash injuries.
The authors selected only Grade 2 cervical acceleration/deceleration (CAD)/whiplash-associated disorders (WAD) injuries (their rationale for excluding more severe grades was not given). Patients were graded during the acute phase and again at 12 and 16 weeks. So we know that the patient group had symptoms at least for 4 months. However, since the mean time between injury and the MRI study was 6 years, and since no assessment of the patients' complaints ( if any) were reported around the time of the MRI, we are left to wonder what proportion of these patients might have still been symptomatic then. [Note: the title of the paper suggests that these were chronic cases, but I don't think we can necessarily interpret it that way.] This is a very important matter to clarify and I shall do so in a future edition of the CRASH Report if Dr. Krakenes gets back to me with the answer. If it were the case that many otherwise recovered whiplash patients do have these high signal areas, the findings will have much less significance than long-term symptoms. It would also be interesting to compare such lesions with those seen on digital motion x-ray studies. None of the patient groups had abnormal radiographs, but the radiographic procedures were not described and it is unlikely that flexion/extension films were obtained in the majority of cases.
One small criticism I have is that the MRI photographs, while excellent in quality, lacked the "arrows, arrowheads, and lines" promised in the figure legends, which is likely to be a bit vexing for those of us who are not radiologists.
It would be interesting to include more severe grades of CAD injury in a future study and to correlate grades of impairment using standard outcome assessment tools (Neck Disability Index, VAS pain scores, cervical spine range of motion, etc.) in order to determine the potential to use MRI in a more reliable and objective way in these patients.
Krakenes J, Kaale BR, Moen G, Nordli H, Gilhus NE, Rorvik J: MRI assessment of the afar ligaments in the late stage of whiplash injury - a study of structural abnormalities and observer agreement. Neuroradiology 44(7):617-24,202
We've seen it all before. Many times. A patient finds their way into your chiropractic office after an automobile accident (or other injury). Sometimes they're there because they were recommended to see you. Sometimes they're there because you are one of the physicians on the PPO list of their group health insurance. In any event, they're in your office for care andtreatment. Because your CA has attended one of our seminars, she knows which no-fault or Personal Injury Protection (PIP) insurance company to bill. The no-fault coverage runs out and you make the decision to continue treating the patient. After all, you're protected by a lien against the third party claim with Larson & Company. The good doctor decides that he doesn't want to bill the group health insurance carrier for amounts incurred after the no-fault benefit's exhausted.
The CA doesn't want to do the paperwork, and the doctor doesn't want to take the discount which the group health carrier will impose on the amounts submitted to them for payment After all, the doctor is protected by a lien.
Sound familiar? Are you guilty of this approach? If so, you're doing it wrong. It is essential that you bill the health insurance carrier when such coverage is available to the patient This is true even when it's a personal injury case and even when the unpaid balance is protected by a lien
There are several reasons for this. First, your patient has purchased health insurance and is entitled to the benefit of his bargain, whatever that bargain may be.
Second, as the patient's attorney and advocate, personal injury attorneys are obligated to do the best they can to get the best economic benefit for the patient Most group health insurance carriers are required to be reimbursed (subrogation) if money is collected from a third party. However, after they have paid out their benefits, health insurance is generally willing to take a reduction towards the attorney's fees assessed against the collection of the full amount from the third party. This means that if the group health insurance carrier pays out $100, they will typically accept reimbursement of only $66.66 as full reimbursement for the amounts they have paid out Any amount of reimbursement which the patient is required to reimburse either to the physician or to the health insurance carrier is paid out of the patient's portion of the settlement since the attorney's fees are taken off the gross settlement Therefore, it is cheaper for the patient to run as much of his medical bills through health insurance as the health insurance will pay. As the patient's advocate, a personal injury attorney is obligated to try to see to it that this is what occurs in order to produce the best result possible for the patient.
Third, billing the health insurance will generally result in an earlier payment to the doctor for that portion of the bill than waiting for the third-party case to resolve.
In difficult cases where it is questionable that the patient will receive very much in pocket after all the doctors, lawyers (and Indian chiefs) are paid, the more money that we can put into the patient's pocket increases the likelihood of the patient's willingness to accept an offered settlement. Some patients will refuse to accept a settlement if they don't receive enough money in their pockets. Consequently, if your patient is represented by a good personal injury law firm, the attorney (as well as the patient) will insist that anything that is payable through their group health insurance be paid through that plan. If the physician does not like being a member of the PPO component of that group health carrier because of the discounts required, we encourage you not to be a member of the PPO. We know of several physicians who are increasingly dissatisfied with health insurance reimbursement rates and are consequently removing themselves from the preferred provider list. In the event that a settlement is reached and we learn that the physician has not submitted the billings to the group health carrier, money sufficient to pay the physician's lien will be set aside and held in trust until after the group health insurance carrier performs its payment obligations on the dollars involved. This will inevitably cause a time delay in the physician getting his money, but it will provide the patient with the benefit of the bargain of the health insurance he purchased.
The above comments should not be taken as an endorsement of health insurance in general. Most health insurance carriers are pirates of the same caliber as property and casualty carriers. However, it is a reality of our way of life that many people are going to purchase health insurance or have it provided for them by their employers. Sometimes they will initially go to a chiropractic physician because he is listed as a preferred provider with that health insurance carrier. There are balancing values when a physician decides whether or not to become a preferred provider. On one hand, the doctor may get some additional patients that might not otherwise be treated by him. On the other hand, there is the indignity of the discounts that are forced upon the doctor for the work that is performed after the fact. Your own personal set of values will determine what is best for your practice. Nevertheless, for those patients who come in with health insurance available to them which covers chiropractic, the health insurance should be routinely billed as soon as treatment starts or as soon as the no-fault or Personal Injury Protection benefits are exhausted if the matter involves an automobile accident. If you are not a preferred provider and are not required to take only the discounted payment for the care you give, any unpaid balance will ordinarily be covered to the extent possible through the lien process. If you are a PPO listed doctor, we feel sorry for you but we can't let you take it out on your patient The patients won't let us.
In short, when an automobile accident victim comes into our facility for care, the order of billing is as follows:
First , bill no-fault or PIP
Second , when PIP is exhausted, submit those bills which are not paid by PIP to health insurance
Third , any bills not paid by PIP or health insurance are billed against a lien on the cause of action if that patient is represented by an appropriate law fume.
This approach is not double dipping. No one is double paid since each insurance only pays its respective portion under its terms. Whatever is left over is paid to the extent of the lien.
In every situation, the patient ultimately remains personally responsible for payment of their balance for their bills. This is true even if for some reason the law firm misses the lien in the file at the point of closure and fails to protect your interest. In the event this occurs, whether it's initially by the law firm or as a simple clerical mistake (as can happen), the patient doesn't suddenly avoid responsibility for his or her bill. All that the hen does is give you an additional avenue to demand payment It gives you a potential cause of action against the law firm if the debt is uncollectible from the patient If needed, you can sue the patient, lawyer or both.
Dr. Jack Cracker, who's a crackerjack back cracker is out this month following a lead that he was given on another insurance scandal. He will be back next month to share the information.
We are now accepting referrals for both Personal Injury and Workers Compensation cases. Here's how to refer your patients to us:
1. Talk to your patient about the need for legal help. Have them read through our brochure (if you need some brochures, call Amanda at 801-446-6464).
2. Either you call us or get permission for us to call the patient. When you call, ask for a member of Bryan Larson's staff. This is critical. You want your patient's case handled by Bryan Larson. If all you do is give your patient our number, they may call or they may not call. If they don't call, their case is in jeopardy.
3. When we talk to your patient, we will go through a short list of questions to get a background on his/her accident.
4. If we are able to help them out, we will set up a free consultation for your patient to come in and talk with us.
5. If we are unable to help them out, we will call and let you know why.
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