Cost Savings for P & C, Work    Comp or Auto Claims       Using In-HouseOn –Line Case Management andResource Allocation In...
Value of MCD tests for a company• On-line, easy to use, case management tool used in  house by the medical department of a...
Reserves of “Bad (untreatable) Diagnoses” which convert to“Good (treatable) Diagnoses” with proper medical evaluation,    ...
Background of Authors of the Test Research•   Donlin Long, MD, Ph.D. former chairman of neurosurgery Johns    Hopkins Hosp...
What are the issues?• Cost containment. How do you achieve this?• You margins are shrinking, so you need to control  worke...
www.MarylandClinicalDiagnostics.com      Internet Case Management and Resource Allocation System                       Spr...
Ease of AdministrationMCD tests can be administered through WorkSTEPS, which isthe largest pre-employment testing company ...
The MCD in-house case management tools for a carrier                                                         Proctoring Lo...
How the Adjuster Uses the MCD Tests• The PVT test tells the adjuster if a claimant is faking  and exaggerating or has a va...
FRAUD DETECTIONThe Action Plan For Using the MCD         Pain Validity Test
A carrier vs MCD methods of Finding Fraud The Old Subjective Method        The MCD Objective• Claim is identified by      ...
California Does a Poor Job of Combating            Worker’s Comp Fraud     (Workers Compensation Report, Vol 15, No. 11, p...
Outcomes from “Standard Insurance               Practices”• Is an independent medical evaluation cost effective? Do  they ...
Average Cost Savings $1,654 Using Pain Validity TestNational Council on Compensation Insurance (NCCI)published a report As...
Scattergram of Computer Scored MCD Pain Validity Test.On the left, 3* is a severe abnormality, 2 a moderate abnormality, 1...
COST SAVINGS USING THE PAIN VALIDITY TEST- SAVE $1,802,000 on 1,700 CLAIMSSuspected FakerCurrent MethodsDetectives        ...
PROPER DIAGNOSISor what to do with the 87%-94%   of patients with a valid pain            complaint    Action Plan for the...
Failure of Chart Review Process• Very often, doctors do not ask the questions they  need to determine if a patient’s compl...
Action Plan -How do you achieve accurate       diagnoses and proper treatment ?• Use automated history taking. A proper hi...
Missed Diagnoses-Neck and Back Pain• The Johns Hopkins doctors did a study of 60 and 120  patients admitted to a pain clin...
Reserves of “Bad (untreatable) Diagnoses” which convert to“Good (treatable) Diagnoses” with proper medical evaluation,    ...
Lumbar and Cervical Strain•
When a Sprain or Strain Lasts More        than 6 weeks-What is it?• If a ligament pulls off a bone, there is excessive mot...
Cost Containment for Sprains                                        • Diagnosis of lumbar• Sprain cause an average of 7.5 ...
Action Plan to Prevent Unnecessary    Surgery or Get Surgery if Needed• Using Treatment Algorithm, and do the proper  test...
Flaws with Just Anatomical TestsMRI- Jensen et. al. (N. Eng J. Med, ’94), 92 patientswith no back pain, but 27 had protrud...
Review of a Bus Company Charts• All cases are 6 months old or older• Of the 260 case cost summaries sent for  evaluation, ...
Summary – 260 Bus Company Cases –sprain or strain N =126             433,879.03 STRAINED BODY PART           433,879.03   ...
Cost Containment for RSD (CRPS)• Johns Hopkins doctors report that    • Misdiagnosis of RSD-3 yrs  80% of all RSD cases ar...
Diagnosis of RSD vs Nerve Entrapment    Stanton-Hicks, Baron, Boas, Gorddh, Harden, et al, Complex Regional Pain    Syndro...
COST SAVINGS USING THE DIAGNOSTIC PARADIGM = $13.000.000 for 170,000 insured workers withlumbar/cervical strain casesCurre...
Does your current system work?• How do you measure if a methodology works?• Do you ask a patient if they hurt less? No val...
Published Outcome Studies-for Litigants*- out of work    for more than 2 years from a clinic using the MCD tests          ...
Advantages of the Tests for Adjusters• Simplifies the decision making process• Saves the adjuster MCD and money, since all...
PVT-Saves $1,654/case• The current methods of assessing fraud are not cost  effective, as documented by the State of Calif...
Diagnostic Paradigm –Saves $80,000• 40%-71% of litigants with chronic pain problems are  misdiagnosed. Just “sprains” alon...
CONTACT INFORMATION• www.MarylandClinicalDiagnostics.com• Mailing address    440 South El Cielo Rd suite #3660    Palm Spr...
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Cost savings for insurance

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This presentation describes mehtods of fraud detection, which can save a slef insured company an average of $1,654 per workers compensation claim, same quarter savings. It also describes techniques, using Internet based tests, developed by a team of doctors from Johns Hopkins Hospital, which improve diagnoses, resulting in increased return to work rate, a 90% reduction in the use of medication, and a 45% reduction in doctor visits, with documented cost savings of $20,000 to $175,000 for long test cases. See slideshare presentation
http://www.slideshare.net/DiagnoseMyPain/patient-cost-savings-documented-with-letters for documentation.

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Cost savings for insurance

  1. 1. Cost Savings for P & C, Work Comp or Auto Claims Using In-HouseOn –Line Case Management andResource Allocation Instruments from MCD www.MarylandClinicalDiagnostics.com
  2. 2. Value of MCD tests for a company• On-line, easy to use, case management tool used in house by the medical department of a company.• Saves the insurance adjustor time and money• Helps adjustor set proper reserve by providing accurate diagnosis for the misdiagnosed claimants• Helps adjuster allocate resources by providing an objective basis for selecting claimant for fraud evaluation. Saves money on fraud detection• Improved return to work rates, with less expense for medication and fewer doctor visits. Reset reserves.• For open claims, get case closure
  3. 3. Reserves of “Bad (untreatable) Diagnoses” which convert to“Good (treatable) Diagnoses” with proper medical evaluation, using the MCD Diagnostic Paradigm Wrong Diagnoses Correct Diagnoses • Fibromyalgia - $90,000 • Lyme disease - $50,000 • Lumbar Strain - $150,000 • Disrupted Disc (IDD)- $60,000 • Cervical Strain -$120,000 • Facet syndrome -$20,000 • Lumbago – $80,000 • Anteriolysthesis – $35,000 • Failed Back Syndrome – • Post laminectomy syndrome – $120,000 $80,000 • RSD (CRPS I) -$1,000,000 • Nerve entrapment –$50,000 • Causalgia – $450,000 • Thoracic outlet -$65,000 • Migraine Headache – $95,000 • C2-3 root - $45,000 Resettting reserves, based on accurate diagnosis results in immediate cash improvement, since lower reserves mean increased income
  4. 4. Background of Authors of the Test Research• Donlin Long, MD, Ph.D. former chairman of neurosurgery Johns Hopkins Hospital, founder and Director of the Pain Clinic, Johns Hopkins Hospital, professor of neurosurgery, Johns Hopkins University School of Medicine• James Campbell, MD –professor of neurosurgery, Johns Hopkins University School of Medicine, past president, American Pain Society• Reginald Davis, MD – former chief resident in neurosurgery, Johns Hopkins Hospital, assistant professor of neurosurgery, Johns Hopkins University School of Medicine, chief of neurosurgery, Greater Baltimore Medical Center• Nelson Hendler, MD, MS-former Assistant Professor Johns Hopkins University School of Medicine, past president, American Academy of Pain Management• Matts Gronblad, MD, PhD –Professor of Rehabilitation Medicine, Rehabilitation Institute, Turku, Finland• John Rybock, MD, assistant professor of neurosurgery Johns Hopkins University School of Medicine, assistant dean for academic affairs, Johns Hopkins University School of Medicine.
  5. 5. What are the issues?• Cost containment. How do you achieve this?• You margins are shrinking, so you need to control workers compensation costs with an in-house tool• Current fraud detection methods are not cost effective (Elaine Howe, State Auditor California)• Proper diagnosis and treatment with good doctors*• Proper treatment results in early case closure• Using *these techniques, Johns Hopkins Hospital cut their workers compensation costs in half, by ruling that any of the 15,000 employees injured at Johns Hopkins had to see Johns Hopkins doctors.
  6. 6. www.MarylandClinicalDiagnostics.com Internet Case Management and Resource Allocation System Sprains and strains are self limiting diseases, lasting no more than 2 months. Any “lumbar strain” or “cervical sprain” more than 2 months old is, by definition, misdiagnosed. Get the proper diagnosis & save moneyDetect Fraud. Accurately Set Reserves. Close Long Term Catastrophic CasesSTEP 1) Administer the Pain Validity Test (PVT) for all claims. Find the fakers. Fakers Real Pain2) 6%-13% of claimants will be 2) 87%-94% of claimants do not need IMEs, FCEsfaking. The PVT finds them with or surveillance but 40%-67% are misdiagnosed85%-95% accuracy. (Psychosomatics , 1993,1996). Reduce expenses 3) Use surveillance and MCDs on Strains last only 2 months. Get the correctpin- pointed claimants. Conserve diagnosis and proper treatmentresources. 4)Bring closure to the case 3) Administer the Diagnostic Paradigm ($800) to5) Average of $1,654/case, same get an accurate diagnosis, and treatment plan.quarter savings, by eliminating FCEs, Accurately set reserves.MCDs, and surveillance in 87%-94% 4) Get proper treatment. Increase return toof the cases (see Real Pain) work* 5) Bring closure to the case. Savings of $90,000 to $2,500,000 (Harvard School and *For claimants out of work for 2 years or more, return to work rates of 19.5% for Workers Compensation cases,of Cybermedicine, 2001) 62.5% for auto accident cases. The insurance industry reports less than a 1% return to work rate in these cases.
  7. 7. Ease of AdministrationMCD tests can be administered through WorkSTEPS, which isthe largest pre-employment testing company in the country,with 900 affiliated locations around the country, and 4,000corporate clients including: (over 100,000 tests/year)Barnes Aerospace Knight TransportationSYSCO Waste ManagementCOMAIR Kinetic Concepts, Inc.Chevron Conoco PhillipsNabors Drilling Trinity IndustriesBorden Republic ServicesJohnson Controls EmbarqProctor & Gamble Missouri DOTChaparral Steel Southern California Edison
  8. 8. The MCD in-house case management tools for a carrier Proctoring Location A carrier Administrator employee administers test to (needs company administrator handbook) claimant (needs test proctoring handbook) A carrier Administrator selects Proctoring Location insurance adjustors, in each office, Administrator selects who will determine which claimant employees to administer should get the MCD tests, and the test (needs proctoring monitor and direct the progress of the administration handbook) claimant Insurance Adjustors selects the claimant to take the MCD tests, & Claimant receives the letter. selects Proctoring Location, where the Claimant then schedules his claimant will take the own test with the testing tests. Then the adjustor sends Proctoring Location, the claimant a and goes there, letter, with instructions. with photo ID (Needs insurance adjustors handbook)When tests results are returned, adjuster either does fraud investigation or uses
  9. 9. How the Adjuster Uses the MCD Tests• The PVT test tells the adjuster if a claimant is faking and exaggerating or has a valid complaint of pain• When adjuster gets the results of the PVT, he (she) notes, in-house, which claimants are identified as exaggerating pain patients• The adjuster uses surveillance, IMEs and FCE to document the exaggerated claim, & deny payment• For claimants identified as objective pain patients, the adjuster requests a Diagnostic Paradigm for the claimant, gets the results, then resets reserves, & sends test results to the medical director or nurse case manager for disposition and management
  10. 10. FRAUD DETECTIONThe Action Plan For Using the MCD Pain Validity Test
  11. 11. A carrier vs MCD methods of Finding Fraud The Old Subjective Method The MCD Objective• Claim is identified by Method insurance adjustor as • All claims coming in potentially fraudulent, receive the MCD Pain based on subjective criteria, Validity Test, which length of claim, past claim identifies potential fraud record, etc with 85%-95% accuracy• Adjustor determines if • Only the claims with a claim goes to SIU, where high chance of fraud are expense of surveillance, referred to SIU nurse case managers, • Increased accuracy of IMEs, or FCE is incurred. claim selection saves What % hit rate? Costs? money for a carrier • Costs $300/claim
  12. 12. California Does a Poor Job of Combating Worker’s Comp Fraud (Workers Compensation Report, Vol 15, No. 11, p.206 May 17, 2004)• State Auditor Elaine Howle says the $30,000,000 annual expense in State of California to combat fraud may be wasted, because they select the wrong claimants to investigate most of the MCD• Insurance companies cannot measure the effectiveness of their efforts using independent medical evaluations and surveillance.• The companies are relying on anecdotal testimony from stakeholders in the workers compensation community, unscientific estimates, and description of local cases involving fraud.• The fraud division publishes statistics showing the number of investigations, arrests, convictions, and restitution, but cannot show if anti-fraud efforts are cost-effective. Saves $6 for $30 spent• The State may spend $5,000 a case investigating 6,000 cases ($30,000,000) and identify 600 cases of fraud (10 % accuracy)
  13. 13. Outcomes from “Standard Insurance Practices”• Is an independent medical evaluation cost effective? Do they ever say patient is misdiagnosed?• Is surveillance cost effective? In what percentage of cases are they used? When they are used, what percentage of the time do they find cheats?• Is “cookie cutter” (everyone gets the same treatment) chiropractic care or PT cost effective?• Is delay in treatment cost effective? Evidence?• Is a Functional Capacity Evaluation cost effective?• Information cannot be based on anecdotal reports. Are there references from the insurance literature to support cost effectiveness of these techniques? Is there evidence? Or is it “company policy”?
  14. 14. Average Cost Savings $1,654 Using Pain Validity TestNational Council on Compensation Insurance (NCCI)published a report Assessing Pain, Real andImagined (11/29/98 www.NCCI.com/painreal.html) Summary of the ReportThe Johns Hopkins doctors reported that 13% of workerscompensation claimants are exaggerating or faking.The MCD Pain Validity Test ($300) can identify fakerswith 85% accuracy, and valid complaints 95% of the MCD.Average savings of $1,654/claim, same quarter savings, byeliminating doctor exams, FCE, surveillance, and nurse casereviewer in the claimants with valid complaints (87%), andfocusing the surveillance on the 13% of claimants who areexaggerating pain patient. But which claimant should be investigated?The PVT helps the adjuster decide which 13% gets surveillance
  15. 15. Scattergram of Computer Scored MCD Pain Validity Test.On the left, 3* is a severe abnormality, 2 a moderate abnormality, 1 a mild abnormality, and 0 is no abnormality on at least one objective medical test. At the bottom, 8-25 represent the score on the MCD Pain Validity Test. 17 or less is an Objective Pain Patient, 21 point or higher is an Exaggerating Pain Patient*3 65/69 = 95% 2 Exaggerating Objective Pain Patient Pain Patient1 11/13 = 85%0 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
  16. 16. COST SAVINGS USING THE PAIN VALIDITY TEST- SAVE $1,802,000 on 1,700 CLAIMSSuspected FakerCurrent MethodsDetectives $2,500 Pain $300Independent ValidityMedical TestEvaluation $1,700FunctionalCapacityEvaluation $1,400TOTAL $5,600 $300Savings $5,300Number of Insured Lifes 170,000Number of WorkersCompensation Claims per Year-Lost MCDRate is 1% of all workers 1700Number ofWorkers CompensationCases/year lastingmore than three months 20% of all claims 340Total cost of Pain Validity Test =$300 X 340 $102,000Cost of old way $5,600 X 340 $1,904,000Cost savings to evaluate these claimsusing the Pain Validity Test $1,802,000
  17. 17. PROPER DIAGNOSISor what to do with the 87%-94% of patients with a valid pain complaint Action Plan for the Use the MCD Diagnostic Paradigm and Treatment Algorithm
  18. 18. Failure of Chart Review Process• Very often, doctors do not ask the questions they need to determine if a patient’s complaint of pain is valid.• Most of the IME doctors do not ask the questions they need to determine proper diagnosis• Chart review is inaccurate because the diagnoses are inaccurate 40%-67% of time• Doctors order the wrong tests. MRI 30% false +.• Therefore, “garbage in -- garbage out” or GIGO• Company missed real cost savings due to bad data
  19. 19. Action Plan -How do you achieve accurate diagnoses and proper treatment ?• Use automated history taking. A proper history gives a more accurate diagnosis. The Internet questionnaire never forgets to ask a question-Diagnostic Paradigm• A single question may have 30 potential answers• Since all doctors are not the same, the automated history taking eliminates inter-rater (between doctor) differences The Diagnostic Paradigm has 95% correlation with JHH.• Computer scoring gives consistent quality interpretation• Outcomes studies published in peer reviewed medical journals prove this techniques works.• Treatment Algorithm indicates proper tests to use
  20. 20. Missed Diagnoses-Neck and Back Pain• The Johns Hopkins doctors did a study of 60 and 120 patients admitted to a pain clinic.* (180 total) RESULTS• Prior to admission, 40%-67% were misdiagnosed with “lumbar strain, cervical strain, chronic pain syndrome, or conversion reaction.”• However, facet syndrome, thoracic outlet syndrome, damaged discs, nerve entrapments, and radiculopathy, were found in these patients, all of which were confirmed by objective testing. (*Overlooked Physical Diagnoses in Chronic Pain Patients Involved in Litigation, Part I and Part II, Psychosomatics, ’93 and ‘96)
  21. 21. Reserves of “Bad (untreatable) Diagnoses” which convert to“Good (treatable) Diagnoses” with proper medical evaluation, using the MCD Diagnostic Paradigm Wrong Diagnoses Correct Diagnoses • Fibromyalgia - $90,000 • Lyme disease - $50,000 • Lumbar Strain - $150,000 • Disrupted Disc (IDD)- $60,000 • Cervical Strain -$120,000 • Facet syndrome -$20,000 • Lumbago – $80,000 • Anteriolysthesis – $35,000 • Failed Back Syndrome – • Post laminectomy syndrome – $120,000 $80,000 • RSD (CRPS I) -$1,000,000 • Nerve entrapment –$50,000 • Causalgia – $450,000 • Thoracic outlet -$65,000 • Migraine Headache – $95,000 • C2-3 root - $45,000 Resettting reserves, based on accurate diagnosis results in immediate cash improvement, since lower reserves mean increased income
  22. 22. Lumbar and Cervical Strain•
  23. 23. When a Sprain or Strain Lasts More than 6 weeks-What is it?• If a ligament pulls off a bone, there is excessive motion around a joint.• This caused muscle spasm, because the muscles now have to do the work of ligaments to hold the bones together.• When a disc is damaged, and there is a loss of disc space height, then there is less tension on the ligaments that hold vertebrae together, and there is excessive motion at that vertebral segment. This results in an unstable spinal segment.• The patient needs discectomy and fusion.
  24. 24. Cost Containment for Sprains • Diagnosis of lumbar• Sprain cause an average of 7.5 sprain for 3 years days restricted activity, 2 days of bed disability, and 2.5 days work • Physical therapy loss (Dept. Health & Human or chiropractic $15,000/yr Services # PHS 87-1592, 1987). • Doctor visits for 3 years• If a cervical or lumbar sprain last $2,500/yr for more than 6 weeks, it must be • Medication for 3 years something else. Malingering or $12,000/yr real? Sprain or facet disease? 33 year old claimant- lost wage/yr• How many cases of lumbar and cervical sprain do you have that $18,000/yr are 3 months old or older? Total for 3 years $142,500• What is the reserve on these cases? Look at the costs. Diagnostic Eval. Using MCD Lab Studies, provocative disco $21,000 Discectomy and fusion $41,000 Total $62,000
  25. 25. Action Plan to Prevent Unnecessary Surgery or Get Surgery if Needed• Using Treatment Algorithm, and do the proper tests to determine is surgery is really necessary• Prevent mioptic approach-relying on wrong tests• If the only tool you have is a hammer, everything looks like a nail. Use provocative discogram• MRI has a false positive rate of 30% (Jensen, et al, New Eng J. of Med, 1994),. Get surgery at wrong spot.• MRI has false negative rate of 78%, (Sandhu, et al, J. Spine Disorders, 2000) Patients don’t get surgery needed
  26. 26. Flaws with Just Anatomical TestsMRI- Jensen et. al. (N. Eng J. Med, ’94), 92 patientswith no back pain, but 27 had protruding disc (30% false positive rate). MRI with Modic (vertebral end plate changes)-21/23 patients had + provocativediscograms. BUT- in 90 patients with positiveprovocative discograms, only 23% had Modic changes, and 77% no changes in MRI. (Braithwaite, et al, Eur. Spine J. ’98). Therefore a 77% false negative rate for MRI Flipping a coin would give more accurate results about which disc is damaged
  27. 27. Review of a Bus Company Charts• All cases are 6 months old or older• Of the 260 case cost summaries sent for evaluation, 126 were sprains or strains = 48% of cases• A sprain or strain is a self-limiting disease, and can’t, by definition, last longer than 7-10 days. Therefore at least 48% misdiagnosed.• The oldest 15 cases cost $3,733,882.35 with an average cost of $248,925.50.
  28. 28. Summary – 260 Bus Company Cases –sprain or strain N =126 433,879.03 STRAINED BODY PART 433,879.03 1 345,039.70 SPRAINED BODY PART 345,039.70 2 266,597.24 TRAUMA 584,651.42 BRUISE/CONTUSION/ABRASION 408,122.16 BRUISE/CONTUSION/ABRASION 210,270.67 SPRAINED BODY PART 210,270.67 3 265,364.19 STRAINED BODY PART 265,364.19 4 353,206.62 BRUISE/CONTUSION/ABRASION 281,088.92 BRUISE/CONTUSION/ABRASION 424,372.35 UNKNOWN 194,757.01 STRAINED BODY PART 194,757.01 5 196,225.58 SPRAINED BODY PART 196,225.58 6 300,392.27 BRUISE/CONTUSION/ABRASION 342,407.24 FOREIGN BODY 281,495.90 STRAINED BODY PART 281,495.90 7 154,293.92 STRAINED BODY PART 154,293.92 8 97,616.18 HEART ATTACK 215,260.65 BROKEN/FRACTURED BODY PART 219,690.79 STRAINED BODY PART 219,690.79 9 183,503.02 SPRAINED BODY PART 183,503.02 10 156,277.06 STRAINED BODY PART 156,277.06 11 241,706.34 STRAINED BODY PART 241,706.34 12 292,068.65 SPRAINED BODY PART 292,068.65 13 304,889.28 STRAINED BODY PART 304,889.28 14 254,421.21 STRAINED BODY PART 254,421.21 15126 cases cost $12,365,366 with $98,137.82 = average.
  29. 29. Cost Containment for RSD (CRPS)• Johns Hopkins doctors report that • Misdiagnosis of RSD-3 yrs 80% of all RSD cases are really • Sympathetic Blocks nerve entrapments. (Dellon, 2006) 20 X $2,500 $50,000• Nerve entrapments cost $50,000 • Physical therapy to treat. or chiropractic $15,000/yr• How many RSD (CRPS) cases do • Doctor visits for 3 years you have. $2,500/yr• What is the reserve on these • Medication for 3 years cases? Most companies have $12,000/yr $1,000,000 reserves for RSD case 33 year old claimant- lost wage• If your company settles the case for less than the reserve the $18,000/yr difference comes to the bottom Total for 3 years $192,500 line.• $1,000,000 -$50,000 = $950,000 Diagnostic Eval. Using MCD Tests income for at 80 % of your RSD Treatment Algorithm $21,000 cases Nerve decompression $29,000• On the right, note cost savings on Total $50,000 treatment basis, not reserve reduction basis Savings $142,500
  30. 30. Diagnosis of RSD vs Nerve Entrapment Stanton-Hicks, Baron, Boas, Gorddh, Harden, et al, Complex Regional Pain Syndrome : Guidelines for Therapy, Clin. J. of Pain, 1998 RSD or CRPS Nerve Entrapment• Pain all around a limb • Pain in nerve distribution• Good response to • No response to sympathetic blocks sympathetic blocks• No response to blocks of • Good response to blocks peripheral nerve of peripheral nerve• Thermal allodynia (a • No Thermal Allodynia painful response to a (no pain in response to normally not painful alcohol drop on the stimulus) painful limb)• Abnormal bone scan • Normal bone scan
  31. 31. COST SAVINGS USING THE DIAGNOSTIC PARADIGM = $13.000.000 for 170,000 insured workers withlumbar/cervical strain casesCurrent Methods over a three year period of MCD for "Lumbar Strain"Physical Maryland Clinical DiagnosticsTherapy $45,000 Diagnostic Paradigm $800Doctor Visits $7,500 and Treatment AlgorithmMedication $36,000 Diagnostic StudiesLost Wage $54,000 Recommend by $20,200TOTAL $142,500 DP&TA Fusion Surgery Recommended $41,000 Total Expense Using DP&TA $62,000Savings $80,500Number of Insured Workers 170,000Number of Lost MCD WorkersCompensation Claims per YearRate is 1% of all workers 1,700Number ofWorkers CompensationCases/year lastingmore than three months which are sprains/strain 10% of all claims 170Total cost of DP&TA $800 X 170 $136,000Cost of recommendations of DP&TA, including DP&TA $62,000 X 170 $10,540,000Cost using old techniques $142,500 X 170 $24,225,000Cost savings to evaluate these claims
  32. 32. Does your current system work?• How do you measure if a methodology works?• Do you ask a patient if they hurt less? No value.• The most objective measures are 1) return to work rates –(what are yours?) 2) number of doctor visits/month 3) use of medication 4) published outcome studies
  33. 33. Published Outcome Studies-for Litigants*- out of work for more than 2 years from a clinic using the MCD tests Clinical Neurosurgery, ‘89 Before After # of Patients Working• Return to Work-Auto 3/19 10/19 (62.5%)*• Return to Work -Work Comp 0/41 8/41 (19.5%)*• Doctor visits/month (WC/auto) 2.78 1.51 (46% reduction)*• Averg. Narcotic pills/month 105 10.8 (89% reduction)*• Averg. Hours out of bed 11.9 15• Trouble falling asleep- /m 22.8 16.1• Pts. with relief (5%-100%) 0 31/60 (51%)• * 6 months after treatment*literature search shows insurance carriers report less than a 1% return to work rate for claimants out of work for 2 years or more on a workers compensation claim.
  34. 34. Advantages of the Tests for Adjusters• Simplifies the decision making process• Saves the adjuster MCD and money, since all new claims would get the Pain Validity Test• Based on results of Pain Validity Test, the adjuster decides who gets surveillance, or MCD or FCE. No guess work, no wasted resources, by putting detectives on pin-pointed valid claim.• For the misdiagnosed objective pain patients, get the Diagnostic Paradigm, and have the company doctor review the results and decide what to do
  35. 35. PVT-Saves $1,654/case• The current methods of assessing fraud are not cost effective, as documented by the State of California• The Pain Validity Test (PVT) saves at least $1,654/case when compared to current methods of fraud detection• Misdiagnosed patients cost insurance companies much more than fraudulent cases. The PVT identifies both• There are at least 4 times as many misdiagnosed cases as there are fraud cases• There are reliable methods for detecting fraud = PVT• Insurance carriers should demand Evidence Based Medicine proof of efficacy of treatment.
  36. 36. Diagnostic Paradigm –Saves $80,000• 40%-71% of litigants with chronic pain problems are misdiagnosed. Just “sprains” alone account for 48%.• Misdiagnosed claimants cost the insurance industry millions in wasted medical treatment &delay of proper treatment. Proper diagnosis & treatment can save money.• Internet administered (automated) history taking is reliable, and produces proper diagnosis and treatment (www.MarylandClinicalDiagnostics.com ).• Using this technique, one pain clinic was able to obtain far higher return to work rates, and claimants had fewer doctor visits, and used less medication, all of which result in cost savings, averaging $80,000 a case.• http://www.slideshare.net/DiagnoseMyPain/patient-cost- savings-documented-with-letters
  37. 37. CONTACT INFORMATION• www.MarylandClinicalDiagnostics.com• Mailing address 440 South El Cielo Rd suite #3660 Palm Springs, CA, 92264• 24 Hour HELP line- 443-277-0306• Email JamesRichMCD@aol.com

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