One of the Most Important Diagnostic Test Results Affecting Case Values in Soft Tissue Injury Cases
By Christopher Quigley DC
Recently at the Massachusetts Association of Trial Attorneys (MATA) holiday party an attorney told me that one of his goals in 2017 was to raise his case value. As you have noticed settlement values have been on a steady downward trend for many years. Some of the decrease in claim value has been the result of insurers bad faith efforts to make their customers premiums an income stream for their corporate shareholders. Some of the decrease is related to the lack of documentation provided to attorneys by the health care industry. The high overhead of the medical practitioner ($100K+ malpractice premiums for a surgeon), coupled with ever decreasing reimbursements, necessitates a high-volume practice and too many critical details in in the doctor’s documentation is left out.
According to James Mathis, a former claims senior supervisor and management specialist for State Farm and Allstate who instituted these claims processing/reducing algorithms, there are 4 case value drivers:
A critical component is the impairment rating. This is due to the fact that the impairment rating unlocks the value in the “Duties Under Duress” and the “Functional Loss” categories. According to Attorney Michael Schafer in his class titled “Demand Packages and Colossus” the impairment rating can unlock up to 75% of claim value.1
The key test that unlocks an impairment rating in soft tissue (ligamentous damage) cases is called Computerized Radiographic Mensuration Analysis (CRMA). This test is the best way to document ligament laxity. It is my experience that up to 70% of your female and 50% of your male clients have this injury and that it is not being documented.
Dr. Bill Gallagher writes in the Attorney at Law Magazine, Greater Phoenix Edition:
“Ligament damage, the main underlying cause of soft tissue injuries can be measured with the proper x-rays and CRMA. When done so, a 25-28% impairment rating can be established.”2
The technical name for ligament laxity and damage is Alteration of Motion Segment Integrity (A.O.M.S.I.). The AMA Guides to the Evaluation of Permanent Impairment 5th edition, page 378 describes A.O.M.S.I. as:
“A.O.M.S.I. can be either loss of motion segment integrity (increased translation or angular motion) or decreased motion resulting mainly from developmental changes, fusion, fracture healing, healed infection or surgical arthrodesis (surgical fusion).”3
On page 379 the AMA Guides describes the definitions and how to determine its presence:
“Motion of the individual spinal segments cannot be determined by a physical examination, but is evaluated with flexion and extension roentgenograms. Loss of motion segment integrity is defined as an anteroposterior motion of one vertebra over another that is:
Loss of motion segment is also defined as difference in angular motion of two adjacent motion segments greater than:
Practitioners as myself, who are trained and specialize in biomechanical failure as a routine course of examination take motion x-rays immediately when the patient first arrives and again in 60 days. The initial x-rays may have muscle spasm and muscle guarding reducing the motion of the spine. After 60 days, the muscle spasm should be reduced to a reasonable level and demonstrably reveal persistent pathology both biomechanically and of the connective tissue.
According to Attorney Schaffer in his video conference on minor impact soft tissue injuries, insurance companies reserve $60,000 when they see a diagnosis of ligament laxity.5
A caveat is that you need to have a “Colossus ready” demand package to create a “fair and equitable” claim value. One attorney, when I sent him this info, put together a two page demand with very little description of the injuries suffered by the client. Combined with the untrained adjustor and the computerized cost containment program, lead to his “low ball settlement offer.” This is common with too many lawyers and is a process that can be reversed to realize fair and equitable settlements.
Attorney Schaffer’s’ courses from the MATA webinar archives (he provides a sample demand package for you in both) helps train you on this matter. Should you want more information, my office will help guide you through the steps to learn more about the technology used by the carriers to value your claims.