In Plain Sight
How 3-D imaging is stemming the growth of medical fraud and exaggerated injuries.
In January 2014, Stacy developed a lingering cough. By June, it had morphed into a hacking cough that would not cease. Something wasn’t right.
Over a six-month span, Stacy went to her primary-care physician three times. On the first visit, the doctor gave her an X-ray, diagnosed her with walking pneumonia, and prescribed antibiotics. On her second visit, the doctor remained convinced that it was walking pneumonia. And on her third visit, she was still not better, so the doctor ramped her up to a higher dosage of antibiotics.
That summer, she had a pre-planned vacation with her husband and children. They flew to South Carolina and then drove 2,000 miles in a Dodge Caravan up the Atlantic coast, hitting North Carolina, Virginia, and Maryland. On three occasions during that drive, the family pulled over to the side of the road because Stacy had to vomit. At one point, her body was so weak that she was unable to climb 10 flights of stairs to the top of one of the oldest lighthouses in the country. Her husband, having lost his mom when he was five years old, was terrified about his wife’s fate.
Once the family returned to Michigan, Stacy went to see her primary-care physician again. He ordered a computerized tomography (CT) scan of her lungs and then booked an appointment for her with a pulmonologist 14 days later. Stacy—a breast cancer survivor—left the doctor’s office and called her husband in tears.
They picked up her CT scan, which they had converted into a 3-D image. Upon seeing the lungs in 3-D with their own eyes, it didn’t take a medical degree to realize that something wasn’t right. So they booked her an appointment at the Karmanos Cancer Institute, a leading cancer treatment facility in the Midwest, for the following day. She underwent a needle lung biopsy. Fortunately, everything was OK. Her walking pneumonia had turned into necrotic tissue and an abscess. With the help of antibiotics, her health scare evaporated within six months.
This example—based on co-author Jorey Chernett’s real-life experiences—provides a new perspective on the power of visual technology. The 3-D perspective changed and influenced Stacy’s behavior, heightened her sense of urgency, and impacted her decision-making. More than anything, seeing it with her own eyes helped her and her family comprehend what was going on.
Insurance Fraud Is Skyrocketing
Today, 3-D imaging is leading the fight against fraud in workers’ compensation, personal injury protection, and bodily injury claims. According to the Federal Bureau of Investigation, the total cost of insurance fraud (non-health insurance) is estimated to be more than $40 billion per year. What’s driving the fraud? In some instances, desperate doctors.
Physician reimbursement has taken a severe dive over the past few years. Governmental cuts in Medicare and Medicaid have hit doctors where it counts—in their pocketbooks. In order to make up lost income, some radiologists have partnered with plaintiff’s attorneys and intentionally are over-reading magnetic resonance imaging (MRIs) in order to collect higher fees. Orthopedic surgeons are performing countless unnecessary surgeries to pad their wallets. It has gotten so bad that one surgeon in Michigan attempted to charge $250,000 for a surgery that he never performed.
How can you level the playing field? Put the image in 3-D. “Medical fraud is a huge problem. 3-D videos of the actual MRI send a powerful message to plaintiff’s attorneys and their clients that we are serious about defending [against] exaggerated and inflated injury claims,” says Christopher Conroy, assistant vice president for litigation management at Energi Insurance Services.
The Earlier, the Better
3-D imaging has been used in the medical community since the late 1990s. The vast majority of physicians are familiar with or have even used it in medicine. It is routinely utilized by hospitals across the U.S. and globally to aid in making diagnostic and life-and-death surgical planning decisions.
The insurance industry is in cost-savings mode right now. Carriers are attempting to close files more quickly while keeping down legal costs. Understanding the difference between a real injury and an exaggerated one early on is important. That is why determining whether an injury claim is legitimate or not in the pre-suit stage is so critical.
How many times has this happened to you? The policy limits are $20,000. The plaintiff’s attorney sends the claims professional a policy limits demand and includes an MRI report showing a herniated disc in the back due to an auto accident. How do you truly know if the treating physician’s report is legitimate? Usually the plaintiff’s attorney provides the report, not the images. However, the images often tell the true story of the case. For workers’ compensation cases, it’s far easier because you already have the images.
Pictures don’t lie. They provide key information to help determine the difference between an injury induced by trauma versus a pre-existing condition or one that is degenerative and attributed to age. Evaluating the images as early as they exist can save time and money. The only way to truly know if someone is injured is to ask for a copy of the scan.
Plaintiff’s attorneys generally want to spend as little money as possible on a case. The fact is, plaintiff’s lawyers do not bill by the hour. Rather, they generate a commission based on the ultimate settlement. Their time and money is an upfront investment that may yield no return. Some plaintiff’s attorneys are cash-flow constrained, and many choose to borrow money at the going interest rates of 30 percent to 40 percent charged by nearly all litigation finance companies.
If plaintiff’s attorneys recognize with their own eyes that no objective injuries exist, they are far more likely to throw in the towel than continue investing their own money in cases. Putting the image into a 3-D format levels the playing field.
The Power of Visual Evidence
Radiologists are taught to process each of the 50 to 75 2-D pictures taken from different angles, called “slices,” to form an MRI study. A radiologist is equipped through years of training to piece together in their head the series of distinct 2-D pictures into a 3-D model.
However, most claims professionals, plaintiff’s attorneys, and jurors can’t make heads or tails out of these black-and-white medical images. 3-D levels the playing field by automatically putting a series of 2-D pictures into a 3-D model, making it easier for most anyone to comprehend.
The insurance carrier will know right away whether the injury is bogus or legitimate. If the injury is exaggerated, then send the imaging to the plaintiff’s attorney. This will convey a message that you are serious about fighting the claim, and the plaintiff’s attorney will be able to see with his own eyes that the image has been over-read, leading him to think twice about further pursuing the claim. The net result is faster claims resolution, reduced litigation costs, fair claims values, and more accurate reserve estimating.
Unfortunately, you won’t always receive the MRI scans in the pre-suit stage. Once a case heads into litigation, often a plaintiff alleges an exacerbation of a prior injury in a workers’ compensation or personal injury protection case.
Again, how do you truly know whether there is a change from the prior MRI? That is what makes 3-D technology so unique; the before and after images can be placed side-by-side so one does not need to attend medical school to see if there is a difference.
Approximately 70 percent of the population are visual learners, and the brain processes visual information 60,000 times faster than text. That is the power of visual evidence. It can make or break your case.
Leading the Fight Against Fraud
Here are five red flags and leading indicators of possible fraud or claims buildup:
- There is resistance or delay in sending the MRI scans.
- Poor-quality images are taken.
- Physicians routinely make the same findings for different patients.
- Serious injuries are claimed on low-impact accidents.
- There is a significant time delay between the accident date and MRI scan.