An “Exposure Analysis” might sound like the pre-prom perusal by a nervous dad of a too scantily-clad teenaged daughter, but for doctors whose practice involves treating patients injured in traumatic accidents, such an inspection can be a whole lot scarier. When performed by an insurance company hell bent on finding a way to avoid providing the coverage it promises, the “Exposure Analysis” of a doctor is like the laser sight on a high-powered rifle.
In previous articles I detailed how insurers have developed trumped up accusations of fraud against doctors to reap billions in bad faith profits over the past two decades. The grand purpose of this illicit scheme is to undermine the value of personal injury claims. Attacking the credibility of the doctors who identify the seriousness and causation of personal injuries is its foundation.
In the scheme’s infancy in the late 90’s and early 2000’s, insurers were shooting fish in a barrel. Bad doctors abounded. But as time wore on and the bad apples were picked off, insurers were left with a dilemma caused by the initial success of their “fraud funnel.” Simply put, there were just no longer enough doctors doing it wrong to feed the insurance industry’s insatiable appetite for profit. Insurers solved this dilemma by inventing a new definition of “fraud” which allowed them to vacuum any personal injury doctor it chooses into the funnel. They christened it the “predetermined treatment protocol” evidencing “non-individualized” care.
In representing doctors of all specialties across the country sucked into the vortex of these patently false accusations, no matter the size of their practice or the amount of their billing to the insurer which has accused them, the very first question I am always asked is why me? Every doctor victimized by a false accusation of fraud desperately searches their records, and their conscience, for the answer to this question.
But the answer cannot be found in any location to which any doctor has access. The truth as to why a doctor is targeted with a false accusation of fraud these days lies entirely within the sophisticated data analytics insurers use to manufacture their fake claims in the first place.
Every injury claim submitted to an insurer teems with mountains of data, just some of which includes: every claim of any kind made by an injured claimant on any policy under any coverage at any time ever; every diagnosis and treatment code ever utilized by any doctor in any claim ever for the claimant; every diagnostic test ever performed on the patient and every testing facility where the test was conducted; every lawyer ever associated with the claimant; and, most importantly, every dollar ever paid out and why it was paid.
Each such mountain of data within a claim is but one of an endless range of connected peaks, the complete picture of which is painted by today’s super-powerful, interconnected computing systems in a matter of seconds. With the push of a few buttons, an insurer can connect every dollar it has paid out in any claim to anyone ever associated with the claim. This ultimate dollar figure is the amount of “exposure” any one doctor, or lawyer, or entity represents to the insurer.
To understand how all of this data gets analyzed to identify an insurer’s “exposure” to a particular doctor, consider the example of a patient with an Uninsured Motorist claim seen by a doctor one time for an initial examination but who, for whatever reason, received therapy and testing and surgery at other facilities. At the end of the patient’s treatment at all of these other facilities, the patient’s lawyer submits a demand to the UM insurer for settlement of the injury claim in the amount of $400,000.00. When that demand is rejected, the lawyer files a lawsuit which is litigated for a year and a half and on the eve of trial, the case settles for $150,000.00.
Let’s say the doctor who provided the initial examination of this patient billed the UM insurer $350.00 and was paid $137.50. The “exposure analysis” on this doctor, however, would identify him as having “exposed” the insurer to in excess of $400,000.00 in claim payments. This is because the demand figure is identified as the insurer’s potential exposure. All of its costs, such as hiring defense counsel to litigate the case for a year and a half, are added on top of that figure. That the actual cost caused by the examining doctor was $137.50 is irrelevant to the ultimate conclusion of the doctor’s exposure analysis.
When it is considered that an exposure analysis takes all claims with which a doctor is associated in any way and aggregates the total “exposure” in each to formulate the bottom line number, it is easy to appreciate how any doctor in any specialty who treats personal injury patients at any level with any frequency can be identified through an exposure analysis as a worthy target.
Doctors cannot prevent insurers from manipulating data to manufacture false accusations, and it would be naïve to believe there is any manner or amount of treatment which insurers would actually deem worthy of payment. This does not mean, however, that insurers can or should be able to get away with this scheme. Doctors who help patients recover from injuries suffered in traumatic accidents are a critically valuable component of our nation’s health care system and they must be protected.
As I have written previously, protection comes from creating more detailed treatment records which prevents fake accusations of “non-individualized” care in the first place, and of course in finding the right counsel who can perform his own “exposure analysis” on the insurer’s scheme in order to defeat it.