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Presenting a live 90-minute webinar with interactive Q&ALeveraging Colossus and Other InsuranceAdjustment Software to Maximize AutoAccident Claim Settlement OffersWEDNESDAY, OCTOBER 26, 20161pm Eastern 12pm Central 11am Mountain 10am PacificToday’s faculty features:Dr. Matthew J. DeGaetano, Program Director and Founder, Personal Injury Institute, DallasJames Mathis, President, Sequoia Visions, Reno, NevadaThe audio portion of the conference may be accessed via the telephone or by using your computer'sspeakers. Please refer to the instructions emailed to registrants for additional information. If youhave any questions, please contact Customer Service at 1-800-926-7926 ext. 10.
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UnderstandingColossus5
Understanding“Rules Of PI”6
Claims software program usedby insurers to manage personalinjury claims7
Reduce overhead, staffing,streamlines claims, takeshuman input out of equation,etc.8
Insurers pay 10-50millionper year to lease the program But they save 3 Billion peryear. Here to stay.9
Even at 3 Billion per year. I get asked are they still usingcolossus? Or I have been told they areNOT using colossus!10
Personal Injury InstituteDoes Colossus exist?11
12
In Australia in the late 1980s, theGeneral Insurance Organization ofAustralia (“GIO”) had noted risinginjury claims losses of 14%/yr. They recruited a programmingcompany called Computations Pty Ltd(“CPL”) to help them find a way todecrease claims payouts, increasingprofits.13
The “Whiplash” portion was written in just6 months. By the time Colossus was completed in1991, CPL had been purchased by anAmerican corporation, The ContinuumCompany. In 1992 Colossus was being tested andimplemented by 8 different insurers.14
Allstate had Colossus fullyimplemented by 1995. Continuum merged with ComputerSciences Corporation (CSC)owner of HCFA/CMS-1500 formsby mid-1996.15
First Mistake Will Destroy API Case Claims Processing Proper Use of HICFA/CMS-1500forms State Farm Story16
According to Aaron DeShaw’s (highlyrecommended) text, Colossus: What EveryPhysician Needs to Know (2006), a groupof the original programmers from CPL wentto CSC to inform them that the programhad errors/problems that needed to befixed. CSC rejected them.17
New software!18
That program eventuallybecame known as ClaimsOutcome Advisor and wasreleased in 1999 and isgenerally regarded as thesuperior program and hasaffected CSC’s bottom-line.19
Colossus is by far the most widelyused program, covering roughly 70%of claims in the U.S. COA evaluates 10% of theremaining cases.20
Between these three programs, theyhandle claims evaluation for 8 of the 10insurers in the U.S. Most notable example of company claimingnot to be using a commercially availableclaims management software system:State Farm21
According to documents and interviewsassociated with the Hensley v. ComputerSciences Corporation class action lawsuitwe learned that CSC marketed Colossus toinsurers as a means to save money andimprove profitability. The “primary goal ofthe evaluation process is to reduce closedclaim costs ” We also learned from Hensley that theprogram can be “turned” to “dial down”settlement offers.22
Colossus determines thevalue of a claim based onFour general components,and roughly 10,720 datapoints of information from themedical records called :valuedrivers”.23
What PI Cases Need FromTheir DoctorsThe Doctors Ability toAddress and Identify EveryComplaint and Injury 24
Colossus determines the value of a claim based on Fourgeneral components, and roughly 10,720 data ofinformation from the medical records called :value drivers”.25
Colossus determines the value of a claim based on Fourgeneral components, and roughly 10,720 data ofinformation from the medical records called :value drivers”. (1.) The injury and related info (Dx, Tx, Px, Dur of S/S,etc)26
Colossus determines the value of a claim based on Fourgeneral components, and roughly 10,720 data ofinformation from the medical records called :value drivers”. (1.) The injury and related info (Dx, Tx, Px, Dur of S/S,etc) (2.) Permanent Impairment rating – AMA Guides 5th27
Colossus determines the value of a claim based on Fourgeneral components, and roughly 10,720 data ofinformation from the medical records called :value drivers”. (1.) The injury and related info (Dx, Tx, Px, Dur of S/S,etc) (2.) Permanent Impairment rating – AMA Guides 5th (3.) Duties Under Duress – Not ADL Questionnaires28
Colossus determines the value of a claim based on Fourgeneral components, and roughly 10,720 data ofinformation from the medical records called :value drivers”. (1.) The injury and related info (Dx, Tx, Px, Dur of S/S,etc) (2.) Permanent Impairment rating – AMA Guides 5th (3.) Duties Under Duress – Not ADL Questionnaires (4.) Loss of Enjoyment of Life – Not ADL Questionnaires29
Colossus determines the value of a claim based on Fourgeneral components, and roughly 10,720 data ofinformation from the medical records called :value drivers”. (1.) The injury and related info (Dx, Tx, Px, Dur of S/S,etc) (2.) Permanent Impairment rating – AMA Guides 5th (3.) Duties Under Duress – Not ADL Questionnaires (4.) Loss of Enjoyment of Life – Not ADL Questionnaires 30Of these 4 categories, the 2 with the highest VALUE, in order, areand .
To summarize:31
Computer Software Program used by InsuranceCompanies The adjuster enters information about the claiminto the program The program accesses over 10,720 rules or valuedrivers to evaluate over 750 injuries The program computes a settlement figure that isconsistent with the severity of the patient’s injury32
Insurance Industry Application ofColossusOther Processors TEACH – State Farm Decision Point – Progressive Claims Outcome Advisor (COA) – GMAC & Fireman'sfund Injury IQ Claims IQ MYND Injury Claims Evaluation (ICE) And one of the newest XM33
Insurance Industry Application ofColossusOther Processors TEACH – State Farm Decision Point – Progressive Claims Outcome Advisor (COA) – GMAC & Fireman'sfund Injury IQ Claims IQ MYND Injury Claims Evaluation (ICE) And one of the newest XM34
Insurance Industry Application ofColossusOther Processors TEACH – State Farm Decision Point – Progressive Claims Outcome Advisor (COA) – GMAC & Fireman'sfund Injury IQ Claims IQ MYND Injury Claims Evaluation (ICE) And one of the newest XM35
When pain and suffering isdetermined?36
When pain and suffering isdetermined?The real question bycolossus 37
Is there a permanentimpairment?38
What is the degree of thepain and suffering?39
What is the degree of thedisability?40
Need Expert Clinical Help? Case issues Documentation Review Exclusive PI TrainingSchedule Your Complementary CallVisit www.PIConsultation.com Today
Instantly Schedule Your ConsultationVisit www.PIConsultation.com Today
Personal Injury InstituteYou can contact me directly at:972-978-2525Or send me an email:drmatt@personalinjuryinstitute.com
INSURANCE CLAIMPRACTICES AND PROCEDURESAND THEIR SOFTWARE THATDENIES CLAIMS44
What do you need to consider: Currently there are:– 86 different software programs in use Medical determination software Claim evaluation software– One significant manual evaluation– 10,720 value drivers– 17,000 severity drivers– 1,600 claim practice procedure programs– One major data management company45
Colossus, , XM, TEACH,TEACH, MYND,Decision Point, Injury IQ, COA, ICEIMS, AIM, MEDICO, MBRS, ADP,Ingenix, HELP Systems, InjuryIQInjuryIQ,,AIM, Mitchell Medical, MedMed-DataAnd now IBM’s Watson46
The Beginning of a new ERA Mitchell/Decision Point relies upon a databasemaintained and manipulated by IngenixIngenix. Ingenix is found to be fraudulently corrupt byNew York Attorney General. The AMA filed a civil suit on behalf of New Yorkvendors against Ingenix and it settled for 380million. Use of Ingenix allows that the insurer to onlyaccept as reasonable a “Percentile” range ofcharge for medical treatment and testing.47
The Beginning of a new ERA CSC, owner of Colossus, is now managing all dataand evaluation of medical billings for Blue CrossBlue Shield and Group HealthHealth. MBRS, ADP, AIM and Med-Data are being fazedout in favor of universal use of ADP and MitchellMedical Expert.48
Resulting Outcome No ownership of claim Deny medical necessity Deny Minor Impact Refuse treatment costs No responsibility for value Take it or leave it attitude Frustration Ship the claim off to house counsel Claim is now dead until the jury comes in49
New Valuation Focus 50Injuries (Number & Type)Treatment Modalities & CostSymptomsPhysician TypeFuture TreatmentBody part at static MMIImpairmentDuties Under DuressLoss of EnjoymentFinal Prognosis
New Valuation Focus Injuries (Number & Type)– Diagnose by body part - not region Standard 25injuries NOT 4– Use of New CMS 1500– Use of Supplemental 1500 Insurance use of scanners– Difference of symptom & injury– Better patient intake form– Many missed body part injuries– Each body part injury createsequation for settlement authority51
Identify all Injuries Injuries Used in Colossus 52AmputationConcussionDisc Injury – herniation, bulge, prolapse, protrusionCrush, extensive soft tissue, deglovingContusion, soft tissue, whiplash, bruising hematomaDislocation – displaced bones at a jointFractureFracture/dislocation – fracture at or near a dislocated jointLaceration, penetrating injury – requires suturesLigament, tendon damage,damage cartilage – usually involves surgerySuperficial – cuts, abrasions, scratchesSubluxation – spine only, confirmed by XX-raySprain/StrainColossus Quick Reference – Colossus Manual
New Valuation Focus Treatment Modalities & Cost– Accurate and complete documentation– Recognize different type of modality Passive– Some more valuable Active– All add to settlement value– Use of CMS 1500– Anticipate reduction Software, Ingenix– Duration, type & frequency– Customary Charge53
New Valuation Focus Symptoms – Complaints–––––HeadacheVisual disturbanceSpasmRestriction of MotionRadiating Pain Numbness Tingling– Sleep Disturbance– Anxiety/Depression– Atrophy54– Pain - for impairment only
New Valuation Focus Physician Type– MD vs DC Not all injuries accepted Not all symptoms accepted Treatment costs may be reduced Prognosis questioned Body part at static MMI Impairment not accepted Duties Under Duress lost Loss of Enjoyment lost Future treatment not accepted Seek an MDV report for claim55
New Valuation Focus Future Treatment––––––Must be stated in dollar amountMust be validated by MDMust have correct prognosisMust not have MMI associated withWith whole patientMust be described as: Probable– 51 to 75% medically certain Definite– 76 to 100% medically certain56
New Valuation Focus Body part at static MMI– Identify only those body parts which havereached static MMI. All other body partswill continue to receive passive and activecare.– Once a body part is determinedto have reached MMI, treatmentis considered to be palliative andnot included in settlementauthority.– Static MMI determination at bodypart needed for impairment rating.57
New Valuation Focus Impairment– Sixth edition of AMA Impairment Guide– Body part is determined to be static MMI– Minimum whole body impairment ratingmust be at least 2% to open windowsallowing DUD and LOE.– Example: 728.4 – Ligament Laxity– At static MMI couldrepresent a whole bodyimpairment rating of25% to 35%, if properlydetermined and validated by MD58
New Valuation Focus Duties Under Duress––––WorkStudyDomesticHousehold– Minimum 2% whole bodyimpairment rating determined orvalidated by MD– Must have correct Prognosis– Adds value to settlement authority– Must be stated by client in writing59
New Valuation Focus Loss of oldHobbySport– Minimum 2% whole bodyimpairment rating determined orvalidated by MD– Must have correct Prognosis60
New Valuation Focus Final Prognosis61– One prognosis provides most value tosettlement authority for claim.– “Ongoing complaints and continuing treatment”– Not possible if client determined tohave reached MMI– Future treatment costs alloweddependent upon this– Allowance for ongoing DUD &LOE additional settlementauthority dependent upon this– Allowance of all treatment costs dependentupon this
New Valuation Focus Injuries (Number & Type) Treatment Modalities Symptoms Physician Type Complications Impairment Duties Under Duress Loss of Enjoyment Final Prognosis Add-ons62
Resulting Outcome Claim valuation has changed. Now, you need to know and understand: 86 and growing individual softwares 10,720 value drivers 17,000 severity drivers Multipliers 1600 individual claim practice programs Current upgrades and/or changes – ICD10 Claim valuation has changed.63
For more informationCall toll free 888-Sequoia or visitSequoiaVisions.comDon’t be fooled by imitationsWith templates and false promises64
Thank YouDr. Matthew J. DeGaetanoPersonal Injury Institutedrmatt@personalinjuryinstitute.comJames MathisSequoia Visionsjj2all@aol.com65
claims management software system: State Farm 21 According to documents and interviews associated with the Hensley v. Computer Sciences Corporation class action lawsuit we learned that CSC marketed Colossus to insurers as a means to save money and improve profitability. The "primary goal of
