By Robert Groysman, MD

Car accidents are an unfortunate reality of modern life, often leading to personal injury cases involving a range of medical professionals, from chiropractors to physical therapists, pain doctors, and personal injury lawyers. However, within this landscape exists a concerning trend of fraudulent medical charges, inappropriate coding, and unwarranted treatment strategies.

Why does this matter? The National Health Care Anti-Fraud Association estimates that the financial losses due to healthcare fraud are $68 billion, or as high as $300 billion. In many cases, these costs fall unfairly on patients and insurance providers.

Here, I aim to delve into these practices, shedding light on the complexities and challenges within the realm of post-accident healthcare.

Parsing Pain From Injury

In 2022, the Texas Department of Transportation reported a staggering 15,299 serious injury crashes, with 18,880 individuals sustaining incapacitating injuries. Despite these seemingly high numbers, it's crucial to recognize that not all car accidents result in traumatic injuries. Pain, often viewed as evidence of injuries, can be misleading. Many individuals involved in accidents experience pain without any observable trauma during physical examinations or imaging procedures. Indeed, many of those patients labeled as "injured" are discharged from emergency departments on the same day without any admission for injuries.

In personal injury lawsuits, attorneys may argue that the severity of impact or vehicle damage doesn't correlate with the extent of injuries sustained by occupants. While this assertion holds merit in some cases, it's essential to emphasize that the presence of acute injury or trauma, as evidenced by thorough examination and imaging, is paramount in determining the legitimacy of claims.

Traumatic injuries, as defined within this context, encompass a spectrum of conditions, including penetrating trauma, cervical spine blunt traumaopens in a new tab or window, and lumbar spine blunt trauma resulting in fractures, dislocations, or internal injuries, spinal cord injuries, and severe bleeding or head trauma necessitating hospitalization. However, based on my experience reviewing hundreds of personal injury claims, the majority of these cases appear to lack evidence of such injuries, often barely meeting the diagnostic criteria for mild sprains or strains.

Acute Injury or Ongoing Condition?

Furthermore, common MRI findings, such as disc herniations and osteophytes, may not necessarily indicate recent trauma but rather preexisting conditions. In some cases, the absence of inflammation around these findings raises questions about their association with acute injury. Chronic conditions like arthritis and spondylosis may be misinterpreted as traumatic damage, further complicating the diagnostic process.

Serious Versus Minor Injuries

Understanding the mechanisms of trauma is crucial in distinguishing genuine injuries from minor strains or sprains. Trauma can manifest as blunt trauma, penetrating trauma, or crushing trauma, each presenting unique challenges in diagnosis and treatment. However, the presence of acute trauma cannot be solely determined by subjective pain complaints but rather demands objective evidence through examination and imaging.

When individuals present themselves to personal injury attorneys, chiropractors, physical therapists, or pain doctors post-accident, they may report pain as their primary concern. However, in the absence of corresponding exam and imaging findings, this pain is likely attributed to minor sprains or strains, which typically heal with time and rest and do not necessitate extensive treatment modalities.

Sprains and strains, categorized into different grades based on severity, range from mild to severe, with grade 1 injuries being the least severe and grade 3 injuries representing complete tears or ruptures. In the absence of visible signs of bruising or hemorrhage on imaging, only mild sprains or strains can be expected, rendering invasive treatments unnecessary.

The Consequences of Fraudulent Billing

One of the most egregious aspects of fraudulent medical practices lies in billing and charges. My review of numerous claims reveals a pattern of creative use of Current Procedural Terminology (CPT) codes, inappropriate frequency of office visits, and unjustifiable up-charges for medical procedures. From the inappropriate use of expired or canceled CPT codes to significantly inflated charges for common procedures and medications, these practices exploit the vulnerability of accident victims and undermine the integrity of the healthcare system.

For instance, some providers charge exorbitant fees for procedures such as interlaminar cervical epidurals or lumbar epidurals, resulting in financial burdens for patients and insurance companies alike. Similarly, billing for consumables such as needles, surgical trays, or recovery room expenses outside of a hospital setting constitutes fraudulent behavior and should be met with appropriate consequences.

Fraudulent medical practices following car accidents pose a significant challenge to the integrity of the healthcare system and the well-being of accident victims. By scrutinizing billing practices, treatment modalities, and diagnostic criteria, we can strive to combat these unethical behaviors and ensure that individuals receive the care they truly need. Healthcare professionals must keep in mind that if there is any substantial injury, there is forensic evidence of it. Don't make assumptions about what happened. Find the evidence of injury to the patient. If you can't, don't treat under the letter of protection.

Through collaboration between medical professionals, legal experts, and regulatory bodies, we can work towards a system that prioritizes patient welfare and upholds the principles of honesty and integrity in healthcare delivery.

Robert Groysman, MD, is an interventional pain doctor in Irving, Texas.