State Farm v. 489732
In State Farm v. 489732 filed in 2019, State Farm claimed that a PTP was taking place.
Also, State Farm claimed that the clinics which were wholly owned by a licensed chiropractor needed an AHCA license because they were performing MRI’s, injections, and surgeries. State Farm claimed that MRI, injections, and surgeries were not within the “scope” of a chiropractor and that MRI reports, injections, and surgeries could not possibly be “supervised” properly. State Farm claimed that an AHCA license was required and a medical director appointed to review the care that was outside the scope of the chiropractic license. In fact, the owner/chiropractor stated in depositions that:
- he simply “just own[s] the facilities” and has “people run the facilities for him”
- he does not have much oversight of the clinic operations because he has staff for that;
- he does not have access to the software used for medical records and billing;
- he is just the owner and the clinic runs on its own.
Cozy relationship with PI lawyers. In EUO’s, numerous clients told the insurance company that they either called a popular 800 referral service and were referred to a PI attorney who in turn referred them to this clinic or they called a PI attorney after a car accident and the PI attorney told them to go to the clinic.
Every single patient had the same “Treatment Protocol” listed in their initial examination report”:
Missing from the PTP was which of the treatment modalities should be used, the frequency of each modalitiy (as needed vs every visit), which body parts they should be applied to, and specifically which type of neuromuscular reeducation or therapeutic exercise should be performed.
Every patient received six or more modaliites on nearly every visit.
Every patient was billed $30 for unnecessary items like cold packs and creams under CPT A9273. The patients were told they were “goodie bags” or “welcome packages” on the first visit and were never told they would be billed for the items. They received the “goodie bags” before ever seeing the doctor and, therefore, couldn’t have been prescribed them.
One patient “OM” testitifed that the doctor stated during the initial exam that she needed “42 therapy sessions” which is a textbook PTP since the patient could have improved after receiving therapy.
State Farm claimed the doctors used a general pain score for the whole body instead of itemizing the pain per body part. Therefore, there was no way to establish a base line for each body part to see if the treatment relieved pain or reduced inflammation.
They billed for neuromuscular reeducation, therapeutic exercise but never report which body parts were the focus of the therapy, the specific type of therapy/exercise was not mentioned, no short term or long term goals were documented, and no meaningful information was provided to compare if the patient was improving, worsening, or plateauing.
Overwhelming majority of Patients received prescription for MRIs on the first visit.
The clinic had a CT scanner out of a mobile trailer.
The patients would be referred to a medical doctor that was “in-house” at the clinic but the referring chiropractor would never mention that they reviewed the findings of the medical doctor with the patient or acknowledge that the patient saw the medical doctor (ie what is the point of the referral to the medical doctor if they don’t find out what the medical doctor thinks).
Even after receiving six or more therapies on each visit the patients are given a Final Examination stating that they are still in pain and have a permanent impairment as a result of the accident and have reached MMI
Overwhelming majority of patients obtain an EMC through the in-house medical doctors on staff.
DISCLAIMER
This is based on a real court case that was previously filed against a medical provider/doctor. The case number has been partially redacted and names have been changed to protect the Defendants’ names. This example is posted to help educate others on the laws and potential pitfalls. This posting is not intended to embarrass or defame anyone. I have limited the information and simplified some of the facts in the lawsuit to reflect key points and make a complicated case easier to understand. This “example” is directly from a complaint filed by an insurance company, therefore, I am using the facts THEY presented. There are always two sides to a story so please understand this is just one side of the story. This information was found through records available to the public.