Anyone who has cared for personal injury patients is likely familiar with the claims processing software known as Colossus (or you should be).
Depending on your data sources (because auto insurance payers aren’t likely to reveal them), the list of carriers who use Colossus to determine your patient’s claim value and how much treatment to permit is pretty beefy. Most experts estimate that more than 70% of claims are administered by Colossus. And when you add in the other “look-alike” software systems such as Claims Outcome Advisor, Injury Claims Evaluator and Injury IQ, the percentage gets even higher. The list of payers who use these tools to tweak your claims is HUGE and includes such common carriers as Aetna, Allstate, CNA, Erie, Farmers, Metropolitan, Ohio Casualty, The Hartford, MetLife, Progressive, State Farm, Travelers, USAA and Zurich (just to name a few).
What’s the Big Deal About Claims Processing Software?
The simple reason this software should scare you (and your patient) is this: it’s a well-documented fact that by using Colossus or other claims processing software, auto insurance payers can “tweak” the value of your claims in their favor. For example, one whistleblower revealed that claims savings could result in a 57% reduction in claim value! In other words, by using claims processing software, Colossus (and its counterparts possess the same potential) could turn a $10,000 claim into a $4300 payment!
So what exactly does that mean?
If you do not fully understand how claims processing software works, you could easily and accidentally be omitting important information that could help establish medical necessity and “earn” your chiropractic personal injury patients the care that they need (and deserve)!
On the other hand, chiropractors who learn how to accurately diagnosis, bill, code and document their services will be rewarded – as input of data from the providers is a primary “value driver” for claims processing software. In other words, give the payer the data that they need to make an accurate determination and your patient’s care can be appropriately handled. On the other hand, if you fail to give the necessary information, it’s “garbage in, garbage out” and the way the payer handles your claim will reflect that!
The Importance of Value Drivers
So, how exactly do you conquer these computerized calculations to defend and earn your care? Though there is no singular answer (which is why we are dedicating an entire day to this topic in our upcoming Chiropractic Personal Injury POWER seminar), one area that definitely deserves attention is the concept of “Value Drivers.”
In short, Value Drivers are part of the input data that help determine the value of a claim. Colossus and similar software programs arrive at a decision by assigning “points” to value drivers associated with each injury. Some of the value drivers have “multipliers” as well, which can add significant value (and points) to the formula that ultimately determines your claim’s value.
The #1 Value Driver in Chiropractic Personal Injury Cases
One commonly known value driver is your diagnosis codes. Put simply, coding accurately and appropriately can increase the value of your PI claim, whereas lazy, inaccurate or sloppy coding can decrease it.
In fact, in terms of personal injury work, the NUMBER ONE value driver is your Diagnosis coding which is something that all chiropractors can learn how to master, in respect to Colossus and other claims software equivalents.
And yes, ICD-10 did change the game for Colossus as well as the rest of us. So if you are still using old ICD-9 “formulas” in the era of ICD-10, you are missing out on some vital communication to Colossus and potentially damaging your patient’s claim (and your payment) in the process.
Unfortunately, diagnosis coding is not the only value driver. There are over 10,720 rules applied to value drivers that enable claims software to arrive at a decision! These additional value drivers also factor into the formula that will ultimately determine your patient’s claim value, duration and potential settlement (as well as the timely paying of your bills).
Claims Value “Damagers”
While we don’t have time to go into all 10,720 items in this post, it may be valuable to take a quick look at the other side of the spectrum: things that decrease the value of your claim. In this respect, here are just a few of the primary items that can potentially damage your personal injury work:
- Poor documentation
- Poor case management
- Ineffective or inaccurate terminology
- Failure to objectify diagnostic findings
- Failure to demonstrate clinical progression
- Failure convert to or communicate active care
What to Do Next
Though I’m not sure which of the above areas you need work in, a good self-analysis will probably reveal that you don’t do one or more of the items well. And that would be a good place to start.
If you’re overwhelmed because you’ve got multiple areas that need improvement, focus first on correct diagnosis coding as its obviously the #1 value driver and can deliver you a big bang for your buck.
And if you’re looking to quickly improve or master your skills, consider attending our upcoming Chiropractic Personal Injury POWER Seminar – where will be covering all the above and much, much more in the way of helping you rapidly improve your MVA coding, documentation, case management, billing and business strategies for a bigger, better, more profitable PI practice! Click the link for more details and to register.