There are many fraudulent practices in post-accident health care

Car accidents are an unfortunate reality of modern life and often result in personal injuries involving a range of medical professionals, from chiropractors to physical therapists, pain management specialists and personal injury lawyers. However, there is a troubling trend of fraudulent medical billing, inappropriate coding, and unwarranted treatment strategies in this environment.

Why is that important? The National Health Care Anti-Fraud Association estimates that financial losses from healthcare fraud are as high as $68 billion or as high as $300 billion. In many cases, these costs are unfairly borne by patients and insurers.

Here I would like to address these practices and shed light on the complexities and challenges of post-accident healthcare.

Analyzing pain due to an injury

In 2022, the Texas Department of Transportation reported a staggering 15,299 serious injury crashes, with 18,880 people sustaining life-threatening injuries. Despite these seemingly high numbers, it is important to recognize that not all car accidents result in traumatic injuries. Pain, often viewed as an indication of injury, can be misleading. Many people involved in an accident experience pain during physical examinations or imaging tests without any apparent trauma. In fact, many of the patients classified as “injured” are discharged from the emergency room the same day without being admitted for injuries.

In personal injury lawsuits, attorneys may argue that the severity of the collision or vehicle damage does not correlate with the extent of injuries sustained by the occupants. Although this claim has merit in some cases, it is important to emphasize that the presence of acute injury or trauma, as demonstrated by thorough examination and imaging, is paramount in determining the merits of claims.

Traumatic injuries, as defined in this context, encompass a spectrum of conditions including penetrating trauma, blunt trauma to the cervical spine, and blunt trauma to the lumbar spine, resulting in fractures, dislocations or internal injuries, spinal cord injuries, and severe bleeding or head trauma requiring hospitalization. However, based on my experience reviewing hundreds of personal injury claims, it appears that in most of these cases there is a lack of evidence of such injuries, often rarely meeting the diagnostic criteria for minor sprains or strains.

Acute injury or ongoing condition?

Additionally, common MRI findings such as herniated discs and osteophytes may not necessarily indicate recent trauma but rather pre-existing conditions. In some cases, the absence of inflammation surrounding these findings raises questions regarding their relationship to acute injury. Chronic conditions such as arthritis and spondylosis can be misinterpreted as traumatic damage, further complicating the diagnostic process.

Major versus minor injuries

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

When people see a personal injury attorney, chiropractor, physical therapist, or pain doctor after an accident, they may cite pain as their primary concern. However, in the absence of appropriate examination and imaging findings, this pain is likely due to minor sprains or strains that typically heal with time and rest and do not require extensive treatment modalities.

Sprains and strains are classified into different grades based on severity, ranging from mild to severe, with Grade 1 injuries being the least severe and Grade 3 injuries representing complete tears or fractures. If there are no visible signs of bruising or bleeding on imaging, only mild sprains or strains are expected, so invasive treatments are not necessary.

The consequences of fraudulent billing

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

For example, some providers charge exorbitant fees for procedures such as interlaminar cervical or lumbar epidurals, creating financial burdens for both patients and insurance companies. Likewise, billing for consumables such as needles, surgical trays or recovery room costs outside of a hospital constitutes fraudulent behavior and should be punished 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 reviewing billing practices, treatment modalities, and diagnostic criteria, we can strive to combat these unethical behaviors and ensure that individuals receive the care they need you really need. Medical professionals must remember that if there is a significant injury, there is forensic evidence to support it. Don’t make assumptions about what happened. Find evidence of patient injury. If this is not possible, do not treat under the protection letter.

Through collaboration between medical professionals, legal experts and regulators, we can work toward a system that prioritizes the well-being of patients and upholds the principles of honesty and integrity in health care.

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