Insurance Companies Use “Colossus” To Assess Medical Records And Settle Claims
If your patient has a personal injury claim, there is a good chance that your medical records will be sifted for certain data to be fed into a computer. Insurance companies created and employ a program called “Colossus” which compares your patients claim against those of other accident victims across the country. This comparison is used too determine the value of your patient’s claim for purposes of settlement.
Colossus assimilates and examines facts provided by your medical records and subjects them to more than 10,000 pre-programmed “rules” (and biases) to evaluate over 600 trauma-induced injuries.
This program is being used by more than half of the insurance industry. For many insurance companies, gone are the days when the claims adjuster would actually review the individual merits of each injury claim and negotiate a settlement accordingly.
The purpose of this article is not to cause worry about the dawn of a brave new post-human world where computers dispense “justice” in the area of claims settlements. Our purpose is to inform you how Colossus thinks and works, so you may understand what information it needs. As a result, we hope your patients will be better positioned to secure fair and just settlements commensurate with their injuries. This, in turn, should make for a better chance of your bills being paid.
Based on your billings, claims adjusters determine which health care services are reasonable and necessary. Your billings should include the date, type and charge for each service, including the proper ICD and CPT codes. Billings not substantiated or with codes that do not match treatment codes or issued by suspect vendors will be rejected.
Having determined what may be considered, the adjuster will then enter data into a computer for Colossus processing. They will then take their marching orders for settlement from what the computer dictates.
Inadequate recordkeeping by our office will result in denial of services and the presumption that the patient is uninjured. “Garbage in, garbage out.”
BUILT-IN BIAS AGAINST SOFT TISSUE INJURIES
Colossus divides injuries into “demonstrable” and “nondemonstrable.” Demonstrable injuries are objectively verifiable by x-rays or other definitive means, i.e., injuries such as broken bones.
“Nondemonstrable” refers to musculoligamentous (soft tissue) injuries which represent the most common type of motor vehicle accident injury. The most significant inherent bias in the Colossus program is its skeptical treatment of “nondemonstrable injuries.”
We will outline the type of information Colossus accepts following the “SOAP” pattern of record keeping utilized by most practitioners.
Each body part affected by the injury must be identified. If your patient complains about several body parts, but some are not specifically identified in the medical record, Colossus will not allow a claim for those not identified. Please encourage your injured patient to tell you every place that hurts; and make sure you document each complaint.
For example, your patient may come to you primarily for neck and back pain, but immediately after the accident he or she may have reported shoulder pain in the emergency room. Injury to the shoulder will not be recognized unless it appears in your treatment records.
Neck pain which “radiates into the shoulder” will be considered as only one injury. If the musculoligamentous structure of the shoulder itself has also been affected, its symptoms should be identified and verified separately, so they get their due.
Colossus will recognize your patient’s “nondemonstrable” injury if it is documented by these diagnostic findings:
- Palpated and recorded areas of sensitivity;
- Postural abnormalities such as tilting the head away from the injured side or flexing the neck;
- Guarding of the neck;
- Range of motion limitations on testing;
- Cervical lordosis (reversal or straightening);
- Tenderness and muscle spasm;
- Muscle weakness; and
- Sensory changes through light touch and pin prick.
State each that applies and document the duration of each symptom.
ASSESSMENT OR DIAGNOSIS
For neck musculoligamentous injuries, Colossus will credit each of the following diagnoses:
- Muscle spasm
- Restriction of movement
- Visual disturbance
- Radiating pain
- Anxiety (must be treated), and
Again, it is imperative that each body part complained of and found to be injured be addressed with a separate diagnosis. Colossus will recognize only diagnosed injuries. It also helps to note whether your patient had a preexisting condition.
PLAN FOR TREATMENT: PHYSICAL THERAPY AND OTHERS
All forms of prescribed treatment and diagnostic procedures must be specifically identified in your chart notes. Unlike other body parts, neck and back injuries require specific treatment dates.
Physical therapy, massage therapy, and manipulative therapy treatments are recognized. Duration/length of treatment (more or less than 90 days) and frequency/intensity of treatment are factored in. Therapy includes both visits to a therapist and home exercises.
Colossus has a built-in bias against chiropractic treatment. However, chiropractic treatment is given more weight if it is sandwiched between visits to an M.D. or D.O. who approves such treatment. Typically, chiropractic care exceeding 60-90 days is deemed excessive and paliative only, which colossus wil then reject. The length and frequency of chiropractic care or massage therapy will be closely evaluated. Your patient should be followed by you to avoid “too much” feel good but short-lived relief from such care. If significant improvements are not make consider alternatives which may be more effective.
Other treatments Colossus will recognize are:
- medications (including aspirin) (identify each medication and the duration prescribed; will be classified as short – less than 30 days – or long term);
- home traction;
- TENS unit;
- injections (type, duration and number);
- immobilizations (soft collars, ace bandages, supports, etc. and duration);
- confinement to bed (with duration); and
- hospitalizations; as well as
- prescribed diagnostic procedures: MRI’s, discograms, myelograms, and their results.
Documenting the duration of each treatment is essential since Colossus requires a stabilization period. Colossus classifies injury stabilization periods as: 1) up to 1 month; 2) 1 to 3 months; 3) 3 to 6 months; 4) 6 to 12 months; 5) 12 to 18 months; 6) 18 to 24 months; 7) 24 to 36 months; and 8) more than 36 months.
Colossus is calibrated to question a stabilization period it deems longer than expected. To satisfy Colossus, the records must clearly reflect ongoing complaints and treatment that reflects progressive improvement.
Gaps in treatment and delays in treatment must be explained in the records, to avoid a negative effect. If the record indicates that the patient decided to try home exercises in lieu of formal treatment, but found he/she had to return for formal treatment, the negative effect of the gap may be diminished. Likewise, if the record shows that the patient attempted to work through or wait out the initial complaints, hoping the pain would subside without treatment, this would explain a delay.
Once the injury has become stable or stationary, Colossus will allow one of the following prognoses: A- Undetermined; B- No treatment recommended/no complaints; C- Complaints/no treatment recommended; D- Complaints/treatment recommended; E – Guarded. Consistent with the Colossus bias, the only prognoses accepted from chiropractors are A, B and C.
The following factors have traditionally been presented by the injured person or his/her attorney. Now, Colossus will take these circumstances into account only if the medical doctor notes them:
- Duties under duress,
- Loss of enjoyment of life, and
Duties under duress are day-to-day living duties which have become painful or difficult as a result of the injuries. These include the necessary domestic responsibilities of a homemaker and/or parent of young children, as well as the necessity to go out to work, as long as these responsibilities are made difficult or painful due to the injuries. Your chart should reflect the difficulty and the reason for the difficulty in performing the duties. The duration should also be acknowledged in the chart. It is not necessary that a prescription be made for the patient to refrain from these duties.
Loss of enjoyment of life encompasses areas of life the patient normally would have enjoyed had he/she not been injured. These include athletics, vacationing, entertainment and socializing. Again, the chart should clearly document the activities and the duration.
Colossus will allow an impairment rating indicated by a medical doctor if it is based on test results and follows the AMA guidelines.
Fortunately, Colossus will accept supplemental reports from doctors addressing injury specifics which may have been omitted from or were indecipherable in the chart notes. You may provide a supplemental written report or clarification note if your records did not detail all of your patient’s injury complaints in terms Colossus needs to hear. Your patient’s attorney may ask you for such a supplemental report before presenting a demand for settlement.
We hope this information will help you as you work with your patients to insure that all medical aspects of their injuries are addressed and charted clearly. This will help us to present the injury claim completely. It will also help the insurance claims representative to “in-put” the full injury story in terms the Colossus computer program requires. More importantly, it will help ensure that both you and your patient are fully compensated.
This article was prepared by Frederick H. Lundblade III, Tom Petersen and Peter E. Yeager