Hour 1

• Introduction
  • Common misconceptions concerning
    • The patient interviews
    • The exam
    • The imaging
    • The treatment
    • The reports (documentation)
    • Specific PIP carriers
    • State PIP Laws
    • The IME Report
    • The IME Rebuttal
• Laying down the foundation
  • The patient interview-
    • The more details the better concerning
      • The vehicles involved
      • People involved
      • Nature of the impact
        • Velocity- surfaces
        • Location of accident
        • Location of actual impact on the vehicle
        • Damage to vehicle (although not directly related to injury)
        • Headrest position
        • Airbag deployment
        • Patient seating position
        • Where was patient facing
      • All Areas of injury and residual pains
        • Injured areas contact with interior of the vehicle
        • Vertigo, disorientation, nausea, tinnitus, double vision, areas of numbness, or paresthesia, contusions
        • Three Collisions When a Crash Occurs First – the vehicle hits an object Second – the occupant hits the interior parts of the vehicle, such as the steering wheel or dashboard Third – the occupants’ internal organs slam up against their skeletal structure, resulting in the most injuries in a crash
      • Visit to E/R with or without ambulance
      • Employment difficulties
      • Pain and disabilities developed after
      • Prior MVA’s and prior health conditions

Hour 2   The Insurance company- Meet your nemesis. Obstructionists

• Collasus
• Delay, Deny, Defend
• AI
• Predictive modeling
• Use to your advantage
• Considerations
• 10 Myths of low impact collisions.- 
• #1 Vehicular damage 
• #2No initial complaint 

Hour 3

• 10 myths of low impact
  • #3Head Position seat back position
  • #4 SIMPLE Sprain /Strain
  • #5 Permanent Injury
  • #6 No abnormalities =No injury
  • #7 Big Settlement 
  • #8 Pre existing
  • #9 Men v. Women
  • #10 no LBP whiplash
• Impact Trauma
  • Trunk
  • Extremities
  • All injuries
• E/R report
  • Request and discuss with patient
  • Amend if necessary

Hour 4

• Examination
  • The Exam- coding
  • Graphic documentation
  • Posture gross anatomy
  • Vital signs
    • B/P
      • Orthostatic
      • Both arms both legs depend on injuries
    • Respiration
      • Difficult / painful
        • Ribs /lung/diaphragmatic
    • Temperature
    • PO2
    • Pulse
  • General physical appearance
    • Skin
      • Contusions (photos)
      • Swellings
      • Perspiration
    • Eyes
      • Shape / size
      • Upper and lower lids
      • Conjunctiva
      • Pupils 
        • Anisocoria
        • Light response- Rogoff’s sign
      • Eye movement
        • Nystagmus
    • Oral cavity
      • TMJ
        • Movement
        • Articular 
      • Teeth
      • Tongue (CNXII)
        • Deviation
        • Atrophy
      • Uvula
        • Deviation (CNX)
    • Posture Analysis
    • Palpation- Algometer
    • Range of Motion Evaluation
      • Use instrumentation for measurement
      • Measure three time and average outcome
      • Always passive motion to point of discomfort
      • This conforms to AMA guidelines      
    • Neuro/Vascular Evaluation
      • FAST (Facial droop, Arm weakness, Speech difficulty, Time
      • Drift Test, Arm Rolling, Finger / Thumb Rolling
      • Tandem Walking
      • Consider results from eye, oral cavity exams and Romberg’s.
    • Orthopedic Exam
      • Cervical spin
      • Thoracic spine
      • Lumbar spine
      • Pelvis
      • Involved Extremities
      • Thompson Leg Checks- cervical primacy – whiplash

Hour 5

• Neurological Exam
  • Head
    • Document TBI/ Concussion / DAI (diffuse Axonal Injury).
  • Neck
    • Relate to head and upper extremities
    • Thompson Leg check for dural torque.
    • High concentration of mechanoreceptors C5 C6.
  • Upper Extremities
    • Muscle strength Finger/ wrist/ arm strength (MSGS)
    • Reflexes
    • Dermatomes
    • Pulses w/ challenges
  • Lower Extremities 
    • Muscle strength Toes / ankles/ legs (MSGS)
    • Reflexes
    • Dermatomes
    • Pulses with challenges
  • General Neurological
    • Rhomberg’s
    • Mittlemeyer’s 
    • Cognitive exam
  • Kinesiological / Gait Exam
  • Functional Capasity
• Radiological Exam
  • Cervical spine
    • APOM, Lat. Flex/ Ext.
    • Obliques an option as clinically indicated
    • AOMSI- (Alteration of motion segment integrity) have documented by outside radiologist always.
      • cannot be seen by IME doctor
      • ii)    cannot be seen on MRI
      • iii)   always implies trauma
      • iv)   indicates “medical” necessity
      • v)    disability rating key
  • Thoracic spine
    • AP, Lat.
  • Lumbar spine
    • AP, Lat. 
    • Obliques if Spondylo present
    • Flex / Ext if spondylo appears unstable on lateral.
  • MRI
    • If DDD or vertebra compression MRI will indicate hyperemic bone and an acute condition
• Disability Rating (hold for final exam/discharge)
  • as per AMA Guidelines 6th Ed. 

• Report of findings 
  • Present patient demographics
  • Present nature, date, time of the MVA
  • List patient injuries
  • Present relationship of injuries to events in the MVA
  • Report Exam findings
    • Relate findings to injuries at each summarized at each section           
  • Report disability findings
  • Causality statement
  • Schedule rationale for care
  • Declare Medical necessity
  • Sign off responsibility clause.
• Documentation of care (SOAP)
  • As detailed as possible
  • Treat / or comment examine all injured parts.

HOUR 6

• IME’s
• Paper Review
• EUO’s

We will be dealing with strategies to best aid our patient’s and to get the remuneration deserved.

• The Exam
  • Documentation
    • ROM- digital- Dr. Croft values per sex and age.
    • Muscle test- digital
    • Algometer- An instrument for measuring the degree of sensitivity to a painful stimulus. Synonym(s): algesimeter, algometer- manual- computerized.
    • Proper dermatome eval.
    • X-rays- 5 views-  AOMSI
    • MRI – C-spine and L-spine (spondylo or prior disk)
    • Soft tissue v.s. hard findings
• The Report
• The treatment
  • State norms.
  • Council on Chiropractic Guidelines and Practice Parameters (CCGPP)
  • ODG- Evidence-Based Decision Support
• Re-Exams- Final exams- Disability rating- 6th Ed. pages
• IME Rebuttals
  • AMA Guidelines 6th Ed.- Art of War- Sun Tzu-“attack your enemy where they are weak, not necessarily where you think you are strong”
    • Waddell – Waddell’s statement - Cultural / language
    • Gender/age ROM
    • Report standards - instrumentation
    • Ortho/neuro test standards
    • AOMSI
    • Functional survey- DASH, etc.
    • Previous conditions
      • Egg Shell plaintiff
      • Medical Records- 2 years back
• Paper Review
  • Most states allow a request for peer-to-peer
  • Statement that most paper reviews are overturned as per insurance companies as reviewer has never examined the patient. He will try to reject on procedural basis.
  • Does he have all your records?
• IME Rebuttal
  • Greatest mistake- Do NOT repeat your findings and do not offer your opinions- published fact only
  • Strongly attack the IME Doctor
    • Be aware of your state law on Chiropractic. 
    • On line check to see if the IME Doctor holds a license in your state and if so, is that license current.
      • If the IME Doctor does not hold a valid license for your state – you may impeach the entire report as per law in most states-, to begin, or change  a Chiropractic treatment one must hold a valid license in that state other wise one would be practicing Chiropractic without  a License. This forces the insurance company to find another doctor with license and buys you more treatment time.
  • Check to see the specialty of the IME doctor.
    • Most states allow a request for peer-to-peer review or IME.
    • If you are stuck with this IME report- Check the affiliations. If they are fellows of any professional group.
      • On line check what that association has a criterion for examination. Specifical, what tests do they recommend.  If that IME doctor is deficient in his examination as per his own profession- begin to impeach the report based on that show how you did find this or that through the PROPR criteria (as per the IME doc’s own profession).
      • Orthopedic refuting x-ray findings- see AAOS radiological Specialty.
  • Check to see the Body parts examined
    • If there was any body part reported on your examination as being injured, and the IME doctor did not examine that body part, even if the IME cutoff is upheld by the insurance carrier 
    • One can simply reply to the carrier that there was no IME cutoff for _____ body part, so you understand that you may continue to treat that body part.
  • Note the orthopedic / neurological tests performed by the IME doctor, are they valid, are there a sufficient number done as per usual protocols.
  • Have your patient purchase something in a store and hold onto the time stamped receipt After the IME exam the patient should return to the same store and purchase anything again holding on the time stamped receipt. This will give us an approximation of the very little time that the patient was in front of the IME doctor and will aid in impeaching the exam as being impossible to have perform all that the report states in the allotted time period.
  • Is there a language issue
  • Was there a nurse of assistant present in the exam room?

Hour 7

• Completing 
• The report should be as precise as possible. It should be heavily documented with published facts. 
• It appears to be a laborious task, but there is need to find a documentation only once, then log it away for further use. You will find you will be reusing documentation often. The IME doctor will almost always do a shoddy job and deliver a report which is easy to poke holes in. Be prepared for a rebuttal to your rebuttal which is almost always a sad commentary on the IME doctor’s ability. It should be easily refuted once again.
• The goal is to present an airtight report so that the insurance company will be shown, that in a court room their expert witness will not have a chance.