Photo Credit: Mercy Health, Flickr.

The most frequently asked question by my clients is how long it will take to finalize or resolve their personal injury case. It is important to understand that each case is different. Each one is typically resolved based upon its own unique set of facts. However, there are certain guidelines which do apply.

If a client undergoes medical care for a muscle straining/spraining type injuries (i.e. whiplash injuries) which require weeks or months of physical therapy and follow-up examinations by their physician, typically they are in a position to have their case resolved within 30-60 days from the time that the individual is pain-free from their injury related symptoms.

However, those individuals who suffer more serious injuries to their spine or joints (i.e. internal injury to the knee, rotator cuff damage to the shoulder or spinal damage) usually involve a longer period of time in order to determine the full nature and extent of their injuries. Whether the injured party will require surgery and then wait until the surgery is performed in order to make sure that an optimum recovery has been attained with no complications.

Often, it is possible to resolve an injured party’s case, prior to surgery, if a determination is made regarding the amount of the policy limits in effect at the time that the incident occurred. It may be possible to resolve the case for the same maximum insurance coverage prior to surgery, which typically would be offered after the injured party undergoes surgery and incurs the additional medical expenses.

The distinction is that if the case can be resolved prior to surgery, then the injured party can avoid providing reimbursement to their healthcare provider for the costs of the hospitalization and related surgery. This distinction only applies for private insurance carriers and not to Medi-Care.

An experienced personal injury attorney, can discuss with you the options available to increase the net recovery that you are entitled to in order to avoid having you incur unnecessary reimbursements, court costs and even legal fees.

Cases that settle prior to trial involve a lower attorney fee.

If you have any questions regarding the options available to handle your case, in order to pursue the maximum recovery you are entitled to, please contact the offices of Gary Sernaker.

San Diego is actually at the epicenter for the development and wide scale application of the policies implemented under what has been referred to as “Managed Care,” which is the system now in place for those of you who have health care coverage, group or individual, that covers you and your family. The original idea was that costs associated with the medical treatment doctors were charging was too high. So the Health Care Insurance Industry started placing requirements that required various medical tests, treatment and even surgical procedures under the review of their employees, most of them not even medical doctors or formally medically trained to assess whether the doctor’s recommendation should in fact be followed. Now you would have some independent contractor who is compensated based on what they save the company, deciding whether the patient really needs the M.R..I. prescribed, or the surgery recommended.

This started having significant results, however, the medical providers were upset about having their decisions reviewed by unqualified individuals. The Health Care Insurance Industry then came up with the brillant idea of compensating the medical providers by the amount and treatment they didn’t provide. Called Non-Utilization Bonuses, hospitals and medical providers started receiving huge amounts of money when they achieved targets set by the Health Insurance Industry for the treatment that they opted not to provide.

The next step was the way that medical providers were paid for services provided under the Health Insurance Contract. The major health insurance carriers negotiate with each hospital and medical group that would like to be covered as an authorized provider for the unions, employers and other groups that have paid premiums for their members to be covered under. The medical provider agrees to provide various services at a reduced or capitated rate, below the amount listed or authorized as the reasonable charge in C.P.T. codes (published lists of accepted fees for specific medical procedures). To offset the discount that the providers have agreed to, in order to gain access of the subscriber of a particular health plan, the insurance carrier also pays them a fee based on the total amount of the subscribers who would be potential patients if they ever became ill or injured. The hospital and medical group, selected by the subscriber, when they sign up for the coverage, is paid every month whether they ever see any of the enrollees or not. The kicker is that if a covered individual actually has to receive medical care then the facility agrees to absorb the amount of their care up to a certain limit. It can range from just $5,000 up to $100,000. The medical group takes the risk that only a small percentage of the potential enrollees who select them will ever actually require medical care that they have to provide but will not be compensated for. That’s one of the reasons why when a person selects a medical group they are required to sign a form that requires the medical group to be reimbursed for the cost of the medical care provided in the event that the patient has been injured through the fault of another. The reimbursement requirement does not offset the cost of the premiums that the patient has previously paid. It also can be required even though there is inadequate insurance coverage for the individual who is responsible for causing the patients injury and need for medical attention.

This system actually encourages medical providers not to treat their patients. It’s the reason why patients are sometimes told that their treatment is not covered when it’s needed due to an accident. That is absolutely untrue, there is no health care coverage that does not apply when needed due to trauma, whether the patient has a claim or not. Patients are also discouraged from receiving appropriate referrals to specialists, or having M.R.I.. testing to diagnosis whether the nerve pain experienced is due to protrusion from a herniated disc, or physical therapy that continues until the patient has fully recovered, if improvement is happening. Not just an arbitrary amount of sessions authorized regardless of actual results.

Unfortunately, these problems have permeated and undermined the quality of the medical care available today. A person who receives medical coverage as a benefit of their employment or who pays their own premimum should not have to worry that their medical provider is influenced by the contract they’ve entered into with the patient’s health care insurance carrier. It is critical that patients refuse to be ignored or mistreated when their medical complaints are not properly diagnosed and treated. Attorney Gary Sernaker has been protecting the rights of his clients to fight for their right to receive the quality of care that they have paid for are entitled to. If you feel that your medical group is not doing what is necessary for you to recover from an injury please contact him for a free consultation.

Photo Credits: Mercy Health, Flickr.