Archive for September, 2014

Fight Brad Fight: Believing in Zebras and Beating Cancer

brad zebraApril 18th has always been a special day for me, marking the birth of my oldest son, Brad. While usually a day of joy, this year was markedly different, for on that day he was diagnosed with cancer. There were no celebrations or cocktails to celebrate his 21st birthday. Rather, the next few months were spent enduring chemotherapy followed by a highly risky surgery.

At the outset of this journey I shared that my greatest fear as a parent had always been a first responder knocking on the door at two in the morning, but perhaps a doctor with a diagnosis of cancer in a child is worse. Living the journey puts a new perspective on things, and I do believe that the knock on the door is worse, as that spells the end. A cancer diagnosis does not.

It’s hard to explain to those who have not been down this road, but sadly many have. Cancer is an insidious disease that comes in many different forms and impacts people from all walks of life. But it doesn’t have to be a death sentence.

In Brad’s case, he had an extremely rare form of cancer called a nonseminomatous mixed germ cell tumor of the mediastinum. In layman’s terms, a mass the size of a volleyball in the chest that contained both cancerous and non cancerous cells. It is well established in the medical community that chemo alone could not eradicate this form of cancer that always has a poor prognosis.

Our first challenge were the local doctors who, while very caring, had clearly had never seen something like this. They speculated and did many tests that came back as inconclusive. As parents, our first concern was getting the best medical care for our son, and it was evident that it wasn’t going to be in our hometown. After much research, we ended up finding a medical team at MD Anderson Cancer Center in Houston, where Brad’s oncologist and surgeon had effectively beaten this type of cancer in the past. There was nothing inconclusive about what Brad had. They knew exactly what it was and had a plan of action to beat this beast.

But the greater lessons of this journey go well beyond the bounds of the medical team and facility. It has been an amazingly spiritual walk that has brought our entire family closer to one another and closer to God. As people, we are all dealt challenges. It is said that God never gives us more than we can handle, but His challenges are there for a reason. It is best not to ask “why” but to focus on how to conquer whatever is thrown at us and using His challenges to become better people in His kingdom.

This can be difficult in a society where so many people say that “winning isn’t everything.” Try telling that to a person with cancer. Winning is the only thing. As Vince Lombardi once said, “If winning isn’t everything, then why do they keep score.” We kept score, lots of scores. We had good days and bad days. As anyone who has gone through the cancer journey can attest, it is like a roller coaster ride.

At the outset, we looked for a way to keep Brad’s mind off of what was happening and created a Facebook Page to not only provide information, but to gather support for Brad’s journey. He kept track of people, both friends and complete strangers from across the globe, as they got behind him with words of inspiration. Some of the most joyous moments came reading stories of others who had conquered this disease.

Brad’s surgery was two days shy of five months from his first trip to the ER with the symptoms that led to his diagnosis. We met, as a family, with his surgeon two days before the surgery and came away very scared. This is a tremendously risky surgery that has complications that can range from loss of a lung to blindness to life on a ventilator to death. Needless to say, we prayed, and prayed some more, and asked others for prayers that were received from all over the world.

The surgery was nothing short of miraculous. In just under six hours, the surgery team at MD Anderson, led by God who put his almighty power in the hands of Dr. Garrett Walsh, a professor of vascular thoracic surgery at the University of Texas, removed a tumor that was roughly 16 cm. and more than six pounds. There were no surgical complications. Brad’s lung was saved. There was no move to the ICU, as had been anticipated. There were no follow up complications or infections. Brad was released several days earlier than expected, and is up and walking without a tumor in his chest for the first time in years; perhaps even his entire life. We also learned, just yesterday, that the pathology report was negative, meaning that he has beaten the beast. To describe this as anything short of miraculous would not do it justice.

We also learned many valuable lessons from others who have faced this ordeal. First and foremost, attitude is everything. You can choose to be a fighter or a victim. Like overcoming any obstacle, it is the fighters who come out on top.

God, so often forgotten in our society today, becomes a focal point. It is He who thousands asked for a miracle and it is He who listened and delivered. But He also has a plan for Brad. We don’t know what that plan is, but believe His divine guidance will take our entire family down the right path.

Throughout any ordeal, it is not uncommon to look for signs of hope. Our first sign was on Easter Sunday, as Brad began his chemo treatment on the day of resurrection. On the day of surgery, a friend gave me a bullet, so that Brad could “bite the bullet” and overcome this. As I write this blog, the bullet sits by my side. Another friend told me to BIZ, or believe in zebras. Zebra is a slang medical term for an obscure and unlikely diagnosis from ordinary symptoms. It derives from the aphorism “When you hear hoofbeats, think horses, not zebras.” We must have faith in medicine’s ability to recognize and save zebras, which it has.

The most recent sign was a clean pathology report, delivered on the eve of Rosh Hashanah, the holiest of holidays in the Jewish religion, a day that emphasizes the special relationship between God and humanity, our dependence upon God as our creator and sustainer, and God’s dependence upon us as the ones who make His presence known and felt in His world.

Now it is time for Brad to take a mulligan on his 21st birthday and start anew. With a new lease on life, it is time for a real birthday party with a cocktail instead of chemo. It is time to return to work and enjoy life as any young person should. But it is also time to reach out and help others and give them the strength necessary to persevere and come out on top, too.

****

Chris Tidball is an author, speaker and consultant. He is also Brad’s dad and can’t thank everyone enough for their prayers, support and words of encouragement. He and Brad are working on their first jointly published book entitled You Got This: 20 Essential Rules For Coming Out On Top After a Cancer Diagnosis Turns Your Life Upside Down, which will be available in the near future at http://www.christidball.com.

September 24, 2014 at 4:47 am 2 comments

Successfully negotiating the right amount on BI claims

Vince Lombardi once said, “If winning isn’t everything, then why do they keep score?” This is some sage advice in a day and age when mediocrity is the far too frequently accepted norm. When it comes to claims, we need to ask ourselves whether we want to win or settle for mediocrity.

But what truly defines a win when negotiating a claim settlement? One could argue that it is accurate outcomes. We win our negotiations by paying exactly what we owe; no more and no less. Beyond the ultimate outcome, are also the investigative steps taken to be in a position to effectively negotiate this outcome.

In negotiations we often talk about win/win situations. This is where everyone comes away feeling like a winner. But there are also win/lose situations where one party wins and the other loses and lose/lose, where both parties come away with a bad result. When it comes to insurance, the perception is often that the insurer wins and the claimant loses. This is driven in large part by unrealistic expectations about what is owed. If a claimant feels that their car is worth $15,000 dollars but the realistic replacement cost for a like kind and quality vehicle is $13,000, then the latter is what the claim is worth. To create a win/win situation, it is incumbent upon the adjuster to empathize with the claimant, while also providing factual evidence to support their own position.

Perhaps this is easier said than done, especially among those who don’t spend time in the field negotiating face to face with body shops, injured parties and plaintiff attorneys. Negotiation is a skill that is developed over time and must be continually honed to maximize ability. To support the strategy there must be a framework to make the negotiation effective.

Beginning with liability, adjusters need to give consideration to all aspects of duties owed, duties breached and the degree thereof. Far too often claims are settled at 100%. After all, it is much easier to pay 100% than to effectively negotiate a comparative result. But is that the right thing to do as a fiduciary?

The reality is that most claims are not full liability situations, yet across the industry only 3% of claims are assessed with comparative negligence. When compared to juries, who routinely assess shared liability in more than half of cases adjudicated, a great opportunity for improvement becomes evident.

One of the challenges facing claims organizations is the push to increase productivity expectations while streamlining staffing. Doing more with less certainly accomplishes some goals, but it can have a detrimental impact on the quality of claims being processed, if appropriate processes are not put in place to improve for organizational efficiency.

Another challenge is the intervention of an attorney on behalf of the plaintiff. In far too many situations, claimants are paid 100% in an attempt to control the claim, only to see the claimant retain an attorney. BI adjusters sometimes feel hamstrung by the decision of the front line liability adjuster without fully realizing that they aren’t bound by it. These situations provide a great opportunity to coach adjusters on the importance of accurately assessing liability and educating the customer at the outset of the claim.

In many situations where an attorney becomes involved, there is indeed an element of comparative negligence. Even in seemingly clear liability situations, such as rear end accidents or parked vehicles, there can be a subset of claims where some negligence, albeit minimal, can be imputed on the other party. Leaving no stone unturned is what separates the extraordinary adjuster from the ordinary.

Some claims organizations have found success with decision support tools, such as ClaimIQ, that assist the adjuster in identifying duties owed and assessing a degree of breach, all the while laying out strengths and weakness of the claim, yet fully empowering the adjuster to make their own decisions based upon organizational best practices.

Moving beyond liability, negotiations will focus on special and general damages. Just because the treating doctor says the treatment rendered was reasonable, doesn’t make it so. It is estimated that as much as 30% of auto related medical bills may contain some level of fraud or deception. Let’s consider two very basic situations; upcoding and unbundling.

Upcoding involves trying to bill a higher level of service than was rendered. Consider an initial office visit billed at $500 for CPT code 99205, which is a “high-level office visit for a new patient” requiring three key components:

 A comprehensive history
 A comprehensive examination
 Medical decision making of high complexity

Most certainly $500 dollars for this type visit isn’t unreasonable. In fact, it is well within the norm across the United States when there is a serious medical condition. However, when looking at the requirements to bill this CPT code, questions should arise.

 Was this a serious medical condition
 Were there potential complications
 Was there threat of mortality
 Did the doctor spend 60 minutes face to face with patient

If the answers are no, then this CPT code is not proper. While this code may be accurate for a patient needing triple bypass surgery, it is not reasonable for a fender bender resulting in subjective complaints of neck and back pain. In order to maximize billings, some providers will upcode bills, hoping to slip them by very busy adjusters. Without medical bill review tools, such as Decision Point or Smart Advisor, many of these bills do just that.

Other providers will unbundle bills, charging for individual services that should have been included together, such as the following example involving a lumbar MRI:

A bill is provided with CPT code 72148 (Lumbar MRI with contrast) for $2400.00 and CPT code 72149 (Lumbar MRI without contrast) for $2600.00. The total billed by radiologist is $5000.00.

By having an effective medical bill review process in place, the adjuster would quickly learn that 72158 is the proper CPT code for a lumbar MRI with and without contrast and that the reasonable cost was substantially less than the unbundled amount.

It is no secret that bills can be manipulated with the full expectation that they will be challenged by savvy negotiators, but certainly not by all negotiators. The challenge to the industry is the latter, as many bills are simply accepted. Most certainly, the plaintiff attorney isn’t accepting them, though. Rather, once they have settled the BI with the insurer, the savvy attorney is turning around and haggling with the provider, creating a higher margin on the settlement than if the claim had been effectively and accurately negotiated by the insurer. By effectively arguing bills, adjusters are merely paying what is owed to all parties involved in the claim.

Moving beyond specials, consider generals. One of the biggest challenges in BI negotiations is the focal point being a single number. This allows plaintiff’s to gain a strategic advantage, as it forces adjusters into a reactive posture.

A better approach is to proactively look at each component of the claim individually; liability, special damages and general damages. Focusing on each aspect allows for a more accurate evaluation, and enables the adjuster to more effectively identify the strengths and weaknesses of each of the individual components on order to formulate a far more effective negotiating strategy.

In many venues, the first question asked of the jury isn’t the value of the claim, but rather the liability of each party. If the claimant is at fault for a percentage, then that needs to be a focal point of the investigation. Let’s face it; many claimants bear some responsibility for the claim, even if it is minimal. In some instances, intense scrutiny on liability can also yield other potential tortfeasors.

Other considerations should also be the impact on lifestyle, the credibility of all parties to the claim and the venue. When looking at such factors, they may add or detract from the value of the claim. If there is no impact on lifestyle, is there really any pain and suffering? Conversely, if a person is unable to work for three months, just how much is that pain and suffering worth? What if the claimant has three prior claims and a felony conviction? What if you insured does? These, and other key questions, play a key role in the claim negotiation.

Next we come to venue which is often a crutch to justify overpaying claims. Not that venue doesn’t matter; it does. It matters a lot. But, it matters only to the extent that a detailed and thorough claims investigation has been conducted.

The important thing to remember when investigating claims is that no two are identical. We often have to take claimants as they come, but that doesn’t mean we owe more than the claim is worth. Each claim needs to be evaluated based upon its individual merits. Adjusters need to not only identify strengths of their case, but that of the other side. The best negotiators understand their opponent’s position and effectively formulate rebuttals.

While claims can vary in complexity, it is important to never forget that the foundation of claims requires establishing two key elements; liability and damages. To achieve mastery of negotiations, it is critical to understand each aspect of the claim, leverage proven tools, formulate a plan of action and execute effectively on claim fundamentals to deliver the most accurate possible outcomes in all negotiations.

Christopher Tidball is a claims consultant, speaker and author of multiple books including Re-Adjusted: 20 Essential Rules To Take Your Claims Organization From Ordinary To Extraordinary! He has spent more than 25 years in the various claims related roles as an adjuster, manager, executive and consultant. To learn more please visit http://www.christidball.com.

September 11, 2014 at 11:16 am Leave a comment


Enter your email address to subscribe to this blog and receive notifications of new posts by email.

Join 146 other followers

Contact the Author

Chris Tidball is a claims and revenue management consultant and author of the "20 Essential Rules" series of self and organizational improvement books. You can ask him a question at chris@christidball.com

Kicked to the Curb

Kicked to the Curb

Re-Adjusted

Finding Millions on Twitter

Error: Twitter did not respond. Please wait a few minutes and refresh this page.