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This is my revised billing policy for legal consultation. IMAGING: Imaging is vital to my assessment of most cases, and I am able to access many studies on-line. For almost any study in Rhode Island, and any Shields study in Massachusetts, I will obtain them myself at no additional charge. Images will be analyzed, selected, and inserted into the reports as appropriate. INDEPENDENT MEDICAL EXAMINATION (IME): This is charged at a flat rate of $875.00. This amount includes all transcription costs, imaging review, and communication with pertinent lawyers or other consultants. As a courtesy, I will review limited medical records that arrive on or before the day of the IME. "Limited" is defined as less than 100 pages of medical records (including cover letter, dividers, etc.) and less than 4 imaging studies. If additional
records or imaging studies arrive after the day of the IME, they
will be reviewed, and the report amended, at a rate of $700 per
hour. COURT APPEARANCE:
My charge for a court appearance is for either a half-day or
a full day. The half-day charge is $5,000 and the full day charge
is $7,500. In the event of the need for travel, relevant costs (airline
ticket, food, etc.) will be billed in addition. The above fees include
record review, pre-trial meetings, etc. DEPOSITION: This is charged at a rate of $875.00 per hour, with a minimum charge of 1 hour. This includes review of any limited additional records and additional imaging studies provided for that meeting (see definition of "limited" above). It will also include all communication with pertinent lawyers or other consultants. RECORD REVIEW: The majority of my consultations involve record reviews, and we charge a rate of $700 per hour. I appreciate the fact that an open-ended commitment in regard to reimbursement is difficult to make, particularly if you are not familiar with our work. For that reason, I have instituted a cap of $2,000 for the review along with a completed report, though it is usually less. In exceptional cases that involve voluminous records, I will not commence until I have contacted and received approval from you. A completed report will usually include references, annotations, whole person impairment evaluation (AMA 6th version), USDOL work level, and pertinent imaging. A typical report is included at the end of the document. We have changed to a paperless office, and except in unusual circumstances, a completed report will be sent via email within 20 business days upon arrival of the records. Please provide your email address in your cover letter. In general, it requires less than 2 hours for me to complete a review, as I can usually review 400 pages and 3 imaging studies per hour. Please inform us if there are time-sensitive issues such as arbitrations, hearings, etc. I will usually be able to accommodate your request. For an expedited
review, an additional charge of 25% will be added. "Expedited"
is defined as a completed review within 15 business days of my receipt
of the records. For an urgent review, an additional charge of 50%
will be added. "Urgent" is defined as a completed review
within 5 business days of my receipt of the records. DESTRUCTION OF DOCUMENTS: I am often not informed when cases are dismissed or settled. If I have not received correspondence regarding a case for 2 years after the time I have submitted my report, I will destroy all records pertaining to that case.
DISCUSSION OF CASES We have made changes in regard to discussion of cases after report submission. I am always happy to discuss cases with referring adjusters or attorneys. However, due to the unpredictability of my schedule with surgery and consultations, I have run into many instances of phone tag that is an inefficient use of everyone's time. Therefore, for discussion of cases, my office will set up a 30 minute telephone appointment for that purpose. The minimum time for this is 15 minutes, and will be billed at the standard $625/hour rate in units of 15 minutes. If a longer amount of time is needed, please let us know.
INVOLVEMENT IN CASES I have reviewed medicolegal cases for over 20 years. I have never refused to give my opinion on a case, and will continue that policy. However, referring adjusters or attorneys should be made aware of certain instances when I will not provide testimony against a physician.
CANCELLATION POLICY We have been experiencing a large number of last minute cancellations and postponements. Many claimants do not show up for their IME's. While we understand the difficulties involved with your scheduling these, and appreciate your involving us in them, we are booking these 2-3 months in advance. We move operations and clinics to accommodate them. FEES FOR CANCELLATION:
stephensaris@comcast.net We appreciate your understanding and cooperation. A copy of this policy will be faxed or emailed to your office at the time of scheduling.
Sample record review performed by Dr. Saris
RECORD REVIEW ON MARK SMITH
On September 17, 2004, he underwent an LS CT at Morton Hospital. No abnormalities were noted. On May 5, 2007, he was seen at Sturdy Memorial Hospital. He had back pain. He had a normal neurological examination. On the pain diagram, he indicated discomfort in the low back centrally. The diagnosis was a soft tissue back injury. On May 8, 2007, he underwent an LS MR at SMH. It showed tiny central L4-L5 and L5-S1 disk protrusions. On June 4, 2007, he was seen at Mansfield Physical Therapy. He had back pain due to a soft tissue injury. On July 3, 2008, Mr. Smith claims he was injured seriously after a motor vehicle accident (MVA, subject accident). On July 3, 2008, a crash description was created. A photograph of the accident scene shows a Honda Sedan vehicle and a truck with a trailer hitch. The front of the Honda has collided with the driver's side of the truck. Photographs show significant damage to the front of the Honda with crumpling of the hood. On July 3, 2008, he was seen at Sturdy Memorial Hospital after a motor vehicle accident. Neurological examination was normal. There was no pain on palpation of the dorsal neck. On the pain diagram, he indicated discomfort in the small of his neck. His diagnosis was a nasal fracture. On July 23, 2008, Dr. Jones, an ear, nose, and throat surgeon, saw him. His conclusion was that there did not appear to be functional or cosmetic deficit from his injury. On September
5, 2008, Dr. Sindal saw him for an initial clinical consultation.
He describes him as a 23-year-old man who worked at Dunkin' Donuts.
Initially, the pain began when he fell at work years previously.
There had been a more recent motor vehicle accident. An
MR showed multiple protrusions. He was 5 feet 5 inches and 150 pounds.
Neurological
examination was normal. He has felt to have sacroiliac joint
pain as well as disk protrusions. 1Color
code: Objective, verifiable information is color-coded as below On November 26, 2008, Dr. Sindal performed an SI injection at SMH. On February 12, 2009, Dr. Sindal saw him at SMH for an SI injection. On April 14, 2009, Dr. Sindal performed L5-S1 epidural steroid injections. On July 16,
2009, Dr. Sindal saw him. He had undergone two SI injections that
were helpful. Neurological
examination was normal. He would continue on his pain medications
and x-rays were ordered. On July 24, 2009, he underwent an LS MR. It showed small central protrusions at L4-L5 and L5-S1. There was no change compared to a May 2007 study1. On July 27, 2009, he underwent x-rays at SMH. He might have right sacroiliitis. On
July 27, 2009, he underwent an LS MR at Shields. It was compared
to a May 2007 study. There was no significant interval change, and
widespread degenerative changes were noted. On July 29, 2009, he underwent a right sacroiliac injection at SMH. On September 11, 2009, Dr. Sindal saw him at Sturdy Memorial Hospital (SMH). He underwent a sacroiliac joint injection. On December
16, 2009, Nurse Anson wrote a letter that Mr. Smith was disabled
due to his work-related injury. On August 12, 2010, Dr. Laswon, an orthopedic surgeon, saw him. The subject accident is described. He was single and had no children, and smoked half a pack of cigarettes per day.Neurological examination was normal. The diagnosis was a soft tissue back injury. On August 18, 2010, he underwent an LS MR at Shields. There was no comparison imaging. There was a central herniation at L4-L5. On August 18, 2010, he underwent an LS MR at Shields. He had a central disk herniation at L4-L5 without compression. On August 19, 2010, Dr. Laswon saw him. An MR done at Shields showed "a central canal extrusion at L4-L5. It does not result in significant central canal narrowing." He would be referred to Dr. Latchaw. On September 7, 2010, Nurse Rodriguez wrote a letter to Mr. Ernst. He had chronic back pain in addition to anxiety and depression. He would benefit from psychological counseling. On September 9, 2010, Dr. Ranison, a neurosurgeon, saw him. He had pain traveling from the back into both buttocks and down both legs. On examination, he was 5 feet 4 inches and 150 pounds. Neurological examination was normal. He recommended an EMG. He had undergone a three LS MRs without structural compression. He did not believe that surgery would help. On February 28, 2011, Dr. Johnson wrote a letter in his regard. Mr. Smith asked him for an increase in Ambien that he refused. He wanted an increase in his Valium that he refused. On April 13, 2011, he underwent a cervical MR at Shields. It was a normal study with a rightward disk-osteophyte complex at T1-T2. On April 19, 2011, Dr. Johnson spoke with him. He was having worsening pain on decreased doses of Oxycodone. He had taken 120 20 mg Oxycodone tablets in two weeks. He was told that he was being discharged from the practice due to noncompliance with pain contract. On October 19, 2011, Mr. Smith put forth answers to interrogatories. He claims that the other vehicle rammed a stop sign and collided with him in Norton, Massachusetts. In answer #5, he claims that about five years previously he fell at work and injured his back. He treated for under a month with physical therapy. In answer #10, he states that the weather was sunny and was dry. The front of his vehicle came in contact with the driver's side of the other vehicle. In answer #17, he states that he had several injuries as a result including back pain. He had treated at several facilities. He underwent an MRI at Shields. His physicians felt that his back would always cause some level of pain and functionality. He felt he would never regain full range of motion in his back. On October 19, 2011, Mr. Smith was deposed. He was not married and had no children. He lived with his parents and his bother. He graduated high school, and attended Bristol Community College without completing his degree. He was not currently employed, and had previously worked for Dunkin' Donuts. He stopped working in September 2009 because of back troubles. He was in another accident on December 6, 2010. On page #16, he states that he returned to work a few days after the accident. On page #18, he states he continued working until September 2009. On page #19, he states that he quit his job and did not look for employment. On page #20, he describes filing a Workers' Compensation claim. On page #21, he describes a work-related injury. He was traveling from a store to the bank to make a deposit. That was the time after the subject accident. On page #26, he describes a back accident about five years previously. He received conservative treatment and recovered fully. On page #30, he describes being treated with Morton Hospital, Sturdy Hospital, Tufts Medical Center, Milton Hospital, and Braintree Rehabilitation. On page #34, he describes his ongoing problems. He had "major muscle spasms" across his low back. The frequency was at least two per hour. On page #35, he describes his current medications as oxycodone 20 mg, OxyContin 20 mg, and Soma 350 mg. He had been on the OxyContin for approximately nine months. This was prescribed by Dr. Jamison. On page #36, he states that he had settled his Workers' Compensation claim and is looking for work. It was his ambition to own his own Dunkin' Donuts some day. On page #42, he describes an MRI in July 2007. It was done at Shields in Massachusetts. His understanding of his MRI showed that everything was fine. On page #46, he describes spinal injections at Sturdy Memorial Hospital by Dr. Sindal. Sometimes it helped and sometimes it did not. No one had recommended surgery. On page #47, he states that after the subject accident he had pain radiating down both legs. On page #51, he states that Dr. Johnson had given him clearance to return to work. On page #52, he describes another accident in December 2010 when he was 24. On page #78, he states he believes he was knocked unconscious by the airbag. On page #90, he describes helping his mother with domestic chores such as carrying baskets of laundry. On page #91, he states that his car was damaged beyond repair at the time of the subject accident. Deposition ends on page #94.
IMAGING: I reviewed the below imaging studies personally. On May 8, 2007,
he underwent an LS MR at SMH. It is a normal study. There are age-appropriate
degenerative changes. There is no nerve entrapment, and no stenosis.
At L3-L4, there is a disk bulge. Protrusions and bulges are normal
degenerative changes as detailed in the footnote below.
On July 27,
2009, he underwent an LS MR at SMH. It is a normal study, and there
is no interval change compared to the 2007 study. _____________________________ 2The
Diagnostic Accuracy of Magnetic Resonance Imaging. Boos N, Rieder,
et al. Spine 20:2613-25,
1995.
Figure 2: The pictures on the left are T1 and T2 sagittal images of the LS spine. As can be seen in comparison to the pre-injury study, there is no change between the two. The same applies to the axial sections through L4-L5 and L5-S1, respectively. ASSESSMENT: I have made the below statements to a reasonable degree of medical certainty. Mr. Mark Smith is a young man who claims he was injured seriously after a motor vehicle accident over three years ago. He had a soft tissue injury that soon healed. He is entirely well from the standpoint of the subject accident at this time, and was entirely well years ago. Mr. Smith had what is termed in medicine a soft tissue injury. This involves twisting or stretching of the supporting structures of the musculoskeletal system. Examples of these are the muscles and ligaments. Similar to an ankle sprain, these are very painful in the short term, and heal in a very brief period of time. The standard time for healing is days to weeks, though they can last for a few months. For that reason, by November 2008, he had arrived at a medical end result. According to the 6th version of the American Medical Association guidelines (see calculation below). He had 0% whole person impairment. He similarly had no functional impairment or disability. He could have returned to normal activities at that time without restriction. That would include not only physically demanding activities in his personal life, but any form of activity at Dunkin' Donuts including lifting 50 or greater pound objects. He could have done so at what the USDOL defines as very heavy work. The standards
by which patients such as Mr. Smith are evaluated are the neurological
examination or imaging studies. There are numerous neurological
examinations documented in the highlighted areas above in yellow.
None show any pattern of weakness, numbness, or reflex change that
would indicate injury to a nerve or the spinal cord. This calls
his credibility into question. 3
Pain after whiplash. A prospective controlled inception cohort study.
Obelienience D, et al. J Neuro Neurosurgery Psych 66: 279-283, 1999.
We have the unusual advantage of pre-injury and post-injury studies of the part of his body where he feels discomfort. Both are normal. Protrusions are a common feature of spinal degeneration in all patients as they get older, even those in their 20s.2 They are not caused by a single trauma, do not cause pain, and require no treatment. For his claim of narcotic-dependent pain to be credible, one would expect to see a serious and structural injury such as a fracture or extrusion. No such findings are present. I am critical of his health care providers, particularly Dr. Ledbetter, who has maintained him on high doses of narcotics when there are no verifiable medical abnormalities. He has developed a substance dependency as a consequence. He should be referred to a trained health care provider for weaning and discontinuation from his narcotics. If any treatments or diagnostic tests have been ordered in relation to the July 2008 accident, they should be canceled. If other records are present such as health care provider notes, imaging studies, deposition testimony, or video surveillance, they should be sent to my office for my review. If he continues to complain of any other problems that he relates to the accident in question, he should be referred to my Attleboro or Providence office for medical evaluation. Signed under
the pains and penalty of perjury this 20th day of December 2011.
_____________________________ 5Guidelines
to the Evaluation of Permanent Impairment, 2008 American Medical
Association, Library of Congress
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Neurosurgery
Associates, Inc. email: questions@neurosurgery-associates.com Copyright ©2012 Neurosurgery Associates, Inc.
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