How to Properly Manage a Personal Injury Patient

Proper management of an injury patient is an important part of patient care that should not be overlooked.  When a new patient comes into my office, I always make sure that the patient has a clear understanding of the process.

The procedure involves detailed documentation of the patient's history, which includes finding out about prior injuries, car accidents, prior medical treatment for any body part, even if the treated body part was not accident related.  The reason behind this, is that all parties involved will want to know whether the patient's new injury overlaps with any prior medically treated areas of the patient's body.

Moreover, included in the history are any other medical conditions, as well as family history, and prescriptions currently being taken.  From this, you can learn a lot.  For example, a patient recently told me that she has a family history of aneurysm resulting in death to her sister and father. Chiropractors should never overlook this history, and blatantly do cervical adjustments on these types of patients.

At the end of the initial visit, there should be an initial report written and each subsequent visit with the doctor should be documented in standard SOAP form.  The patient always signs the chart note for the visit.  No signature and no visit ever happened.

I almost always make sure the patient is quickly referred to an orthopedic specialist or his medical doctor who could also diagnose emergency medical condition if necessary.  Emergency medical condition or EMC, is specific to Florida, and is required if the patient has a more serious injury, and its purpose is that it frees up the patient's full insurance benefit, if extensive treatment is necessary.  The insurance company is counting on the fact that the patient will not have an EMC and will only be responsible for 25% of the claim.  Without it, the insurance company takes away 75% of the patents insurance benefit.

Soft tissue injuries are better diagnosed with objective tests, like MRI.  Sometimes, X-rays are ordered if fracture or dislocation is suspected.  Most of the time however, x-rays do not turn up injury in patients that have injuries that are soft tissue in nature.  Over the years, I have seen some broken ribs, sternums, and bones in the hands and feet, but this is rare.  X-rays have shown dislocations, over the years,

Depending on the frequency of the visit, the course of treatment can vary between a couple months and upward of 6 months or more.

Any other referrals will be made if necessary, including orthopedic doctors, neurologists, podiatrists, mental health doctors, etc.

Finally, a report is generated when the patient is released from standard care, at maximum medical improvement, MMI.  If there is a request for an impairment rating, I will provide the rating in the report, and forward the report to the attorney who is helping to resolve any claims.

During this whole process, COMMUNICATION is key so that everyone is on the same page, and nothing is missed.

I have been seeing mainly personal injury type patients for 20+ years.  If you have been involved in a car accident, don't hesitate.  Please call my office to schedule your first visit.  If you are a lawyer and have a client who you think could benefit from an experienced doctor in regard to accident care, I will love to see that person.  It is NOT my goal to provide GOOD care to my patients;  it IS my goal to provide EXCELLENT care to my patients.

Alan Himmel, DC PA.
954-659-8600

Will Florida PIP Cover Me if I am Traveling out of Florida?

Will Florida PIP Cover Me if I am Traveling out of Florida?

Alan Himmel, DC PA

In your own car: YES.
In a car that is not yours, including a rental: NO
In Mexico:  NO
In Canada:  YES

Here is a scenario:  You are a Florida resident and have a Florida registered and insured car and travel north to go skiing in the Smoky Mountains.   You decide to pile your family into the family SUV, and make a trip. You manage to get through Florida and Georgia safely, but when you get into Tennessee, someone runs a red light and smashes into your car causing injuries. In this scenario, you were in your own car, so there IS coverage for you and your family.

Let's say you find that there is no snow in North Carolina and decide to travel into Canada?  Yes, there is PIP coverage for injuries to you and your family if you have an accident in Canada.

HOWEVER, lets say you decide to FLY to North Carolina, and rent a car.  You have an accident in North Carolina while occupying a rental car.  NO, there is no coverage under your Florida PIP policy. Same is true if you are in a friend's car in NC, It's not your car, so no PIP. 

Let's say you are in your relative's car in NC, providing that the relative is a NC resident, No Florida PIP here either.  How about if you are in a relative's car in NC and the relative is a Florida resident with car insurance coming from Florida?  No coverage here either unless you and the relative LIVE together.

In Mexico in your own car and there is NO coverage.

In regard to resident relatives:  There are some companies that will deny a claim if they determine that the policyholder did not disclose all people in the household when the policy was purchased.  They will deny the claim based on "material misrepresentation."    So, always let the company know all people living in the house, no matter if the addition of these extra people in the house will increase the cost of the policy.  If you hide this information from them, they will find out and may deny your claim.

I'm not a lawyer.  I am a chiropractor with 26 years experience treating auto accident patients, and I have been exposed to many different coverage scenarios.  Get all legal opinions from a licensed attorney.

See this Fantastic Whiplash Video Infographic. This is Why you have so Much Pain!

Dr. Himmel

I have been treating patients who have sustained whiplash for practically the last 2 decades. 

 Many people are unaware that even a small impact rear end collision can cause significant pain and impairment in certain cases.  Symptoms include pain, stiffness, headache, shoulder pain, arm pain, numbness, tingling, and weakness in the upper extremities.

If you have been injured in a rear end collision, do not hesitate.  You must get examined and if treatment is necessary, you should begin as soon as possible to try and prevent future, permanent, chronic problems.  

Call our office Today:  954-659-8600

Compliments of Accident Injury Centers of Atlanta,

Forget being a Chiropractor, be a Neurobiologist

Today you can be a Neurobiologist...

Dr. Alan Himmel

I am a subscriber to Medscape, which for those who don't know, is an email digest of significant new medical research that comes out almost daily from the medical community.  I have been a subscriber for at least the last 10 years, and I highly recommend that anyone who is involved in healthcare should also check this thing out.   

The reason I am writing this post, is that this is the first time since I have been a subscriber, that I have seen Medscape distribute this as news (front page headline, by the way) of an article written by chiropractors (half-doctors) and published in a distinguished and respected journal such as The Annals of Internal Medicine.  I mean, everyone knows that this is a journal that only real and "serious doctors" get their information.  

The article is written by CHIROPRACTORS (plus a MD and a PhD in Biostatistics).  So maybe they got in the journal because they "carefully" placed an MD on the list of authors? Still, the head authors are DC's and the journal accepted the research and published it.

Anyway, let me tell you how difficult this is:  Medical journals have a board of "peer" reviewers who read over submissions to the journal, slice it up with comments, and often times, stamp a big denial on the paper and send it back to the author.  In other words, just because you can write well and you are articulate, and you can back up your paper with actual results and referenced research at the end of your manuscript, these distinguished doctors who make up the peer reviewers and editors often times deny your paper if they simply don't like you or don't agree.

So, I think this is a significant event.  Medscape's subscribers are made up mainly of medical doctors and specialists.  Maybe more than 100,000 doctors read this paper.  

When you try and subscribe to Medscape, you will see that "DC" is not even on the dropdown list where it asks, what your specialty is.   Hint:  pick another specialty when you become a subscriber--maybe someone you have always wanted to be like a Neurobiologist.  

Original Research | 16 September 2014

Spinal Manipulation and Home Exercise With Advice for Subacute and Chronic Back-Related Leg Pain: A Trial With Adaptive Allocation

Gert Bronfort, DC, PhD; Maria A. Hondras, DC, MPH; Craig A. Schulz, DC, MS; Roni L. Evans, DC, PhD; Cynthia R. Long, PhD; and Richard Grimm, MD, PhD

[+] Article and Author Information

Ann Intern Med. 2014;161(6):381-391. doi:10.7326/M14-0006

Text Size: A A A

 (0)

Background: Back-related leg pain (BRLP) is often disabling and costly, and there is a paucity of research to guide its management.

Objective: To determine whether spinal manipulative therapy (SMT) plus home exercise and advice (HEA) compared with HEA alone reduces leg pain in the short and long term in adults with BRLP.

Design: Controlled pragmatic trial with allocation by minimization conducted from 2007 to 2011. (ClinicalTrials.gov: NCT00494065)

Setting: 2 research centers (Minnesota and Iowa).

Patients: Persons aged 21 years or older with BRLP for least 4 weeks.

Intervention: 12 weeks of SMT plus HEA or HEA alone.

Measurements: The primary outcome was patient-rated BRLP at 12 and 52 weeks. Secondary outcomes were self-reported low back pain, disability, global improvement, satisfaction, medication use, and general health status at 12 and 52 weeks. Blinded objective tests were done at 12 weeks.

Results: Of the 192 enrolled patients, 191 (99%) provided follow-up data at 12 weeks and 179 (93%) at 52 weeks. For leg pain, SMT plus HEA had a clinically important advantage over HEA (difference, 10 percentage points [95% CI, 2 to 19]; P = 0.008) at 12 weeks but not at 52 weeks (difference, 7 percentage points [CI, −2 to 15]; P = 0.146). Nearly all secondary outcomes improved more with SMT plus HEA at 12 weeks, but only global improvement, satisfaction, and medication use had sustained improvements at 52 weeks. No serious treatment-related adverse events or deaths occurred.

Limitation: Patients and providers could not be blinded.

Conclusion: For patients with BRLP, SMT plus HEA was more effective than HEA alone after 12 weeks, but the benefit was sustained only for some secondary outcomes at 52 weeks.

Primary Funding Source: U.S. Department of Health and Human Services.

Topics

back pain ; exercise ; lower limb pain ; manipulation, spinal

Can Whiplash Cause Concussion?

Can Whiplash Cause Concussion?

Dr. Alan Himmel

Talked about it before.  Let's talk about it again.  Can a mild whiplash cause a concussion?  The literature says, yes.  And, I have had several patients over the years, and one currently, who has the affects of post concussion syndrome.

Attorneys who represent injury clients need to be aware of this issue as well.  The most recent patient that I am treating who I am sure has suffered a concussion, has all of the symptoms of this injury, including headache, vertigo, disorientation, and confusion.  This will be a patient who will tell you that their head just doesn't feel the same since the accident.  It can be very frustrating to the patient, and the patient may find themselves searching doctors who could figure it out.  Oddly enough, attorneys will very often dismiss concussion, wanting to focus the claim on disc injuries and the usual soft tissue findings. Why?

I think that the major sticking point for attorneys is simply not understanding the physics involved in a car accident, and not knowing what a concussion actually is.

You don't have to strike your head against the inside of the car and you don't have to get hit in the head by something to cause concussion.  Think of it like this:  The brain is encased within the skull and around the brain is a thin layer of fluid which separates the brain from the inside of the skull so it does not touch (among other purposes of the fluid). The fluid is called cerebral spinal fluid or CSF.  So, the brain, in a way, is swimming in this fluid and the small fluid space between the brain and the inside surface of the skull is like a barrier because you don't want the brain to touch anything.

Okay, now think about what will happen to a person's head when at rest, when the car he is in is hit from behind.  The person's head will move in the direction of where the force came from.  This is one of Newton's laws of motion.  Every action has an equal and opposite reaction.  But, what about the brain which is "floating" within the skull?  It too, must obey the laws of physics, and at this point, the brain will then crash into the inside of the skull on the opposite side.  Right there is your concussion.



Now, keep in mind that concussion is not always possible to see on MRI or CAT scan.  Concussion is regularly diagnosed based on neurological symptoms, signs, and complaints.  Lawyers and insurance companies want objective proof, but they cannot always have it with concussion.  The lawyer who is representing the client with concussion, must be aware of these things.  A lawyer who is representing injury clients must be an expert in the law, and although its not required to be trained like a physician, he should also have a working knowledge of different types of injuries involved.

So, keep an eye out for a concussion when whiplash is involved.  They are generally not life threatening, but concussions can be quite serious, and recurrent concussions can be even worse.

I can be reached at 954-659-8600

My office address is:

Alan Himmel, DC, PA.
3161 Dykes Road
Miramar, FL. 33027

The Changes to the Florida PIP law have worked to stop fraud: True or False?

The Changes to the Florida PIP law have worked to stop fraud:  True or False?

Dr. Alan Himmel

The articles are beginning to come out stating that the changes in the PIP laws that occurred in 2012 have decreased the rate of fraud, and costs to insurance companies, and ultimately to consumers.  This is a good thing if its true.  It may be that the decreases in payouts are due to the $2500 insurance cut off, or the 14 day rule, which states that you better get to a doctor within 14 days or you get $0.00 in coverage.  It may also be due to the fact that now, there is no coverage for acupuncture or massage, two effective, safe, alternatives to medications and surgery.

As a practitioner who sees accident patients in FL, doctors now have two less options to offer patients when they are suffering from painful injuries from automobile trauma.  Plus, patients have to get better with 75% less insurance coverage than they had in the past, since not all patients will have an "emergency medical condition"  (EMC) which is supposed to allow the patient to have their full benefit.

So, I ask you:  What do you think is the true reason that insurance companies are reporting savings?   Could the answer be that there is now more opportunity for the insurance carriers to deny coverage, since the payouts are capped now in many cases?  Or, could it be true that the savings is due to less fraud?   I would be one of the first to start celebrating if I was sure that the savings to insurance companies was about the reduction in crime, but I am not 100% sure about that one.

FL EMERGENCY MEDICAL CONDITION PIP DENIALS BEGIN

FL EMERGENCY MEDICAL CONDITION PIP DENIALS BEGIN

Dr. Alan Himmel

Just as predicted, there are some companies who are ignoring Emergency Medical Conditions and denying PIP coverage beyond $2500.   So, a medical provider, in many cases a specialist, will look at and examine a patient, and say, "Yes, without medical treatment, this patient is likely going to suffer long term permanent impairments,"  and write it exactly as the law is written, and certain insurance companies are having the doctor's notes and records reviewed by one of their doctors to say that its not true.

I just had a patient with an shoulder impingement syndrome denied.  The patient cannot raise her arm up past 90 degrees in any direction.  She cannot take a half gallon of milk out of the fridge due to pain and weakness in her shoulder, and an insurance company doctor says she needs no further treatment. The MRI alone was more than half her PIP benefit.

Surprisingly, this denial is happening with major providers.  You would think that the small rip-off companies would be doing this, but as I said, even the big boys are doing it.

So, what do you do?  As a doctor who spends a lot of time with patients one on one (sometimes more than an hour), I have to make a decision.  The decision is whether to release the patient from care, or to continue treating in the hopes that in the end, a suit can be filed, and the insurance company will eventually pay.  SInce this whole EMC thing is a new thing in Florida, there are a lot of unknowns.

The first unknown is whether a suit can be won in the first place.  Lawyers cannot guarantee a win. And, as I said, this is a new program in FL, so there is not a whole lot of new case law.   Secondly, if a suit is won, will the WHOLE bill be paid, or will only part of it be paid?  What if a Judge says, pay the bill, but only 20% of it?  Can they do that?  A colleague of mine seems to think so.  He may be right.

My patient with shoulder impingement I am continuing to see and treat.  She is doing better and better. Without treatment her condition would likely turn into frozen shoulder.

RESPECT

                                          Respect.

Dr. Alan Himmel

Two Things:

1.  Patients:  Why is respect such a difficult thing for people?  I mean is it too much to ask, that if you cannot make it to an appointment, you call and let the office know?  It takes 30 seconds out of your day.  Thats it. Its just basic consideration.  

2.  Lawyers:  Again, respect.  Its not okay to divert your client away from their treating doctor.  You do not hold a license to practice any kind of medicine.  By making referrals to a health care provider, you are practicing medicine without a license.  You can try any type of lawyering to try and convince me otherwise, but you are wasting your time.

VIDEO OF PIP APPEAL HEARING

VIDEO OF FL PIP APPEAL HEARING:  SEPT 17, 2013 

Dr. Alan Himmel

FL PIP Appellate hearing video.  I don't know why the video was cut off before Attorneys Levine and Lirot were allowed to speak.

http://oavideo.1dca.org/OAPlayer.aspx?ID=1307&CaseID=43680&File=131355.smil



Also, please take a look at the what I copied off the court calendar for September 17, 2013.  Take a look at the name on the top of the list for the appellant.  Folks, I see it like this:  If Paul Lambert is on the side of the insurance companies, then he is probably there because he would rather deal with the EMC, than deal with no PIP insurance at all.  Maybe its all over.  Maybe its just a matter of time before PIP is repealed and BI becomes mandatory.  The way I see it, however, I would rather go down with a fight. 

KEVIN M. MCCARTY, IN HIS OFFICIAL CAPACITY, ETC.

Paul Watson Lambert; C. Timothy Gray, A.G.C.; Katherine
E. Giddings, Marcy L. Aldrich of Akerman Senterfitt; James
Bruce Culpepper of Department Of Insurance Reg; Nancy
M. Wallace of Akerman & Senterfitt; Maria Elena Abate,
Matthew C. Scarfone of Colodny, Fass, Talenfeld; Allen C.
Winsor of Deputy Solicitor General; Rachel E Nordby;
Theodore "Ted" E. Karatinos of Holliday, Bomhoff &
Karatinos; Kimberly A. Driggers,

 For Appellant,


- VS - 1D13-1355

ROBIN A. MYERS, D.C., ET AL

Luke Lirot; Jessie L. Harrell of Creed & Gowdy, P.A.; Bryan
S. Gowdy of Creed & Gowdy, P. A.; Adam S. Levine; Mark
S. Sussman,

For Appellee.

15 MINUTES PER SIDE
------------------------------------------------------------------------ -----------------------------------------

Lets Get Rid of BI and UM Coverage in Florida.

Lets Get Rid of BI and UM Coverage in Florida.

Dr. Alan Himmel

I love it when a lawyer comes out and says to get rid of PIP.  Sure, Mr. "For the People,"  lets do that. Lets throw the baby out with the bathwater.


http://www.wctv.tv/news/floridanews/headlines/Attorney-Says-Auto-Insurance-Changes-Will-Be-Costly-218003841.html


Why should all the legit people and doctors be penalized for the dirtbags in this state?  This mentality makes no sense to me.  Mr. For the People would like to see PIP go away and instead make BI mandatory.  This sounds good as long as you are a PI lawyer.  As long as HIS livelihood isn't affected its good for HIM. Well I have a family to support and bills to pay.  I don't go on fancy vacations, drive a fancy car, or have my own airplane.  I am just trying to survive.  When I read this from this guy, it just infuriates me.  Maybe he should change his slogan to "For Me."


Crack down on the fraud.  Get the bad people out.   That's the solution.

One Man's Formula for Success.

WASTEFUL THINKING. WASTED TIME.

Dr. Alan Himmel

I want to tell you about something that happened about 8 months ago while I was at the office working. Like most people these days, I always have my cell phone with me, and this way , I never miss an important call, especially if its a new patient.  So I'm with my patient and my cell phone rings and I excuse myself for a minute to answer.  I answered the usual way I do, which is just my last name by itself.   “Himmel!”  Its strange that over the years I just dropped the Doctor part, and just say my last name. There is actually a story behind that, but I will leave that for another day. So a man’s voice came on with a raspy New York voice and asked me, “Chiropractor?” I answered with an affirmative and, “How can I help you?  This is Dr. Himmel.” He said his name was Mr. Smith (actual name withheld of course).  He said, “I need you to come to my house; my back is hurting very bad.”  I said, “okay Mr. Smith, but would you mind giving me about 30 minutes to speak with you about this?”  I told him I was going to call him back as soon as I'm finished with this patient. He said,”Okay, but don't forget.”  I assured him I wouldn't forget.

So about 30 minutes later I'm finished with my patient I'm actually walking to my car to leave to go to lunch. At the moment I am just getting into my car, the phone rings and it's Mr. Smith. He said really loud, “This is Mr. Smith, you said you would call me back in 30 minutes.  It’s 30 minutes right now, did you forget about me?” I said, “No, Mr. Smith, I was sitting in my car and was about to call you.”   He said, “Okay.  Again my name is Mr. Smith.  I want you to come to my house. My back is hurting me.  You need to help me, please.”  I listened to this man talk and then had to ask him what exactly is going on.   He said again, “My name is Mr. Smith and I'm 94 years old.  He then said, money is no object.  I don’t care what you charge.  Please just come to my house.”  At that moment I heard another voice in the background of a woman.  It was obvious that she was disapproving of the last comment that Mr. Smith said to me, that money is no object.  Again, and not caring, he mentioned to me that he is willing to pay any amount that I charge if i can come right away.  Before I could answer, he tells me to hold and puts the woman on the phone with me, who was there with him. She said that she was Mr. Smith’s personal assistant and he would like me to come to the house and see if you can help him with his back.  I told her to just give me the address and I will come as soon as I finish the last patient at the office.

Once I got the address,  and realized where I was going, I realized this gentleman did not live around the corner from my office.  He lived on Fort Lauderdale Beach, right off the 17th Street Causeway at the end, in a large high rise building overlooking Port Everglades. I had never been to this building before but I knew exactly where it was, because I used to spend a lot of time at the beach when I was younger and I have driven past it dozens of times.   So later that evening when I was finished with my patients, I drove down to this man's house. Actually it was not a house, of course.  He lives on the 7th floor of a condo that overlooks the Atlantic Ocean.   So I Drive all the way over to his place, I park my car in the parking lot, and walk to the lobby of this building. When I got there, I told the security officer that I was going up to see Mr. Smith.  He acknowledged and told me that he was expecting me and directed me to the elevator. So I take the elevator up to the 7th floor, get out, and walk over to the guy’s door and knock. A voice calls out and tells me just to come in. So I open the door and walk in carrying my treatment table and bag.  Sitting in a chair toward the large windows was a man with a big smile on his face. It wasn't a smile on his face that was mocking or arrogant in any way. It was a smile that you get from a gracious person. I put down my table and my bag, I walked over to him, introduced myself, and shook his hand, which I noted was a very strong grip for an old man. He offered me a chair, I sat down, took out a pad and started taking a history.  Again he told me he was 94 years old, but just looking at this man he did not look 94. In fact, he looked more like a man in his 70's. He was not in a wheelchair, he certainly was not in a nursing home; his vision and hearing were good as far as I could tell.  He proceeded to tell me that every morning, especially when waking up, his back was so painful that it would take him over an hour to get out of bed.  He said that the pain would ease up as the day went on. 

He had a lot of vitamins on the counter top. There were several bottles.  In fact there were at least 15 or 20. His personal assistant would create portions that was broken down not only by day, but by AM and PM.  She took care of everything for him. She made him breakfast, she made him lunch, and she made him dinner. She reminded him of every vitamin that he should take and when.  She straightened his house for him and also drove him around to doctor appointments and to the movies.  He loved going to movies.  They would go at least once a week to see a movie.   After the history, I got up, opened up my table, and asked him to have a seat so I can give him an exam. I went through the usual, but noticed one thing interesting, which was the amount of muscle that this man had on his body for being 94 years old.  I commented that for a 94 year old man you're in terrific shape, actually.  At that he then laughed and ask me then why he doesn't  feel like he’s in terrific shape?  I told him you are 94 years old. Anyone who is 94 years old, is bound to have aches and pains and have a good amount of arthritis which generally can give you that stiff and inflexible feeling, especially in the morning.  

He asked me if I could help him.  I never tell a patient that what I'm going to do is remove all of their pain.  Sometimes this happens after one visit, but its not typical, especially for someone advanced in age.  But, the majority of the time what I'm really looking for is simply a decrease in pain of maybe 20 or 30 percent with the first visit. If we get more than a 20 or 30 percent reduction in pain, I call it a bonus, and of course, it makes me look very good.  Realistically, however, with a 94 year old man I was not expecting too much at all.  So, after the exam, I gave him a very light treatment, which included some stretching and tissue work to the affected area.  I also gave him a very light adjustment, which is actually a joint mobilization technique to get his back moving a little better.  He was very strong and so I didn't even feel that my adjustment was very helpful when I did it.  To make a long story short,  it turned out that the next morning, he was feeling incredibly better.  I wasn't completely surprised, because he actually had me convinced more than normal that I was going to fix him up.  He was very positive in that regard.  His energy was almost overwhelming.  He then asked me if I would be his “captain.”  I asked what do you mean, be your captain? He said he had, “not felt this good in a very long time and I want you on my staff.” Obviously, I'm in no position to be a live-in doctor. But, I agreed to come and treat him 2 or 3 times a week until we really got his back pain under control.

I think, to be honest, I was more intrigued with this man than he was with me. Although it was quite a drive to go see him, I would actually look forward to be in this man's company. There was something about him and I wanted to find out what it was.  Those that have gone to chiropractors, know that chiropractors very often spend a lot of time with patients.  Well, at least I do.  Very often, in fact when a patient is on the table not only am I performing adjustments on their spine, and making their back and muscles feel better, but I am also listening to their personal issues and so forth.  I get to know patients on a personal level that I doubt a regular doctor ever will achieve.  This man, however, never talked about bad things or problems that was going on in his life. I found it interesting that for a 94 year old guy, not only was he in good  physical shape, but he was also good emotionally, spiritually, and mentally.  He would often talk about ideas that he had for business.  I was fascinated of his positive attitude, and his forward-thinking.

One day when I was at his house, I had to ask, “How is it that you have become so successful in your life?  He seemed like he actually enjoyed the conversation that we had, so at this point I did not feel like I was prying or being nosey.  He was actually more than happy to answer. He said to me something, that I still think about almost every day. This thing that he said has actually helped me cope with problems that I have in my life.  He told me the trick to success is not to worry about the little things. I asked him to elaborate on that. He said that throughout life we are bombarded with things.  Some of these things are good and some of the things are bad and are very stressful.  Some of the things we have to deal with are terrible and even,  devastating. But there are also things that have no bearing on your life in the long run. He said, what most people do is spend too much time worrying about little things that have really no bearing or things they can't do anything about. He explained that most people spend too much time worrying about things that have passed, like how they would have done things differently.  He gave me a few examples of things he doesn't worry about, like getting a parking ticket, remembering somebody's birthday, or even remembering somebody's phone number.  He said all those things and more are, a waste of time. How he asked, are you able to concentrate on the important things if you are wasting time on the little things?  However, he said to me that you have to make a choice, of what you consider important or something that is not important.  He said unfortunately when you don't worry about the little things like he has done in his life, people get the impression that you are an uncaring person.   He explained that it doesn't make him a bad person if he doesn't keep track of birthdays and anniversaries.  People get upset about it, he said, but you asked me how have I become successful.  This is how it worked for me, he explained.  This is how I lived my life.  He told me that he is as close to his family as anyone else is to their family. He speaks to his children every day and they both live up north in Connecticut.  So, this was Mr. Smith’s little trick.  This is what helped him throughout is life in business.  He eliminated all the little things that he considered insignificant, so he can focus his energy on what he considered the big things.

So, it turns out that this man had a very interesting life. He grew up in a very poor family, up north, in New Jersey. He ran away from home when he was 15 and never finished high school.  He joined the military eventually and was one of the soldiers who stormed the beach at Normandy.  He showed me photographs in scrapbooks but didn't like talking in detail about it.  When the war was over and he came back to the United States, he was still very broke, but he had a skill that he could carve objects out of wood, or soap.  He said he used to do it only has a hobby but it was his passion.  Since he really loved doing this type of work, he got a job in a factory like most people, but this wasn't enough for him. He wanted to open his own company. So he saved up a small amount of money, borrowed some more money from other people, and started a company that manufactured candelabras and chandeliers that he designed.  Over the next 25 years, he grew his company to the largest American manufacturer of these objects. At one point he had over 4,000 accounts of different department stores and shops around the United States.  He told me that he could have never done this if he spent time worrying about every small issue or little hiccup along the way. He told me the idea is to point your nose in the direction you want to go and don't let anything distract you, like those little things.

Its been a few months since I have spoken or seen Mr. Smith.  But, I have to say that whether he taught me a free lesson, or I just listened to one man’s formula for success, I think the principle of ridding oneself of thoughts that are wasteful, is sound.  

Look at your life.  What do you spend time worrying about?  Do you worry about what someone said? Do you worry about what some other person did or is doing?  Do you exhaust yourself thinking about what you COULD HAVE been?  Could someone write a drama based on your life?

If you answered yes to any of those questions, you are probably holding yourself back and limiting your potential.  Once you decide to free yourself of wasteful thoughts, you will feel like you have much extra time on your hands, and you will be more able to accomplish your goals.  Try it.

Rotator Cuff Tear: Understanding This Common Occurrence in Personal Injury

Rotator Cuff Tear:  Understanding This Common Occurrence in Personal Injury

Dr. Alan Himmel

Anyone who has ever treated or represented a person with a rotator cuff tear, is fully aware of the troublesome nature of this injury.

But, what do we really know about this traumatic condition?

First, a little anatomy:  The rotator cuff is group of four muscles.  They are the Supraspinatus, Infraspinatus, Teres minor, and Subscapularus.  For purposes of remembering these muscles, just think "SITS."  This is an easy mnemonic, which any student of anatomy should remember.  The names of these muscles, like a lot of structures in the body, often tell a little bit about where they are located within the body.  For example, "supra"-spinatus is located superior to the "spine" of the scapula.  The "infra"-spinatus is located inferior to the "spine" of the scapula.  The "sub"-scapularus is located behind or deep to the scapula.

These muscles, like all skeletal muscles have a function, and they are to move bones by pulling on them, and also help give support to the bony structures of the body. Skeletal muscles must connect to bones in order to be able to pull on them, and they are connected by way of tendons.  The tendon on a muscle is what actually connects the muscle to the bone.  Unlike muscle which can contract and stretch, tendons do not have this ability.  They are simply there to connect the two structures together.  They are generally in-elastic and are very strong.

Notice the white colored tissue?  These are the tendons of the SITS muscles, and these tendons are connecting to the head of the humerus.  They will cause movement as well as to help to stabilize the joint and hold it in place.

The SITS muscles control very specific actions of the shoulder. And, the supraspinatus muscle is of most interest, because its the most commonly injured of the SITS muscles. The supraspinatus controls the action such as raising the arm out to the side (abduction) and turning the arm backward (external rotation). Because of this motion, one can easily see the stress it would be under, by a baseball pitcher, for example.

Abduction and external rotation of shoulder

So, where is the injury?  Where is the "tear?"

Most commonly, the rotator cuff injury is to the supraspinatus tendon.  Again, this tendon connects the supraspinatus (which sits above the spine of the scapula) and connects to the head of the humerus.  And more specifically, its the far end or distal end of the tendon, very close to the humoral head.   There is a small area that is known as the "critical zone" which is an area within the actual tendon that is much less rich in blood supply. This area of hypovascularization is a weak spot on the tendon because it is not supplied by rich blood, to the same extent as other parts of the tendon and muscle are.  It is thought that this is the reason most of the tears occur in that area.

What else can cause a traumatic tear of the supraspinatus besides a sports injury?  Falling on an out stretched arm can cause a tear.(1)  Sometimes when the person falls, the collarbone is fractured or the gleno-humeral joint (shoulder socket) is dislocated at the same time as the tear, although it is not necessary to have a fracture at the same time as the tear.  I have had a few patients over the years who have experienced a fall which resulted in a torn supraspinatus tendon.  In fact, in my personal experience the damage to the tendon is more common in falls than in sports related, or repetitive motion activities.  

The impairment and  treatment are almost always the same.  Usually the patient presents with pain, weakness, los of motion, and swelling in the shoulder.  They tell me they cannot take a gallon of milk out of the refrigerator with the affected shoulder.  Treatment consists of anti inflammatory modalities including icing.  Non steroidal anti-inflammatory medication is suggested.  Strengthening exercises are started.  

The MRI is the diagnostic type that is best suited to definitively diagnose the tear, since the injury is soft tissue in nature.(2)  X-ray very often turns up nothing unless there is a fracture of the humeral head where the tendon attaches, the collar bone is broken, or there is a dislocation.  

Clinical correlation is important.  When did the patient first start feeling the pain?  How was the shoulder prior to the fall?  Did the patient have his arm outstretched at the time of the fall?  All good questions and part of the patient history.

I always suggest the least invasive and safest treatment options for my patients first, but sometimes if strengthening and rehabbing the torn tendon fails, the next step is that the patient tries cortisone injections and unfortunately, surgery may become part of their future.

How this injury will affect the patient in the future is important to document.  The shoulder is never exactly the same as before the tear.  There is always some degree of pain and loss of range of motion.  Frequent exacerbations due to use of the shoulder are common.  Is the patient dominant handed on the side of the injury?  If so, the impairment will be more significant.  Will the injury have any impact on the future income of the patient?  Sometimes this is yet to be determined.

My contact information is:

Dr. Alan Himmel

3161 Dykes Road

Miramar, FL.  33027

954-659-8600

1.  Arthroscopy. 2013 Feb;29(2):366-76. doi: 10.1016/j.arthro.2012.06.024. Epub 2013 Jan 3.An evidenced-based examination of the epidemiology and outcomes of traumatic rotator cuff tears.

Mall NA, Lee AS, Chahal J, Sherman SL, Romeo AA, Verma NN, Cole BJ.

Sports Medicine Program, Rush University Medical Center, Chicago, Illinois 60612, USA.

2.  J Orthop Surg (Hong Kong). 2012 Dec;20(3):361-4.

Non-contrast magnetic resonance imaging for diagnosing shoulder injuries.

Arnold H. Orthopaedisch - Unfallchirurgische Praxisklinik, Orrthopaedisches Zentrum Fichtelgebirge, Rehau, Germany.

Simple Trick to Get More Money for Your Totaled car.

Negotiating your total loss.

Dr. Alan Himmel

If your car was totaled in a car accident, do you have to accept the first offer that your insurance company makes?  I think not.  Most people do accept the first offer, however, by doing this, they may be leaving a good amount of money on the table that belongs to them.  Over the years, I have helped many patients get more money when their car was deemed a total loss.  You don't need to be a master negotiator, nor do you need to be a lawyer to do this.  There is a trick, and I will tell you how it works:

First, it helps to have some knowledge of the way insurance companies process claims.  I happen to be a licensed public insurance adjuster, aside from being a chiropractor, so I have some first-hand knowledge of this procedure.  Not only am I a chiropractor for 26 years, but I am also a licensed public adjuster in Broward County   You have to know that most auto insurance companies process property claims based on what's called Actual Cash Value or ACV.  What this term basically means is that the insurance company will value your property based on the current market rate is for that particular property.  You just ask yourself, "what would I have to pay right now today, to replace this car?" This little piece of valuable information regarding ACV is written into your policy.  It's in the boring part that most people never read.

Here is an example of the way ACV works:  If you buy a car in 2003 for $20,000, and you file a claim for a total loss of that car in 2013, provided you have coverage, the insurance company will use a system of multiple sources to determine what it would cost to replace that same exact car, now, in 2013.  So, unless you got a banging deal on that car or its a one of a kind collector's car, most likely the car is worth less than the $20,000 that you paid; the car has to be worth less because of 10 years of depreciation.  Their system will determine what the market price in your area is for that car.

Now, there are a few things to consider here:  You must consider the deductible on the policy.  If you are filing the claim through your own policy, you most likely have a deductible and that would be subtracted from the amount they determine the car is worth.  If you file through the at-fault carrier, then there is NO deductible.  The claim is paid at 100%.  Next, the insurance company has to pay you the applicable tax on top of the amount they decide to pay you.

So, here is a breakdown.   Hypothetical numbers:

2003 Car purchased for $20,000.00
2013 Car total loss
2013 ACV of the car is    $4,500.00
Policy deductible  is          $ 500.00
Carrier pays                   $4,000.00
Applicable Tax is               6% (FL) or $240.00

Carrier sends a check for $4240.00

Okay, here is the simple trick that works, in my experience, at least 75% of the time to get more money:  What you simply do is look in as many places as possible including the Autotrader, the classified ads, and the flyer and try to find your car with similar mileage and specs, for a higher price than what the insurance company is paying.  You then clip those ads.  Get as many as you can find but if you only find 2 or 3, this may be enough.  Next, you need to forward the ads to the claims adjuster showing that in YOUR market, it would be impossible to replace the car for what they allowed.

Sometimes I have seen that the insurance company is actually very fair with their allowance, and sometimes, believe it or not, the insurance company is actually paying more than what it would cost to replace. In either of these cases, just take what they are allowing. (Don't try and negotiate down!)

As I have said.  About 75% of the time it works out in your favor and you can expect to receive a supplemental check in the mail of sometimes over $1000.

Better in your pocket than theirs.  Good Luck.

How to Survive when your car is off the road and sinking in a canal...

If You Find Yourself in a Car and Sinking Fast, You Need to be Aware of This.

Dr. Alan Himmel

In South Florida, it is not uncommon at all for a driver of a vehicle to wind up driving his car into a canal.  Whether this is due to your error as a driver, or another driver's fault,  its highly probable, since there are canals all over the place down here, that you may find yourself in a situation where you are in your car and your car is sinking fast.  As a matter of fact, often times when a person and his car go missing down here, one of the places that the police look, are the canals.  What they do is try and predict where the person was driving, e.g. to work, to church, shopping, and they look straight down using a helicopter or small airplane, and they look for the big black outline of a car in the water.  You definitely don't want to be "found" in your car at the bottom of a lake or canal.

So, the purpose of this article was to give you the necessary information, that if you were to find yourself   in your car and sinking in the water, you would have a chance of surviving.  You actually only have a minute.

I found a good video that explains this.  Its worth watching.  It could possibly save your life one day.
Dr. Gordon Giesbrecht, an expert on submerged vehicles, explains...

And here is another video from ABC news also featuring Dr. Gordon Giesbrecht.

   Unfortunately, you will not be able to practice this survival maneuver.  The first time you try this, is the one time you will be in a car and sinking.  Learn this technique.  It could be a life saver.

HB 119 — Florida Personal Injury Protection PIP No-Fault

CS/CS/HB 119 — Motor Vehicle Personal Injury Protection Insurance

by Economic Affairs Committee; Insurance and Banking Subcommittee; and Rep. Boyd and others (CS/CS/SB 1860 by Budget Committee; Banking and Insurance Committee; and Senator Negron)

This summary is provided for information only and does not represent the opinion of any Senator, Senate Officer, or Senate Office.

Prepared by: Banking and Insurance Committee (BI)

Senate Bill 1860 revises the Florida Motor Vehicle No-Fault Law. The bill primarily amends laws governing Personal Injury Protection (PIP) benefits under the No-Fault law and laws related to PIP motor-vehicle insurance fraud. The major changes enacted by the bill are as follows:

 PIP Medical Benefits

The bill revises the provision of Personal Injury Protection medical benefits under the Florida Motor Vehicle No-Fault Law, effective January 1, 2013. Individuals seeking PIP medical benefits are required to receive initial services and care within 14 days after the motor vehicle accident. Initial services and care are only reimbursable if lawfully provided, supervised, ordered or prescribed by a licensed physician, licensed osteopathic physician, licensed chiropractic physician, licensed dentist, or must be rendered in a hospital, a facility that owns or is owned by a hospital, or a licensed emergency transportation and treatment provider. Follow up services and care require a referral from such providers and must be consistent with the underlying medical diagnosis rendered when the individual received initial services and care.

The bill applies two different coverage limits for PIP medical benefits, based upon the severity of the medical condition of the individual. An individual may receive up to $10,000 in medical benefits for services and care if a physician, osteopathic physician, dentist, physician’s assistant or advanced registered nurse practitioner has determined that the injured person had an emergency medical condition. An emergency medical condition is defined as a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in serious jeopardy to patient health, serious impairment to bodily functions, or serious dysfunction of a body organ or part. An individual who is not diagnosed with an emergency medical condition, the PIP medical benefit limit is $2,500. Massage and acupuncture are not reimbursable, regardless of who the type of provider rendering such services.

PIP Death Benefit

Personal Injury Protection now offers $5,000 in death benefits in addition to $10,000 in medical and disability benefits. Previously, the death benefit was the lesser of the unused PIP benefits, up to a limit of $5,000. The increased death benefit is effective January 1, 2013.

PIP Medical Fee Schedule

The bill revises provisions related to the PIP medical fee schedule in an effort to resolve alleged ambiguities in the schedule that have led to conflicts and litigation between claimants and insurers. The bill clarifies that the reimbursement levels for care provided by ambulatory surgical centers and clinical laboratories and for durable medical equipment is 200 percent of the appropriate Medicare Part B schedule. The Medicare fee schedule on effect on March 1 will be the applicable fee schedule for the remainder of that year until the subsequent update. Insurers are authorized to use Medicare coding policies and payment methodologies of the Centers for Medicare and Medicare Services, including applicable modifiers, when applying the fee schedule if they do not constitute a utilization limit. The bill also requires insurers to include notice of the fee schedule in their policies. These provisions are effective January 1, 2013.

Attorney Fees

The bill amends provisions related to attorney fee awards in No-Fault disputes. The bill prohibits the application of attorney fee multipliers. The offer of judgment statute, s. 768.79, F.S., is applied to No-Fault cases, providing statutory authority for insurers to recover fees if the plaintiff’s recovery does not exceed the insurer’s settlement offer by a statutorily specified percentage. The bill maintains current law allowing a party that obtains a favorable judgment from an insurer to recover reasonable attorney fees from the insurer. The bill also requires that the attorney fees awarded must comply with prevailing professional standards, not overstate or inflate the number of hours reasonably necessary for a case of comparable skill or complexity, and represent legal services that are reasonable to achieve the result obtained.

Investigation and Payment of Claims

Provisions relating to the investigation of PIP claims by insurers are revised, effective January 1, 2013. Insurers are authorized to take an examination under oath (EUO) of an insured. Compliance is a condition precedent for receiving benefits (the insurer owes zero benefits if the insured does not comply). An insurer that unreasonably requests EUOs as a general business practice, as determined by the Office of Insurance Regulation (OIR), is subject to s. 626.9541, F.S. of the Unfair Insurance Trade Practices Act. The bill also provides that if a person unreasonably fails to appear for an independent medical examination (IME), the carrier is no longer responsible for benefits. Refusal or failure to appear for two IMEs raises a rebuttable presumption that the refusal or failure was unreasonable.

Changes are made to the statutory process for the payment of PIP benefits, primarily to assist claimants in their claim submissions, effective January 1, 2013. A claimant whose claim is denied due to an error in the claim is given 15 additional days to correct the erroneous claim and resubmit it timely. The insurer must maintain a log of all PIP benefits paid on behalf of the insured and must provide the log to the insured upon his or her request if litigation has initiated. If a dispute between insurers and insureds occurs, the insurer must provide notice within 15 days of the exhaustion of PIP benefits. Insurers must reimburse Medicaid within 30 days. The electronic submission of records is authorized, effective December 1, 2012.

Prevention of PIP-Related Insurance Fraud

House Bill 119 contains numerous provisions designed to curtail PIP fraud. The bill defines insurance fraud as knowingly presenting a PIP claim to an insurer for payment or other benefits on behalf of a person or entity that committed fraud when applying for health care clinic licensure, seeking an exemption from clinic licensure, or demonstrating compliance with the Health Care Clinic Law. Claims that are unlawful under the patient brokering law (s. 817.505, F.S.) are not reimbursable under the No-Fault Law. A health care practitioner found guilty of insurance fraud under s. 817.234, F.S., loses his or her license for 5 years and may not receive PIP reimbursement for 10 years. Insurers are provided an additional 60 days (90 total) to investigate suspected fraudulent claims, however, an insurer that ultimately pays the claim must also pay an interest penalty.

All entities seeking reimbursement under the No-Fault Law must obtain health care clinic licensure except for hospitals, ambulatory surgical centers, entities owned or wholly owned by a hospital, clinical facilities affiliated with an accredited medical school and practices wholly owned by a physician, dentist, or chiropractic physician or by such physicians and specified family members. The bill creates standards for evaluating whether an entity claiming it is exempt from the requirement to obtain clinic licensure is actually wholly owned by a physician.

The bill defines failure to pay PIP claims within the time limits of s. 627.736(4)(b), F.S., as an unfair and deceptive practice. The OIR may order restitution to the insured or provider, but is not limited in its other administrative penalties, which may include suspending the insurer’s certificate of authority.

Law enforcement is required to complete a long-form crash report when there is an indication of pain or discomfort by any party to a crash. All crash reports completed by law enforcement must identify the vehicle in which each party was a driver or passenger. For all crashes that do not require a law enforcement report, the vehicle driver must submit a report on the crash to the Department of Highway Safety and Motor Vehicles within 10 days of the crash.

The bill creates a non-profit direct support organization, the Automobile Insurance Fraud Strike Force, which can accept private donations for the purposes of preventing, investigating, and prosecuting motor vehicle insurance fraud. Monies raised by the Strike Force may fund the salaries of insurance fraud investigators, prosecutors, and support personnel so long as such grants or expenditures do not interfere with prosecutorial independence. Funds may not be used to advertise using the likeness or name of any elected official or for lobbying.

Mandatory Rate Filings and Data Call

The Office of Insurance Regulation must contract with a consulting firm to calculate the expected savings from the act, which must be presented to the Governor and Legislature by September 15, 2012. By October 1, 2012, each insurer that writes private passenger automobile personal injury protection insurance must submit a rate filing. If the insurer requests a rate that does not provide at least a 10 percent reduction of its current rate, it must explain in detail its reasons for failing to achieve those savings. A second rate filing must be made by January 1, 2014. If the insurer requests a rate that does not provide at least a 25 percent reduction of the rate that was in effect on July 1, 2012, it must explain in detail its reasons for failing to achieve those savings. The Office of Insurance Regulation must order an insurer to stop writing new PIP policies if the insurer requests a rate in excess of the statutorily required rate reduction and fails to provide a detailed explanation for that failure. The Office of Insurance Regulation must perform a comprehensive PIP data call and publish the results by January 1, 2015. The data call will analyze the impact of the act’s reforms on the PIP insurance market.

If approved by the Governor, these provisions take effect July 1, 2012, except as otherwise provided.

Vote: Senate 22-17; House 80-34