Well, hello, and welcome to the African-American Physiatrist Community Session as part of this year's 2021 Annual Assembly of AAPMNR. I am the current chair of the African-American Physiatrist Community, and my name is DeJuan Carpenter. I am an attending physician currently located in Louisiana, Hammond to be specific, practicing inpatient medicine and also working on life care planning certification. Hello and good afternoon or good evening, everyone. I'm Dr. Coriander Williams. I'm a proud PMNR attending, and I wanted to introduce myself as the co-chair for the African-American Community with AAPMNR. Before we get this session started, I did want to remind everybody of a few housekeeping rules. We are recording this session, so please keep everything professional. In line with that, we ask that everyone mute their mics so that we can clearly hear the speaker and to reduce background noise. We would love to keep this session as interactive as possible for the benefit of all participants, and so there'll be a couple of polls that pop up. We ask that you please participate. Additionally, there will be an option for questions and answers via chat, and please know that there is tech support if you're having any difficulty. Now, I'm going to hand it back over to our chair, Dr. Carpenter, for the introduction of our wonderful speaker. Thank you, Dr. Williams, and today we are so happy to have our speaker and presenter for tonight, Dr. Philip Marion, MD, MS, MPH. Dr. Marion completed his medical degree at the New York University School of Medicine. His clinical training was completed at Bellevue General Hospital and the Rusk Institute of Rehabilitation Medicine at NYU. He is triple board certified in physical medicine and rehabilitation, electrodiagnostic medicine, and pain medicine. While completing his residency, Dr. Marion simultaneously obtained a master's degree in finance and health policy at the Wagner School of Public Service at New York University. Ooh, making me feel like I haven't done enough. Dr. Marion, this is great. He also began his medical career as an attending physician at the National Rehabilitation Hospital and during that time completed the master's of public health degree at the George Washington University. While at the NRH, Dr. Marion was promoted to the medical director of outpatient services and simultaneously the administrative director of outpatient services. Dr. Marion was selected as a congressional fellow and health policy fellow for the Robert Wood Johnson Health Policy Fellows Program. As a health policy fellow, Dr. Marion worked on issues such as health reform and public health policy on the Senate Finance and Senate Judiciary Committees. Dr. Marion is currently the clinical professor of medicine at the George Washington University Medical Center. Dr. Marion is also medical director of the Polytrauma Amputee Network site at the DC VA Medical Center. In addition to his triple board certifications described earlier, Dr. Marion is also a board certified independent medical examiner as well as a board certified life care planner. Well, without ado, I introduce to you Dr. Marion. Thank you so much for being here. Wonderful. At your service. Thank you very much. That sounded really nice. Thank you, Dawn. I appreciate that. I think we're starting a little early, so I don't think we have the number of participants yet, but I think that we're going for quality, not quantity, at least to start. I was going to do the first poll, but I think we need to wait a little bit until we get a few more people here just so we get our numbers up. It just wouldn't make sense to do the poll without an appropriate end, if you will, to really get the numbers up to see where we're coming from. We'll get to that. Now, did you do the housekeeping things on the first slide? Did we do those already, Corey? You're on mute there, I think. Sorry about that. Yes, we did get the housekeeping tips out. OK, so we finished the first slide. We got that out of the way. OK, good. All right. Again, I want this to be somewhat informal in that I'll convey, obviously, the information that's appropriate and for CME credit and those things, but I do want there to be some give and take, and we'll allow for some time for that. This really, like all of us, or I'll speak for myself at least, more comfortable with having a give and take and a personal face-to-face, if you will, presentation. I don't think that Zoom necessarily lends itself to that, but we'll make the best of it. So we'll sort of move on and we'll go with this. I want to say a couple of things before we start this. Well, it's going to go in four phases. We're going to cover four principal areas, and let me get to the first slide here. OK, we're going to cover independent medical evaluations, medical file reviews, life care plans, and medical witness experts. It should be medical expert witness, but anyway, I think it's the same thing. And I think what we want to do is sort of go through these four categories, and I'm starting with independent medical evaluations because that's sort of the closest of actual clinical practice. And as physiatrists, and just in general, not just physiatrists, but neurologists, neurosurgeons, orthopedics, those tend to be the folks who more likely than not are going to be doing the IMEs, independent medical evaluations. It's closest to your clinical practice. You're actually seeing an individual. You're doing an evaluation. You may be developing a treatment plan. You may be determining diagnoses, et cetera. And so it's as close as really you can get to actual seeing patients. I want to tell you, in all of these things that I'm doing, I kind of fell into them. And just a couple of things that I would just give you after sort of 30 years of practice is a bit of things that I've learned. First thing, particularly younger in your practice, get as many credentials as you possibly can because it's a lot easier getting those credentials when you're younger than as you get older for a variety of reasons. One reason is credentials get harder to get the longer they are established. For example, I got my pain boards when they first opened up for physiatry in the year 2000. At that time, you did not need a fellowship to take the boards in order to be board certified. Now you need a fellowship to do so. So if you don't have a fellowship, you can't take the board. And if you can't take the board, you can't become board certified. And then these exams, when they first open, they're a little bit easier to get into because they want entree of people into them. But then over time, as they become more established, they become obstacles. So you really want to get as many credentials. And also life gets more complicated as we get older with other responsibilities as we all know. And so time becomes more valuable. You have less of it. And as a result, it's more difficult to get these credentials. Same with EMG. EMG, you know, the test wasn't that hard. And you didn't need to take the test every, I guess it's 10 years or so. Now you have to. And the same with PM&R. But that's just the way it is. Also, when you're doing this, and I'm just giving you these four things as examples of things you can do. You really, and we'll talk more about this, you want to make yourself the center of your career. You don't, you know, you want to be the embodiment of what the market wants. And so, and we'll go into that and you'll get what I'm saying a little bit later. And the other thing is, you know, you want to investigate as many things as you possibly can in your career of things you might want to do. Because, I mean, I remember this talk that Julie Silvergate, she's out of Spaulding, but she was at National Rehab as a resident. But she made a point that you never know where your career is going to take you. And many of the things, for example, life care plans, medical file reviews, IMEs, for the most part, when I started my practice, for the most part, really didn't exist. And now they're very common. Just a short aside of how I started IMEs, I, you know, I remember when they, IMEs are relatively a new phenomenon, because IMEs tended to be done by really insurance doctors, and they were employees of the insurance companies, for example. But then they started sending these IMEs out, sort of farming them out, and the people they had doing them were orthopedists. And we're talking early on, doing anything that was administrative was kind of looked down upon. And so, you know, whether it was an insurance company, or an employer, or an attorney, they would send an individual for an independent medical evaluation, usually to an orthopedist. And this is a generalization, of course, but the reports, for the most part, tend to be lousy. They were just lousy reports. They were one-page reports, and they'd ask, for example, is a person disabled, and an orthopedic surgeon would say yes, and they'd say why, and the orthopedic surgeon would say, because they say they are. Yeah, you know, you would see stuff like that. And so I asked if I could do a couple, and I did them, and I made a point of doing the best job I possibly could. And it wasn't that hard, because most IMEs, while, for example, they may have a past surgical history, are not about a surgical procedure. And lo and behold, I was able to do a pretty good job, and now I turn several down, as a matter of fact, because I just don't have the time to do it. And also, the other thing is, I have four things up here, and you really want to diversify your practice if you can. The key to any level of security is to diversify your practice. That's very, very important. And I'm talking about IMEs, medical file reviews, life care plans, being a medical expert. I'm going to spend maybe 10 or 15 minutes on these. You could spend, you know, I go on the courses where they spent a week on medical expert testimony, from the plaintiff's perspective, the defense perspective, how you present yourself, the psychology involved. I mean, all of these things. Dawn and Corey and I, we were at a recent life care plan academy meeting. That was, what, two, three, four days. So these things, I'm just going to give you a snippet, so you kind of get an idea of what these are. And if any other folks have personal experiences they want to share, other tidbits, please, you're welcome to do so. So we'll go on. I don't have any conflicts. I'm not representing any, I may mention some companies during my talk, but I don't work for them. They don't work for me. I have no financial interests in anything. No one's paying me for this. I should say, unfortunately, but I won't say that because I have no conflicts. I show this picture because it, you know, the whole concept of, you know, disability impairment. You know, this is Noah Galloway, very famous. I mean, he was on Dancing with the Stars, and he's been in several magazines, as you can see, he's an above-elbow amputee and above-knee amputee from the Iraq-Afghan conflicts. Operation Iraqi Freedom and Operation Enduring Freedom, I think they were called, and of course, New Dawn, which was the surge. But is this, and so, does this person have impairments? Yes, he does. Obviously, the amputations. Is he disabled? Well, that's a different issue, and I think we'll talk about that, and I just want to use that as an example as we move on. Okay, you want to remember that when you're, you are the expert who is independent of the referral source. You're not a company doctor, I mean, you know, you're not the insurance company's mouthpiece. Whether you're representing, you know, or you're the expert for the plaintiff or the defense, you're the expert. You're not the plaintiff's expert or the defense expert. You're not. You really want to call balls and strikes. Now, you want to be cognizant of what side you're the expert for, but you really want to be as objective as possible. Same with workers' compensation. You don't want to be a shill for, you know, the workers' compensation board, or if an employer of a large Fortune 500 company is hiring you to do assessments for disability at the company, you really want to be as independent as possible. You want to be independent of your referral source. One, it gives you more credibility, and two, it makes you more valuable in the marketplace. Now, with independent medical evaluations, you can have several resources where they're sending you. It could be workers' comp, personal injury, medical legal. Someone may be sent to you for a treatment plan, impairment ratings. They could be sent to you again for life care plans. You may be evaluating a person for pre- or post-functional capacity evaluations. You may be seeing them for life, health, or disability insurance. So, there's a myriad of different resources, referral sources, if you will, that you can have in doing an independent medical evaluation. Most tend to be workers' comp, personal injury, disability, impairment ratings. Those are the more common. Where do you get paid for these things? Now, I'm going to give you actual numbers in this area, you know, and it could vary by where you're living, etc., I'm in the Washington, D.C. area. And usually, for an IME, you tend to charge in this area between $1,000 to $2,000 per case. So, for a given IME, it tends to be about, if you sort of split the difference, about $1,500 as of, you know, this today. Now, some people charge a separate rate. They may charge separately for the review of the records, they'll charge separately for the physical examination, then they'll charge separately for the report. It doesn't make a whole lot of sense to me because, you know, the report is the most important thing. So, what if the company says, well, just give me the report. I don't really want, you know, the physical exam or review of records part, but you know, you could do it separate and itemize it that way. Some people do that. What I tend to do is I will, I'll charge for my IME and I'll give them the first 100 pages of documents for free, but then I'll charge in between $100 to $150 per 100 pages of additional records so that the risk is not on me with respect to when I get a case. So that, you know, if I get a case and, you know, I've got 100 pages of documents to review, you know, then it's $1,500. But, if there are 2,000 pages to review or 2,100 pages to review, that extra 2,000, that's 20 times $150 or whatever that is, plus that's an extra $3,000, plus the $1,500 base rate for the case, that's going to cost $3,500. What I tend to do also is I get my payment in advance. This isn't like an insurance company where you provide a service, you bill for the service, and then they take off 20%. No, I don't do any of that. All my cases I get paid for in advance. And there's a cancellation fee. For me, if you cancel, you know, and there's not five business days, you get five business days. If it's within that five business day sort of time frame, you don't get your money back because I don't get the time back. It's very difficult for me to then get that time that I had scheduled for that IME to put another person in. So, I really take as much risk off myself and really put it on the payer. But, I like to think that I do good work, and they like to think that it's worth it, and so it's the incentive for the individual to show up. Because you've got to remember, for many of these IMEs, for the individual, there's no real benefit for that person to show up. So, that kind of keeps everybody honest. When you do an IME, you've got to remember the IME begins when they walk in the door. For example, if they're sitting down filling out the registration materials, but they tell you they can only sit for five or ten minutes, obviously that's something that you want to observe. Transportation. How did they get to your office? Did they drive? If they indicate that they have cognitive deficits, how are they able to drive? As they're completing the registration, are they right-handed, left-handed? How is their ability to write? Fine motor manipulation? You want to evaluate them just before and right after the physical examination part. And also, finally, you want to ask them what is their condition when they come in, and what is their condition when they go out? It's not said that the individual says, well, gee, I was doing great, but then the doctor, he jacked me up, and now I can't move. No, you say, so-and-so, how are you doing after this exam? I hope the stretching and the movement didn't hurt you. Are you okay? You always ask that, and I always make a point. Also, when you do this, it's important that you have a disclaimer. You are not the treating physician, and you have to make that clear. You make that clear to the individual. You say, listen, I'm not your treating doctor. You were sent by so-and-so for the evaluation. This is not a doctor-patient relationship. I am not going to give you any treatment recommendations. If you think that I do, you are mistaken. When you do your report, try not to refer to the person as my patient or the patient. Do not provide any treatment recommendations directly to the patient, if you will. Do not comment on the care provided by treating physicians directly to the patient. You may just look at the chart and say, oh, this treatment has been lousy. Don't say that to the individual. Don't teach. What you say can and may and can be used against you. When we see our patients, or I've been in a year with academic environments, I tend to teach. When I'm going over something, when I'm doing a differential diagnosis, et cetera, et cetera, I tend to teach. Don't. Don't teach. Please, don't teach. You're there to do a particular job, and you're not there to teach because it can be taken out of context. Again, you want to comment on the individual's condition when they come in and when they go out. The format, again, this is just nuts and bolts. Disclaimer, synopsis, past medical treatment history, symptoms, pain ratings, pain drawings, activities of daily activity, medications, prescribed by whom it's prescribed. They bring in a list of the medications. That's nice. Documents reviewed, job description. You want to comment on prior FCEs, physical exam, any Social Security Administration, ALJ, determination. Put all of that stuff down. A couple things. Please stay in your lane. Don't. Sometimes, some of the referral sources may want to save a buck. They say, well, doc, could you comment on the diabetes or could you comment on neuropsychology? Don't. I know you're tempted to, and if you're not an expert in that, please don't do it. Stay in your lane because that can come back to haunt you. Please be direct, clear, and thoughtful, and you've got to have a foundation of evidence. You really have to back up whatever you say. You just can't make it up. You'd be surprised how many people make stuff up. Also, please answer the questions. Medical condition, relationship, accident injury, what's the impairment, restrictions, limitations, treatment plans, impairment ratings. Again, for impairment ratings, and I'll talk about this a little bit later, you've got to learn this. I think one of the best is the American Board of Independent Medical Evaluators, ADIME. That's the group. You may get emails from them all. I do all the time. That's where you learn the AMA guidelines. Some jurisdictions require I think it's fourth edition. Others require the sixth edition. Those are very, very different additions to impairment. The fourth is pretty easy, but sixth is really hard. You've got to know the difference between the two. They may want to ask you about prognosis, et cetera, when you're doing the IMA. I was going to go over a little bit about the difference between impairment. You know impairment is a physical pathology, and it's something that you can see, touch, feel, that type of thing. I won't go into a whole lot of detail about that only because of our time, but you've really got to know the difference between impairment and disability. You can look at the AMA guides. They have definitions. It's pretty straightforward. That's impairment ratings. Again, they're always going to ask you about the impairment ratings. You do an impairment rating once the individuals attain maximum medical improvement. You can't do it before then. They want permanent impairment. Sometimes when you're doing a medical file review where you're not seeing the individual, they want you to do an impairment rating. Don't fall into that. As you're reading the guides, you have to evaluate the individual before you can do the impairment rating. You just can't based on the medical file review. They want an examination. These are just definitions of disability. We're just going to go past that, but you can see this at your leisure in the report. Impairment is not a disability. You can lose a lost tip of your finger for a piano player versus a banker. Again, the definition of disability is kind of odd, so you want to be careful. A banker may not be disabled but lost the tip of a finger with a piano player. It may be the same with a toe injury for a computer programmer. No big deal. For a ballerina, it's a big deal. That's it. That's two. What I want to do is, do we have enough people to take a poll? I want to know who does IMEs and how do we do that, DuJuan or Corey? Anybody? We're here. We do have a little bit more people that have joined. You want to start with the first poll with just kind of where people are? Can we skip the first poll in case we get a few more people in? Since I just talked about IMEs, what kind of experience people have had with those? Just to go with that for a moment. I'll go ahead and launch that poll. Arts almost have no experience and one has some experience. Okay, can I open this up for a second? I've got some questions for the people who have no experience. Is there a particular interest? Obviously, there's interest in doing IMEs. Is there any particular things that folks are hesitant about with respect to starting to do these? And I'll open that up to anyone who would care to answer, particularly those who have no experience or even the person who has some experience. What's stopping you? Hey, this is Dr. Eric Giantson with some experience. I guess my concern is I'm in an orthopedic practice, I'm doing spine and pain, and I've done some. I have some templates I got from IME and I think I do an excellent job, but I just always have some concerns with any specific certifications or anything that I need to do these. So I kind of held off because I wasn't sure if legally I should have a cert from I, from ABME or any kind of cert that says, yep, you've been certified to do these, even though I feel like it's not that hard to do. That's a good question. You don't need a particular certification to do IMEs. And I found that even though I'm certified by the American Board of IMEs, the certification really doesn't mean as much to me compared to the knowledge I gained from attending the course and really knowing how to use the guides. The guides are really the more important thing to me than the certification. Certification doesn't hurt, you know, but it's not essential. I think the difficulty I have, now you say you have an orthopedic practice, so are you in a, you're in a group or are you employed? I'm part of a group on a partnership track. Okay, because one of the difficulties, and we'll talk about this with the other areas as well, is if you do this, particularly if you're employed or even the partnership track, if you get a pretty big practice doing this, the other partners may want a piece. And if you're getting a pretty good size IME practice, while you may be doing all of the work, it may be hard for you to wanna, to necessarily part with some of the revenue, but they may get some of the revenue depending on how you share expenses and revenues, that type of thing. But I would think in those cases- I do 90% and then 10% go to the group reconciliation as personal. Okay, okay. No, so I think, particularly in the orthopedic practice, I would think that, if anything, that much of that would be, if they're sending IMEs, that much of that would be sent over to your practice. Now, how big is the group and how many orthopedics versus physiatrists? There's 37 of us and there's two, well, there's two, four divisions, two pain specialists. So one of them is anesthesiologist, the rest of us are physiatrists and three of us have done fellowships, the other three haven't. All right, so you're fellowship in pain? I did a fellowship in pain. Okay, okay, and so that, and also that becomes the question, of course, is, how much are you gonna be in the procedure suite and wear the lead jacket versus doing these other things as well? But to answer your immediate question, you don't need a particular certification, it doesn't make a difference, but I do think going to the ABIME, again, which I have no particular interest in, to really learn the guides because that will serve you well over time. Okay, thank you. Yeah, anyone else? So we move on to the, what is our, I wanna just make sure I'm keeping track of my time. All right, so we'll move to the next one. How do we get rid of this? Do I get rid of this? Yes, while you're pulling that up, there was another answer in the chat. Sierra says she has no experience, but she just finished residency, so she's doing general inpatient consults. However, IME wasn't anything that was discussed as an option. Yeah, they don't tend to discuss these things. None of these things that they really discuss in residency programs, which is a shame, but as we all realize, depending on what residency and where you do your residency, it tends to be occupying the, getting people to do the work that they need them to do, depending on the environment they're in. For example, I trained at Rust, which had 160 beds, so their priority was getting the residents to cover those beds, and we didn't tend to get a lot of information about this. Also, I don't know, because this is more of a business aspect of a practice, I don't know if residency programs see this as somewhat unseemly. You know what I mean? That it's not as legitimate. You know, I don't know. But I have to tell you, when you get out there and practice, it makes a difference. And I think that you can train yourself to do these things. They're not very hard. So I think that, you just have to sort of, again, start with, and the other thing that I like about American Board of Independent Medical Examiners is when you go there, you'll see like-minded people, and you can really get a lot from talking to other people and what their experiences are, and really get a, sometimes there are often referral sources that go to these meetings as well. And again, these are things that are done really face-to-face as opposed to virtual. That's, you know, in many of these meetings, and I won't speak for the Academy, they try to say that the virtual's just as good as the face-to-face, but it doesn't compare when it comes to really meeting people individually and getting their individual comments in, so the input and information that you can't otherwise get unless you're person-to-person. Anyone else? All right. Then we'll move on to the next one. And actually, let's do the, I'm curious, who does file reviews? Can we bring that poll up? We might as well bring that one up now. We're going to talk about medical file reviews next. OK. So we got, again, most with no experience, someone with some experience. Yeah. Medical file reviews. And I got the, yeah. Medical file reviews can be about a lot of different things. Basically what it is, if someone will send you, and it can be, and when I say someone, it can be an insurance company, a utilization review company, an attorney, hospitals. They will send you, they will ask you a question. And those questions can be anything from medical necessity. Does the person need diagnostic studies? Do they need procedures? Utilization review. I mean, for example, someone said they do inpatient consultations. You may want someone to go from the acute care hospital to either a skilled nursing facility or acute rehabilitation. Well, you as the expert, you may get a medical file review, and someone will email you that question and say, this person just had a stroke in the hospital. Should they go to a skilled nursing facility or a subacute? Or should they go to an acute? Should they go to a long-term acute care hospital, et cetera? That's one type of medical file review you can get. You can get one where the person works in the telephone company, and they are putting in a claim for total disability. And so they're going to give you the files, and they're going to want to ask you, is this person disabled? Can they do their job? Or if they can't do their job, do they have an impairment? And if they do have an impairment, how will that impairment affect what restrictions they need to do their job? And so you very commonly get these. And again, people think, well, I can do these medical file reviews sitting on the beach and do this. And no, it's real work, because they pay a lot of money. And so they're not going to want you to do a shabby job or something. So doing a medical file review, again, someone wants you to answer a question. And again, it could be anything from medical necessity to disability to sometimes I'll get a case where they'll say, you know, this doctor is practicing this, and he's already doing all these testing, doing all these procedures. Are they medically indicated? And you go through each procedure, and you say yes or no, or why or why not. And it has to be backed up, obviously, with the literature and the clinical records, et cetera. There has to be a foundation of evidence. That's important. And again, this term is very important. And again, I use all time. From a physical medicine and rehabilitation pain manager perspective, as well as within a reasonable degree of medical certainty. That's the phrase that pays. You have to use that terminology. Or you can say within a reasonable degree of medical probability or reasonable degree of medical certainty. You can interchange certainty versus probability. But that's the standard. It's the standard of your opinion within that realm. And within reasonable medical probability is 50% plus a feather. You know, that's the weight of the evidence. Again, the format when you're doing a medical file review, you put a disclaimer in, of course. I'm not, you know, I've not seen the patient. I've not evaluated the patient. This is a paper report. There's no doctor-patient relationship. I don't have any interest in x, y, z. You have to put that disclaimer in. That's very important. What you do, you do a synopsis of what the situation is. You go through the document review. You document if you discuss the case with the attending physician. For example, you may get a extensive clinical record review of thousands of patients or records. And they'll say, but we also want you to also call the attending physician. Now, everybody's busy. So nobody really wants to hear from you. But you call them anyway. And most will take your call. And they'll say, Ms. Jones says that she's totally disabled. You're the orthopedic surgeon that did the back surgery. Doctor, is she disabled? And if they say, yeah, you are, well, why? Why is that? Or if they're not, what can they do? What can't they do? What would you recommend? You know, you want to review whether prior reviews, whether functional capacity evaluations. We can talk about functional capacity evaluations. That's a whole different issue. And the legitimacy as such. But you want to mention that in your report. Are there attending physician statements in the documents? Disability statements, job descriptions, what are their activities of daily living forms? You want to pay attention to Social Security Administration ALJ, Administrative Law Judge Determinations. Did they make a determination of disability? What data did they use? Remember, the criteria you use to determine if someone can work, they need restrictions, is going to be very different than someone from the Social Security Administration, because they're using age, age since they worked, particular statutes. There are all kinds of documents they're going to use that you're not going to use, and vice versa. There's lots of clinical information you may have access to that they don't have access to. So that's important. What's the condition that's causing the impairment? Do they have an impairment? Remember, pain, numbness, dizziness, those are not impairments. Those are not impairments. Having a stroke or hemiplegia, that's an impairment. Having an amputation, it has to be something that's physical. It's something you can see. And as a result of the impairment, do they need restrictions? For example, if you have a below-knee amputation, you can't climb telephone poles. So that's a restriction. Or actually, it's a limitation, you just can't do it. But you should be restricted from doing anything that requires balancing. But you're not restricted from working at a desk, for example. In a medical file review, they may ask you specifically for a treatment plan. They may ask you to comment on the medications. I mean, for a long time, actually, until I don't know if anyone's watching the TV show Dope Sick, which is on Hulu. I highly recommend it. It talks about the opioid crisis. It's very good. But anyway, very often, I got cases for medical file reviews commenting on XYZ doctor is prescribing boatloads of OxyContin. What's up with that? You're going to get that. I got medical file reviews we'll talk about a little bit later. But I was the expert for Maryland Attorney General's office for looking at pill mills in Western Maryland. And so you very often may have to comment on that. How do you get paid for this? Most commonly is hourly. The growing rate in this area, it's usually per hour. And they also have a funny way of usually they say an hour usually takes 100 pages. And so based on 100 pages, that's kind of weird. It's about, it varies between $150 to about $400 per hour to do a case. If you've got a case that's 1,000 pages, just for the math, you're anywhere from $1,500 to $4,000 for that medical file review. And if it's a big medical file review, it may take you a half a day or so. But that's $4,000 in your pocket. There's no, the only, I mean, I have a dictation service. You can use Dragon if you want. I'm just lazy and I just use a service. But Dragon will, that'll decrease your overhead. Some companies, they don't do it anymore because everything's digital now. But they used to pay you by the height of the pages. How thick was the file, like a half an inch, they gave you this much. I just wondered if they just used cheap paper or something. So they made the height smaller. But anyway, you can charge also on the complexity of the case. That is, how many questions do they ask you and how complex are the questions? You also charge AP contact. If you have to contact one, two, three, four physicians, that, you charge for that. And turnaround time. Most cases tend to have, it depend on what it is. If it's a utilization review and they wanna know should this person be admitted to an acute care rehab or should they get an MRI scan or should they get X, Y, Z physical therapy, that turnaround time may be 48 to 72 hours versus if it's, is this person disabled and do they need work restrictions, something like that, the turnaround time may be seven to 10 days. So it depends on the case. But I have to tell you, when you do this type of work, it's pretty lucrative. And I think it's, again, I would diversify. I don't know if you'd wanna do this 24 hours a day, seven days a week. One, it's hard to, because very often when you do medical file reviews, they really want you to also have a clinical practice. They don't want you to just be a paper doc. That's someone that just sits in front of a computer and just does medical file reviews, because it kind of takes a bit of credibility away for a number of reasons. They'll say, well, doc, when's the last time you saw a patient? This is all you do? So you wanna be careful of that. So, but it can be a part of your practice. The other thing is this is, sometimes you're kind of somewhat of an albatross around your neck in that, if you have to contact the physician, you contact the physician, they're not usually available. They may call you back. You could be in the middle of seeing patients, for example, whatever. You got, you have to take the call. You've gotta, you know, so this really does take a fair amount of commitment. But I think that as a part of your practice, I think that it can pay off well. A couple of things I would also say about this, you know, and many of these things are really not hard to find, you know, with all sources. You can just Google them. You can just Google medical file review and you'll get, you know, 50 companies. But you wanna be careful who your associates associate yourself with, because some companies are not as reputable as others. You know, I mean, some companies they want, they, you know, if you say, for example, you know, so-and-so, you know, does not meet, does not clinically appropriate to go into acute rehab, and they should go into a subacute, then they'll say, fine. But if you say, well, I think they need really acute rehab, and then they may send it back to you and say, well, doctor, we don't really like your answer. Be careful of that. You know, you don't want to be hired by a company, if you will. And even in your, I'm an independent contractor, but wants a particular answer from you. I remember I was doing cases for long-term care insurance, and I was getting cases where they wanted me, where under the long-term care insurance, they would ask you the question, does this person meet the criteria for long-term care payments? And these were like elderly people who wanted to stay in their home. They don't want to go to a nursing home. And so these long-term care insurance policies would pay them a certain amount of money, not them, but for, you know, home health aid and those types of things. And I remember I would get cases and I'd say, oh, you know, you got this lady, you know, she, little old lady, she broke her hip, she's a fall wrist, but she's doing better now. She's kind of frail, but lives in her house, but needs some help with activities of daily living, custodial care. And I'd say, yeah, you know? And those cases would turn around to me and say, well, doctor, we're really not sure. And, you know, do you really think she really needs this? And it doesn't, you know, it doesn't take a genius for you to realize that what they're looking for is doctors to deny these people who were appropriate to receive it long-term care payments. And so you really don't want to be caught up in companies like that. And if you see that, you know, say thanks, but no thanks, and just move on because you don't want to get that, you know, you want to be ethical about these things and you want to do a good job. And the longevity is to really get a reputation of someone who's going to really call it the way it is. And that will serve you well. And you can sleep better at night too, you know? So I would recommend that. Also, many of these companies, they will, they'll say, oh yeah, hey doc, yeah, you know, we heard of you real quick, you know? Sign up for us. What they want to do is, they may not have the work available, but they want to get you on their panels so that when they get you on their panels, then they can look for work and say, oh, well, we've got Dr. Carpenter here and Dr. Williams here and Dr. so-and-so here. So give us, you know, give us the contract. So they're really just using you to get your name on their panel so they can get work. That's a waste of time because filling out these documents and all that, you know, they need the board certifications and the licensure and this and that and this and that. It takes time to fill out the documents. You know, unless they can really tell you that they can provide work for you, don't do it, you know? And you really want to be really cautious about who you put your name next to because your name is the most important thing you have. It's really your reputation. And that's very valuable. Don't, you know, you don't come cheap, you know? So don't do that. So keep that in mind. But again, you're looking for a typical medical file review. Depending on it, it can be anywhere from per case. As I said, for smaller ones, $250. For the larger ones, upwards of five, six, $7,000 per case. So it can be fairly lucrative depending on the case, but it takes time. Three, so let's open this up. Any questions about medical file reviews? Anybody, anything, any comments? I'll add a question. Yeah, anybody do, anyone here do medical file reviews other than me? No. I've done one. You've done one? I've done some as well. Well, I think that, you know, it's, I think the difficulty, it depends on the case, difficulty, it depends on the type of practice you're in in order to do these things. And, you know, again, if you're a full-time employed physician, for, you know, say when I was at the National Rehabilitation Hospital, for example, these are full-time, geographically located employed physicians who are there and they get a salary there, and it's a fine job, but all of, you know, their malpractice, et cetera, et cetera is paid for by the hospital. Not really paid for by you, it comes out of your salary, but anyway, it's a different issue. And so many places may not let you do medical file reviews, even if you do them, if you will, on your own time, you know, even if you do them off hours, if you will, because some of them require you to contact the attending physician and that attending physician might call you back at two o'clock in the afternoon, which I don't know if that's considered your time or, and I'm using the example of National Rehabilitation Hospital's time. So you have to be careful of that. And for many of these, of course, you have to have malpractice insurance. I've not been sued for any of this yet, and I hopefully never, but you know, you never know with these things, but it's always a possibility. So you always need to have some level of malpractice insurance. It's pretty cheap, incredibly cheap, but it's something that you have to have. Any questions about medical file reviews or anything or how you would go about it? Again, I would go to another, I'm gonna write this down, so another one is called SEEK, S-E-A-K. I don't have any financial interest in them, but they're very good. And they offer, again, two, three, four-day courses on medical file reviews, independent medical evaluations, et cetera. And what's good about SEEK is, as with ABIME, is when you go there, they also have the referral sources there as well. They'll have companies that do medical file reviews who want you on their panels, companies who do medical legal work, companies who do physician life care planning. So going to these, something like SEEK, which I can recommend, because I gave a talk there, but that's not why you should go. You should go because it's a good place to go, that they're legitimate. There's some places, some of these courses, you think you're going to get something, and you're hoping, and then you would get there. It really wasn't what you expected. But I think this one is pretty good. They're expensive. I should note that as well. Easily, not counting hotel, you're looking at a few $1,000. So it's coming out of your pocket. So keep that in mind as well. But I would recommend SEEK, S-E-A-K. Look them up. They're very good. They're very good. And again, and you can also talk to the referral sources there. And you can really have a conversation about what they expect, what the format of their reports are. And you can talk. You say, well, how much, because in the end, it's about the money. You ask, how much do you pay? What's your range here? Don't be afraid to ask people what the fees are. Don't do that, because again, they're going to try and get you at the cheapest possible, and you're trying to get as much as you can. I mean, it's, you know. And don't sell yourself cheap, please. I'm always struck by, I don't know if it's women or African-Americans or whatever, but I do find that we tend to, I'll speak for my, well, I don't do it anymore. I learn better. But sometimes, I tend to ask, I had a habit of asking for less than I even thought that was worth, and I would not recommend that you do that. No, you want to get your foot in the door, so maybe you're going to take a bit of a hit early on, as part of your learning, but not too much. Because remember, once you agree upon a rate, it's really hard to get that rate increase. The best, your best negotiation is when you start, not when you're in. So kind of keep that in mind. We have another poll, any questions or comments, or do we have a poll? One question, you mentioned about contacting the attending physician. Is that something that is always required as a standard, or is it just when specified? That's a good question. It depends on the type of medical file review. If you're doing a standard quick turnaround time, should this person get an MRI scan? Should this person get this particular medication? Should this person get X number of visits for physical therapy? Should this person go to a long-term acute care facility? Those are 24 hour, 40 hour, if there's no attending physician contact, that's really indicated for that. That's really just your opinion. Should this person get a microprocessor above knee prosthesis? Those don't require attending physician contacts. What tends to, however, are the larger cases, the larger disability case, for example, that these are 600, 700, 800 pages, 1,000, 2,000 page cases. And a part of that will be, because they want these to be as complete as possible, is so-and-so has real bad back pain and neck pain, and they had a surgery a couple of years ago, and they're so bad off, they can't do anything. And you guys have seen this. I'm sure in your practice, a patient will give you an attending physician statement or something that you fill out, and you say if they're disabled or something, and then they may want you to call that physician and say, hey, Dr. X, I see that you filled out an attending physician statement that said that Ms. Jones is disabled. Why is that? This person, it looks like, typical conversation might be, Ms. Jones, you say she's totally disabled, and she might be. I don't know. But she's independent with activities of daily living. She drives a car. She goes grocery shopping. And she works virtually answering the telephone. Why is this person unable to do their job? And then you go back and forth about that, and you have that type of discussion. And again, what happens very often, you're calling folks in the middle of the day. They're busy. Everybody's busy. So they may not take that call, but they may call you back at 4 o'clock that afternoon when you're busy. But you got to take the call. And that's one of the difficulties, the downsides of doing medical file reviews, is that sometimes you're at the mercy of the case itself, and that becomes the priority. Now, it's not a huge burden. I mean, usually the call takes 5, 10 minutes. You're not on the phone that long. And you really want to be very, very pointed. It's not a general conversation. You have specific questions you have that you need to frame, and as easy a way as possible to get the answers that you need in order to complete that report. So I would say, for me, if I'm doing a big disability medical file review, 20%, 20% to 25% would be physician contact. Now, when you get on these panels and you do these medical file reviews, you can request that I want to do medical file reviews, but I don't want attending physician contact. The difficulty with that is everyone's kind of like, whatever is the easiest to do. So many of these folks who are sending you these cases tend to be nurse case managers, and they don't want to look through the case to say, well, who was going to talk to the physician and who was not. They're going to just send it to the person who was just going to take everything, and they'll decide. So you want to be as available as possible. And the harder you make it with respect to what you will and will not do when it comes to taking the case, it makes it difficult to sort of get a number of cases under your belt, if you will. So again, I'd say, to answer your question, about 20% to 25% of that particular type of medical file review. I had a question. You mentioned about it. So it was my, and this is probably, I was mistaken, but I was not aware that malpractice was needed if there was no direct patient care involvement. Right, well, it's not, but you will find, and I don't think that there should be either, but you will find that when you sign up for many of these panels, they really want proof of malpractice. And I'm not, I mean, if I'm going to argue with them and say, no, I don't really, I don't think I need malpractice, I don't, you know, they're not going to put you on the panel. I mean, and I think you're right. If you're not seeing the patient, there's no doctor-patient relationship. But many of these, I've not seen a company yet that hasn't said that we need proof of malpractice. There may be some out there, but, and you can make that point to them, but they're probably not going to put you on the panel, you know, but you do make the good point. I have another question, because I, so I recently left a practice and joined another at an academic center that allowed me, that is allowing me to do my, you know, everything on my own, as long as I get malpractice insurance, you know, on my own, but I'm being contacted by patients, attorneys that I did used to follow, whether it was workman's comp, and at the time they would pay the practice that I was direct, you know, directly, because I, this was not negotiated in my contract early on after residency. And now they're offering to pay me directly. Is there, are there any legal, ethical, you know, additional considerations that I should have, or? Well, no, tell me this again. So you were with a practice and they were sending you patients and I guess they were paying the practice? Yes, so they were, well, these were patients I was seeing, you know, I see a lot of patients with concussions. They happen to have some litigation or workman's comp or whatever, but they were paying, I was not getting paid for that. I'm no longer with this practice. And these attorneys want me to continue to, you know, comment on, on, on prior, you know, exams that I did just to support their cases and are, you know, now wanting to pay me directly. I've even been subpoenaed to testify. And I actually did get paid for that, for that, you know, to go to court based on a patient that I saw. I'm just no longer seeing these patients. I was just wondering if there's anything I should be concerned about with that. Well, a couple of things. First of all, if you're seeing the patients, now when you were seeing them, were you seeing them under insurance or were you seeing them that the attorney was paying you to see them? No, I was seeing them, they were my patients. So I was seeing them under insurance. I was not getting paid for that, right. So if you're seeing them under insurance and you know, that's malpractice and, you know, setting up the insurance, et cetera, et cetera, you know that, that's fine. And there's no, as long as it's transparent that you're letting the patient know that your attorney contacted me and, you know, this is what we're doing, that's fine. That's not a problem. Now, remember that you're, it would be, that's, you're still gonna need the malpractice insurance and you're gonna need a set, and we'll talk about this with the medical legal stuff a little bit later, but you're still, you still want some sort of either assignment or arrangement with the attorney to make sure that, you know, you are being paid what you feel is appropriate. And you still have to do that. But as it, if it's transparent, it's fine. It's fine. But I think the difficulty sometimes is you gotta make sure that you make it clear to the attorney that if it's your patient, you're an advocate for the patient, you know, independent of what the attorney says. Right, right. That's sometimes hard for some people, but you gotta be very clear about that. Versus for me, if an attorney sends me an individual to evaluate, I make it clear to the individual, listen, I'm not your doctor. Your attorney sent me here to, you know, evaluate you and to answer these particular questions, but, you know, I'm not gonna offer you any treatment recommendations. That's a different relationship. And that's interesting that you work at a academic institution and they let you do this other thing, which is good. Which is good. You know what, after I found out how much the attorneys were getting paid, I mean, how much the institution was receiving at the prior institution, it was something I was able to negotiate. And of course, if I do it with them, it's gonna be, they take 40%. So I just, they allow me to do it on my own. Indeed, indeed. All right, next, what's the next one we're doing, like medical legal or life care planning? I think it's, all right, can we pull that up? Who's done life care plans? All right, we have one person there and the others have no experience. Okay, that's fine. All right. Life care planning. So what's a life care plan? This is from the case management handbook. A dynamic document based upon published standards of practice, comprehensive assessment, data analysis, and research, which provides an organized, concise plan for current and future needs, with associated costs for individuals who have experienced catastrophic or have chronic healthcare needs. Listen, a life care plan is really essentially an extension of an assessment that you do on a patient. For example, when you do a consultation, it really is. Except when you do a consultation, say on an individual who's in the acute care hospital and they want you to evaluate them for rehab. You'll do all the things, you'll look at the clinical records, you'll take the clinical history, physical examination, then you look at all the diagnostics, et cetera, et cetera. And then you will then talk about, well, as a result, this person will need physical therapy, occupational therapy, this particular type of medication, these DMEs, this type of wheelchair, et cetera, et cetera. And you'll do it for that particular short-term period. What a life care plan does is do exactly what you're doing, but extend it out for the rest of their life. That's exactly what it is. So that, let's see, I'm doing about three or four lifetime care plans right now at about the same time. It's incredibly busy right now, I think because of COVID, because I'm not usually that busy with life care plans, but what I'm doing today, individual, oh, individual fell down the stairs at a place that was wet and et cetera, et cetera. They got injured, had to have surgery on the foot, broke their foot several places, and then developed complex regional pain syndrome. And now I'm evaluating that person. And so what I do is, and this is with physician life care plans, and we'll talk about different organizations. What I'll do is they send me the information, it's all via their website, et cetera. And I get the document, I review the documents. I tend to, I like to go to the person's home because I like to see them in their environment. Sometimes they'll come to the office, but I like to go to their home. And I've flown all over the country, different places to these folks' homes and see how they live, which is, that's a kind of crazy experience. If we have time, we'll talk about that. And then I'll do an examination, I'll get all the records, and then I'll put together a plan that says what physician services, what diagnostic tests, what medications, what DME equipment, what surgeries, what procedures, I mean, everything from sympathetic nerve blocks to spinal cord stimulators. And how often does that need to be changed? If the person say, I think this person's in their 40s and their life expectancy, I believe, is 82. And so over the 40 years, how often will you change the stimulator and how many injections do you think they're gonna need? And are they gonna have another surgery, et cetera, et cetera. You have to put that in a plan. Now, the way, so that's what you do in a life care plan. Let me give you a little bit of history. Life care plans are not really new. To go back decades, a few decades, life care plans really weren't done by physicians. They were done by nurse case managers, usually. And we had nurse case managers, maybe vocational counselors, and you would have someone who say had a catastrophic spinal cord injury. And high level, C4, C5, something like that, tetraplegia. And once the immediate care was done, then you'd wanna know, say for insurance purposes, what kind of care this person's going to need for their, I mean, care, therapy care. Will they need a home health aid? Will they need ongoing medical care? What kind of labs are you gonna be drawing on them? What's the risk that they're gonna have? What kind of hospital bed, in particular mattress they're gonna need? I mean, all of these things, what kind of motorized devices are they gonna need, et cetera, et cetera. And they would put that together and that would be the life care plan. Now, they've changed considerably since then. and now what we have more so are physicians who are doing this, and physiatrists really are absolutely perfect for this. I mean, this is what we do all the time anyway, and I particularly, I work with one company, Physician Life Care Plan, which is an excellent company, and again, I'm an independent contractor. I'm not employed by them, but there are several other companies out there, but what's nice about this company is that they're this central place where all the documents come to. They sort of really put the documents together so that you can evaluate them, they summarize them with the original documents, so you can read all the hospital documents, ER documents, all the treating physicians, and then when you can upload your, when you see the individual, you can upload your physical examination and your diagnostic categories, and then there's sort of a checklist, and you can check off what services they need, and then they're the ones who then call up Walgreens and CVS and whatever pharmacy to see how much, you know, in your particular area, how much gabapentin costs, or how much, you know, tizanidine costs, or how much, you know, Tylenol costs, or, you know, how much, what is the cost of this particular, whether they charge in that area for phthalate ganglion blocks or sympathetic nerve blocks or something, they do that groundwork, because for you to do that, for me to do it, it would take an incredible amount of time, and I just don't have that kind of time, but again, then with all that information, you put the document together, and the people who tend to ask for these plans tend to be attorneys, and also, of the attorneys, tends to be plaintiff's attorneys, because remember, when you're in a court of law, say something terrible happened, for example, I did a, it was a shoe case, and the tractor trailer went off the edge and hit this tour bus, and lots of people, it was in the newspaper, lots of people were killed, and all kinds of terrible, terrible things, and so was a class action suit, and so the people that were alive, you know, they had some pretty bad injuries, and so the accident itself was not in dispute, you know, people knew, it was in the news, you see, the accident itself, and who was at fault also wasn't in dispute, the tractor trailer went on the other side of the road, and it, you know, it hit this tour bus, you know, but what they want to know is, okay, care is going to be needed, how long is the care going to be needed, and how much does it cost? That's the document, that's the life care plan you provide, you provide that, and so you provide that plan, so you provide the plan, usually it's the plaintiff's attorney, you know, it goes to the plaintiff's attorney, they look at it, and the plaintiff gives it to the defense attorney, and of course, they look at it, and then they argue, you know, they, it's an adversarial, you know, thing, and then very often, you are then called upon to defend your plan, usually you're called to defend the plan initially with a deposition, so you are deposed, and you, you know, we'll talk about that a little bit when we talk about medical legal work, and then there are most times these things don't go to trial, it's just the way that most, I would say, of the cases that have been deposed, less than 10% have gone to trial, less than 10%, but the ones that do, you, you got, you called for trial, and then you, you're, you're the expert, and so everybody kind of looks at you, and you defend your plan, you say, here is why I believe with reasonable medical certainty, or reasonable medical probability, same thing, that's, that's the standard, that's the standard, that's the weight of the evidence, with reasonable medical certainty, 50% plus a feather, this is what I believe, and as, you know, and that's, and you defend it, and those are life care plans, and when you get paid for these, do I have that here, I don't know if I have that, oh, oh, I'm sorry, let's, I don't know if I have, when you pay for these, usually a typical plan, that sort of non-catastrophic plan, that really is not, you know, something like neck pain, back pain, maybe a back surgery, but it's really not going to impair your, it's not going to, your activities, daily living, you're still able to do those things, I don't know, typically three, four thousand dollars a plan, particularly if it, and then you charge, obviously, it's going to be additional monies for the deposition, for additional documents to review, if it goes to trial, prep time, etc., etc., and if it's a catastrophic, you're looking at five, six, maybe, you know, seven thousand dollars, again, depending on what else is involved, so they can be lucrative as well, it's pretty substantial, but again, the questions you have, that they want you to answer is, what's the subject's condition, what medically related goods and services does the subject's condition require, and how much will the requisite goods and services cost, you know, so what do they have, what do they need, what does it cost, those are the questions, and, you know, you're not supposed to do this, but I'm sure when you give the, you know, the plan over to the defense attorney, they're all looking at the bottom line, how much, how much is this going to cost, and, you know, many of these catastrophic cases, I've done cases where it's two, three, four, five million dollars, you know, of care over time, you know, and that's just the care, you know, and that's, particularly if it's a head injury, spinal cord injury, several million dollars, absolutely, it's not unusual, one of the biggest costs is care, is nursing care, custodial care, I mean, these are labor intensive, you know, you know, 50, 100,000, 200,000 a year, over the course of 20 years, you know, that's four million dollars, right there, that's just that, that's just the care, that's just custodial, or even, you know, nursing care, so these things can add up, and I love it, I just think life care, but I just get such a kick out of it, because I think, and I mean, I think you get it, you know, sometimes we're so encumbered by our insurance system, you know, very often, when you're seeing a patient, you are hesitant to maybe prescribe something, because their insurance won't cover it, or, you know, you got to go through, they're going to bury you in paperwork, if you say that they need this microprocessor, you know, above the prosthesis, so you're going to order a mechanical one, or you say, you know, whatever, when you're doing a physician life care plan, insurance costs should not count, it's what does this individual need, it's really the most basic and purest form of providing care to someone, it's sort of, I think they need XYZ with reasonable medical certainty, they will benefit from this, it's medically necessary, you then can put it in, and it's one of the rare places you can do this, is in a life care plan, and it's respected on both sides, it really is, so I would recommend getting involved with this, again, I would look at the American Academy of Physician Life Care Planners, you can google it, a couple of folks here on there have been to it, I think they give very good courses, you have to, you know, you really, well, you really have to be certified in this, there are two certifications, there's a basic certification, I'm a certified life care planner, you really need to do that, because when you're deposed, that's one of the first things they ask you, after they ask you, you know, are you board certified, and so and so, and they always ask you, did you pass your exams the first time, I don't know, I mean, I did, but I mean, I guess they're trying to embarrass you, if you didn't pass it the first time, anyway, and then they, but then they're going to ask you, are you a certified life care planner, and if you say yes, they just move on, so you really want to be certified in this, it's not that hard to get, it just takes a, it's kind of laborious, but it's not harder than the board or anything like that, so, and it's not that expensive, and again, the clinical objectives of a life care plan, you really want to diminish or eliminate the physical and psychological pain and suffering, you want the individual to reach and maintain the highest level of function, you want to prevent complications, you want to afford the individual the best possible quality of life in light of their condition, and that's what we do when we, when we do a consultation, you know, for an individual who's in the hospital, if they come to the office, that's exactly what our objectives are, it's no different in a life care plan, and again, as I talked about the basis for payment, case for hourly rate, is it a catastrophic or non-catastrophic case, time frame, travel on site, revisions, documents reviewed, teleconferences, staff partnership, contracted rates, etc., and again, for all of these things, you charge for them, all of them, you charge for them, and again, you can look for, for non-catastrophic, as I said, maybe four or five thousand dollars, maybe a catastrophic one, you know, or six, seven, eight thousand, again, you're adding on depositions, trial, very often, you can get up to twenty-five, thirty thousand dollars if you add in, you know, depositions, trials, revisions, documentary review, it can become, you know, travel, you know, especially if you're going out of state, etc., but this is something that you want in your arsenal. Again, I recommend, whether it's life care plans, medical legal work, medical file reviews, independent medical evaluations, I would not recommend just doing one thing, diversify, diversify, diversify, diversify, because it decreases the risk that any one thing is going to fail for you. You'll always have, you know, I can tell you, there was a time when, you know, the pendulum swung where I was doing a lot of IMEs, and then it swung at those same people that would have done IMEs, they want to just do medical file reviews, and then they go back to IMEs again, so you really, you don't want to be caught up in one particular thing, you really want to diversify your practice as much as possible, and that is the least risk, I believe, and the most lucrative. And again, and maybe I didn't say this earlier, you know, I care about patient care, and the patient comes first, and that's my raison d'etre is to be there for the patient, and I'm an advocate for my patient. This isn't about that. These are not your patients. Now, you're there to provide a service, and you're there to be an expert, and you're there to, you know, put your knowledge to good use, but this comes down to how much are you being paid for it, you really want to be paid for your services, and you want to be compensated appropriately, because you've got a lot of training, a lot of education, et cetera, et cetera, and you want to be compensated for that. Don't get sold short. That's very important. Again, integrity first, you know, and again, this is not about patient care, and you want to do the best job possible, and so, but you want to be paid for your services as well. Please, please, please, please, please do not sell yourself short. As an example, when I was doing, I started my first case, this is decades ago, an attorney asked me, well, how much do you charge, and I didn't know. I just made up a number. I said a thousand dollars, and then, you know, the case was over, et cetera, et cetera. I did the deposition and the testimony, and I guess it went well, and I get a check for ten thousand dollars, and I can't believe it, so I call, you know, the attorney. I said, hey, you know, what's up with this check here? I can't believe this, and he says, what, we didn't pay you enough, and I, and I, and he said, I said, what are you talking, he says, you said a thousand dollars an hour, right, and because I put in ten hours of work, and he paid me ten, I just meant a thousand dollars for the whole thing, but, you know, it was a thousand dollars, you know, so I said, no, my mistake, wrong number, you know, I kind of hung up, and that was that, but the point being, you know, we'll talk about the rates in a moment for medical legal work, but, you know, a thousand dollars an hour is not, particularly in these parts, that's not unusual at all for, and again, you're usually paid in advance. I seldom get paid after the fact, almost never, I mean, it's, it's, it's beforehand, but, but again, but you have to be worth it, you know, you have to come in there with the expertise, with the integrity, and with ethics on your side, you know, if you have all those things, then believe me, the phone will keep ringing, it'll ring off the hook, I guarantee, so anyway, that is life care plans in a nutshell. Any comments, questions, anybody, any, any other comments about life care plans, anybody interested in doing these things, if you, if you haven't, and you're interested, what has been the hesitancy? Dr. Fleming, did you want to unmute and ask your question? Yes, thank you, I'm driving, so forgive me if I come in and out, thank you guys for doing this session. I did have a question, do you need separate medical malpractice insurance to be the life care planner? I know that they offer, like the Academy of Physician Life Care Plans, they offer the separate insurance for this, and it's, I think it's like $700 for the year, so, I mean, that's, that's what we're talking, it's very inexpensive, I don't even know if it's $700, I think it might be less than that, but that's, they, I have my own malpractice anyway, just because I'm in private practice as well, but it was, it was $700, I said fine, so my point is, I don't know if you need it, but I got it because it was so cheap, and it didn't hurt me. Right, it provides another layer of coverage, that's a good point. You mentioned talking about the rates, I guess that's going to be later on in your talk, so I'm not sure if it's by state or geographical region, or whether or not you have some specialty certification. No, I think it comes down to what the rates are, and, you know, how good you think you are, I mean, it really comes down to that, and I'm gonna, I'm gonna, you'll, you'll know what I'm saying when I, when we get to that, but you determine the rate, you determine the rate, you know, if you say you charge $750, then you charge $750, you say you charge $2,000, then you charge $2,000, it's up to the attorney to say if you're worth it or not, but you determine, there's not an insurance company that tells you otherwise, and they don't take, it's not 80% of what your charges are either, it's what you charge. You're great, yeah, that's a great point, because then you have the option to either accept or decline, is that how that works? Right, exactly how it works, and then sometimes there's some negotiation involved with that, you know, you know, attorney might say, well, listen, you know, I can't really pay, you know, with this kind of case, I can't really pay $1,500 an hour, but I can pay $1,000 an hour, and it's going to take this, and that, and etc., etc., and you may say this is the first time we've worked together, but I think that we're going to have a longer relationship together, and there may, you know, you can do that, you have the freedom to do that, but in that is you have the freedom to do that, right, you dictate it, not the other way around, and that's what's key to all of this, you dictate it. Anyone else, any other questions? Last one, Duann, what's the next, last one as we're kind of finishing up here? Expert medical witness? Yeah, who's done more, any medical witness work on, anyone? I did for the first time this year. All right. Okay. All right, let's move on, and I'm going to sort of, and again, I'm going through all of these things very, very quickly, and as I said, for example, medical, you can spend, you can have courses that last for weeks on end. I mean, I've gone to several different courses that, you know, really takes into account all kinds of aspects of being a medical legal, being a medical witness. It's fascinating, actually, the things you can get into, and how you go about doing these things. So, let me, I'm going to close this now, Duann, okay? As a medical expert witness, you are designated the smartest person in the room. You are the, everyone, the judge, plaintiff's attorney, defense attorney, the jury, the people in the audience, everyone has pointed to you and said, this clerk is the smartest person in the room. You have to know that and know that's what your role is. You are the expert. No one knows more about that particular subject matter than you. Now when you go in there, there's this humility, respectful, plain spoke, and that goes the wrong way. Look the part, act the part, storytelling empire. I wonder what I meant by that. I'm not sure what I meant by that, but anyway. A couple of quick things I want to say. I want to go back a bit. It has been my experience, I've gone to a lot of different meetings, and depending on what the meeting is, I can tell, well, I can tell you very often what the meeting's about based on what the audience looks like. So what has been, and this is just me, I'm an inner one, it's anecdotal. What I found was those meetings that had to do with public health, general care, primary care, that really weren't very lucrative aspects of medical care and healthcare, tend to be populated by women and people of color. This is the way it is, I've noticed that. And when I went to meetings that had to do with sort of higher level complicated interventional pain management techniques or medical legal work, they tended to be more white and more male. So they tended to be white male. And so what I, and one of the reasons that really I wanted to do a talk like this was to really bring us to the table, because I think that we can, we are a part of this, I think that we can do just as well if not better. So I think that's very important. What you'll find is, particularly when you're testifying, that very often, many of the plaintiffs, they're people of color, and very often the jury, a large percent very often are people of color, and you will be surprised how well you can speak to them as the expert, and how important your testimony can be. And I think that gets lost sometimes, when we see others doing this and think that we're not a part of it. So I wanted to sort of put that out there. And when I say look the part, I think that's important. I'm always stunned, you know, where I'll see cases, and I'll see an individual, usually it's a white male, and it's fine, no problem. But we'll go and they'll be in front of a jury with an open collar shirt, and, you know, khaki pants, and, you know, Docksiders, what are you doing? I mean, how can you, you, whereas I, you know, I'm, you know, I'm a jacket and tie, and, you know, I, you know, I'm looking the part, you really have to look the part, I think, in order to do this, because it may or may not have anything to do with what your intelligence is and what you have to say as an expert, but you really have to convey to that person what their sense is, because you're talking to the jury, what their sense is, what a learned physician is, what their, and you really want to, that's very, very important, and you want to act the part, because again, you're telling a story, you're telling the story that you want to convey to the jury, that's very important, and you, and you want to, you want to speak with them in a very respectful, plain spoken tone to get across what you're trying to say, don't use a lot of jargon, don't use a lot of this and that, don't do it, you know, don't speak down to them, speak to them, and I found, you know, and whether I'm doing a case in Manhattan or I'm doing a case in, you know, rural part of Kentucky, you know, you really have to, your opinion is the same, but how you speak to that audience may be very different, and you want to be cognizant of that, and all of us, we all know code switching, we all do it very well, well that's kind of what you're doing when you're an expert, you know, you know what you have to say and what you need to say, you just have to know the audience that you're saying it to, because that becomes very important, again, excuse me a second, on the deposition, it's the witnesses sworn out of court testimony, you're on the oath, that's the same thing as if you're in court, you know, and it may be used in trial, if it's, for example, if you're representing plaintiffs and defense is deposing you, if you mess up, if you do something wrong, you say something out of turn, that's not appropriate, whatever, it will be used against you, not might, it will be, so you got to be very careful. Deposition, look at it as sort of just the facts, ma'am, you know, just the facts, get your point across, be respectful, answer the questions, whereas trial testimony, all eyes are on you, you know, the medical expert can be pivotal, and I think very recently we all saw where it was incredibly pivotal, I don't know if many of you paid attention to the George Floyd case, the expert witnesses were brilliant, they were absolutely brilliant, if you remember all the stuff about, well, you know, the guy, you know, well, that didn't count, well, he was on drugs, and he had these other medical problems, the medical experts for the prosecution squashed it, they said no, and they, in very clear detail, very respectful, you know, that there was no doubt that that officer's knee on that, George Floyd's neck killed him, that was it, and so there was no room for any other interpretation, so when the jury came back, they actually said no, the experts were pivotal in this case, because they made it clear that what killed George Floyd was, the proximate cause was from the guy's, you know, from the officer's knee on his neck, that's what, and so that's the, you know, the medical expert is absolutely pivotal in the trial, and so while you are designated the expert and the smartest person in the room, your role is very, very important, and remember, the other side's, you know, once, well, first of all, you're the expert for, say you're the expert, you know, for the defense, they'll build you up, plaintiff's gonna tear you down, but in the end, you have to be still standing, you know, in the end, you have to be still standing, and that's, and that's, and the jury will respect that. Our payment, hourly, usually, it usually is hourly, and the way I do it is, if I'm gonna do testimony, I do at least a half-day minimum, my half-days are five hours, my full day is 10 hours, very often, I'll do a retainer, I think my retainer usually about five or six thousand dollars just to take the case, it's paid in advance, it's non-refundable for me to just take the case, my travel rate, I have an hourly rate just to travel, it's portal to portal, from the time I get, from the time I leave my house to the time I get back to my house, I'm charging the rest of the way. Now, I don't charge this full 24 hours, I don't charge, you know, I just charge a 12-hour day, you know, I don't charge when I'm asleep, and I don't do that, some people do, I don't, you know, but I charge for every bit of it, all expenses, of course, all expenses are charged, you know, I don't, I don't overdo it, but I eat a decent meal, you know, you know, the hotel, etc., etc., the flight, that's, you know, it's business class, that's all charged, record review, everything I review, and I, you got to look at everything, but you charge for it, opposing, you know, the, including opposing depositions, if the other side of plaintiff's side has depositions in your defense, you got to read them, and vice versa, you got to read everything, again, I'm paid in advance, please get paid in advance, you know, say, hey, listen, now, something, you don't know how it's going to, you know, you kind of have to do the numbers a little bit at the end, you know, well, there was a little bit more, a little bit less, whatever, that's fine, but for the most part, listen, if I'm, you know, if I've got a trial next, you know, Tuesday, I've already been paid for it, I've already charged the five or ten hours, I've already done that, I've already charged the travel time, that's done, I don't take assignment, you know, a lot of times with these personal injury cases, they want you to take assignment, well, you know, you know, we'll pay you, you know, $2,000, and if we win, we'll pay you $4,000, $4,000, no, no, no, no, no, no, I'm the expert, I don't want to have skin in the game where I kind of care about the outcome, I mean, I want to do the best job I can, but I'm not, I'm not rooting for one side or another, necessarily, I'm the expert, so I don't take assignment, also, it's non-refundable, you don't get your money back, you know, this is my you know, my retainer, it's non-refundable, and I think I'm worth it, and you've got to, because if you don't think you're worth it, they don't think you're worth it, you know, they don't, so keep that in mind, and again, usually, it's about $1,000 an hour, usually, that's common around here, so I have to testimony 5,000, full day 10,000, same thing, you know, using record reviews, $500, $600 an hour, typical around here, don't be afraid to ask for what you're worth, please don't, please don't, because if you don't ask, you're not going to get, you know, so you, again, you have a heavy responsibility being the expert, it's, I don't want to just, you know, blow it off and say, you know, no, it's for real, it's, and again, it's not just, you can do medical legal work, not just as doing testimony, for example, I worked, I was, I did some work for the Department of Justice, where they had, I won't mention a name, but a very well-known subacute rehab place was really charging Medicare a lot of money for therapy, you know, for the physical and occupational therapy, and they called me in, and so I reviewed thousands and thousands and thousands and thousands of pages of documents, I mean, they were, I mean, it was all digital, you know, but it was, you know, that took a lot of, that took months, you know, or, you know, again, I did some recent work with the Maryland Attorney General's Office, where they were looking at physicians in, I got to tell you, you know, who were just prescribing crazy amounts of narcotic opioid medications, I mean, pill mills like you wouldn't believe, I'm like, geez, don't these guys read the paper? You're still doing this? But, you know, you, and they want you to, and so the documents are voluminous, but you're the expert, and so it's important to recognize that, and I, but I do think, again, SEEK, S-E-A-K, was good for, they have a lot of sessions on this, you really want to learn your craft, you know, you just don't want to walk in there and not know what you're doing, because, again, a couple things, everything you do is recorded, it's recorded for life, so that, you know, if you do another case, said attorney may, you know, they may, well, they say, well, doctor, in that case, you said this. Now you're saying, well, what's going on? So you want to be very, very careful about what you say and how you say it. It's important. I mean, you want to train at this and really develop your skill and your craft as best you can. And I can tell you, I think the biggest area right now for medical legal work, as far as physiatrists, is head injury. I mean, concussions, so-called mild head injury, concussions, post-concussion syndrome, all this stuff with CT, that's big. That's big. And there's a lot of cases like that out there. That's just a big area. So to get certified in head injury, I would highly recommend doing that right now. And who knows what's going to be in the future? I don't know. But I think it's a very important area. And I think it's a place that I think African-American physicians, I think, would do very well. And I've had a good career doing this. I turn down more than I take. Just the way it is. Again, I can't do this 24-7. Again, I can't do any one of these 24-7. And for me, I couldn't. I just couldn't do it. I like to diversify. I'll do a little bit of this. I'll do a little bit of that. And you get busy that way. Again, resources, I would say. SEEC, American Board of Independent Medical Examiners, AAPLCP, and PM&R. I mean, they had a, I think it was two years ago. I think it was just before COVID. They had actually the pre-conference. They had the conferences. And they did one on medical legal. I don't know if anyone attended. I did make note that maybe there were 60 people there. Maybe three people were people of color there. I did make note of that. I think it's important for us to be in the game. I did hear that they're going to start a special interest group on medical legal from the Academy. They're talking about that now. Maybe you all have seen those in the listserv. They've been talking about that. That's another thing. You can join. You'll get resources there. You talk to people. But there are plenty of opportunities. And I just remember, just briefly, to sort of finish this off, I promised myself, this was 25 years ago, when I worked for National Rehab. And I was let go from there after I'd finished my sabbatical as a Robert Wood Johnson Fellow. And I promised myself I'd never, you know, I'll never work for another single employer again. I fear the tyranny of a single employer. I do not want one individual, one individual company, one individual person being responsible for how I put food on the table, whether I pay my rent, whether I can pay for my kids' college. And since then, I've never worked for a single entity since then. I've done OK. So it can be done. And I would recommend it. You know, in the end, invest in yourself. Because if you don't, nobody else will. So let me just end that with that. These are some resources. And again, there are others. I'd just like to put this up here. Again, this was New York Times in, I think, 2014. If you notice right here, he's wearing, he's a below-knee amputation. He's on the front lines. I mean, you look at this guy, the guy looking at him, what are these guys doing? But you know, this is the capacity that we have. And again, this is who's protecting our freedoms. Whatever you think about the military, plus or minus, look at this guy. This guy's, he's an above-knee amputation. He's protecting the wall. I want him on that wall. I need him on that wall. So with that, I think that's all I have. Now, there's some housekeeping things. Who do I turn it to? And then we'll have some questions if there's anything. I can handle the housekeeping things here. Sorry, let me just go back. Were there any questions or comments about medical, legal? And then we can go to the housekeeping. Then we'll open it up further if there's anything. Yeah. I had a question, Dr. Evans. My question was, do you have a strategy for preparing for depositions? Like, do you keep a running log of particular articles, landmark articles, things that you take notes from or bring with you to deposition? Good question. First of all, here's the strategy. Be prepared. Read everything about the case. Know more about the case than plaintiffs or defense. You know that case better than anyone. I remember once I did a deposition, and I was plaintiff's expert, and this was a depo, and defense expert. I knew the case pretty good, but defense knew the case backwards and forwards. And it really showed when I was answering the questions for the deposition. And I promised myself, this was several years ago, I said, I will never, ever let that happen again. And part of it was, you know, I was like, well, I know enough, and I don't really want to charge the attorney for more time of putting in or doing this. No. Put the time in, charge for it. Know the case backwards and forwards. I would not, I have found that, you know, quoting articles in a database really isn't helpful, because remember, once you quote an article, you become responsible for knowing everything about that article, including the articles that are cited by that article. And so you can get yourself into a lot, you know, into this sort of wormhole of going here and there with articles. Don't, I would not, I really wouldn't cite the literature. It doesn't help you as the expert. No one really cares. I mean, now things that are pretty obvious about the literature, you just want to know, but you really don't want to cite particular articles on a deposition or in testimony. You don't want to do that. You want to be aware of the literature, but please don't cite it, because then you become responsible for knowing everything about that particular piece of literature and the articles that are cited from it. So I would stay away from that. When you mentioned a head injury certification, are you talking about a brain injury fellowship or is this a separate- It's not an injury fellowship. I mean, if you can do something like that, all the better. If you're certified in it, all the better. But I think that one of the big areas right now really is head injury. It's just such a huge area for medical legal. And that can change a couple of years from now. It could be something else. But if you're an expert in something, certified in something, fellowship with something, all the better, all the better. And the boards that really matter is the American Board of Medical Specialties, not the sort of other boards. I mean, I'm boarded by the medical review officers. That doesn't really mean a whole lot. It really doesn't. But you really want the American Board of Medical Specialties. That's really the boards that count. Anyone else, any other questions? Do you ever, I guess, based on charging in advance, have to give them money back? No, you said everything is non-refundable. Right, I don't give money back. No, no, no, no. I do not give money back. No, no, that doesn't happen. That doesn't happen. And no one's ever, but can I be honest, no one's ever asked for any money back, ever. You know, as a matter of fact, I've had some cases where the attorney, when the case is over, the attorney says, well, you know, we've got some more money left over in the case. You know, do you want it or can we? And I'll say no, if they pay me fairly, I don't listen, no, no, no, no. I'll get you next time. You know, I don't, you know, I mean, what's fair is fair. And I'm really fair. I like to be, I say, I like to think that I charge, I'm not cheap, you know, by any means, but I like to think that I charge a fair rate and I think that I provide a valuable service. And so far so good, you know, the phone keeps ringing. So, you know, so far so good. And again, I'm not known as a plaintiff's expert or defense expert. I don't do that. I don't want to be known that way. I don't want to be known as shading one side or the other. But what you have to remember, what you have to do, at least particularly for the last five years, you have to keep a list of all the cases you've testified. So whether it's a deposition or, you know, testimony or trial, you have to just keep a running list of that. That's kind of a pain in you know where, but you really want to keep a list of that. That's important because they're always going to ask you to pull that out. Anyone else? Okay, housekeeping. All right, we're going to switch over here. Hello everyone. Once again, I'm Dr. Coriander Williams. I'm filling in on the behalf of our chair, Dr. DeJuan Carpenter. And just wanted to remind everybody that they can claim CME for this event. On this slide, you can see the instructions. You guys can read, and this will be available as a recording later on through the AAPMNR website as well. Please, please, please claim your CME. It's important and it'll help for credentialing later on for your medical license. All right, and it's also very important that you guys complete a session evaluation as well, because that gives us feedback on how to improve for the years to come. Thankfully, Dr. Carter actually did something actually a little bit pivotal this year in having a designated speaker for this event rather than networking. And I feel like it was really a great benefit to the group to be introduced to this very important and very like upcoming field within PMNR. Because we spent a good amount of time kind of delving into some of the topics, we won't necessarily have time to network during this specific session that we originally planned for breakout, but we really do encourage people to be active and be available through the FIS Forum, which you can locate either an app on iPhones or on Android, or you can locate the FIS Forum through the AAPMNR website. It is for members. For those who may not have AAPMNR membership, we still encourage everyone to be active within the African-American community. I feel like the networking is important and you can find the Black Physiatrist Group through Facebook as well. And so there are many opportunities to link up and to serve. We encourage everyone to build together. All right, we do thank everyone for their time, especially our wonderful speaker, who was amazing in answering all the different questions and helping to educate us on this aspect of PMNR, which honestly we never really get to hear about otherwise, unless we know somebody who's actually active within this aspect of the field. If anybody has any questions, I welcome you guys to reach out to either DeJuan Carpenter or me, Coriander Williams. I'm also known as Cori Williams. You can find us, as I said, through FIS Forum, through AAPMNR on, through the Black Physiatry website. All right, well, thank you guys once again for your time. And again, thank you, thank everyone. I appreciate it. And if you wanna reach out to me, just send me an email. And again, I would also say, just you never know what's gonna happen. Try these things out, investigate. Only good things can happen. I mean, knowledge is never wasted. So if you can, check it out. And again, if I can help, let me know. Awesome, all right. Oh, and just last, if you wanna contact me through email, that would be cori.mdphd at acmedicalexperts.com, just in case anybody has any difficulty kind of linking back to the group or need further information on this subject. Thank you, everyone. Bye-bye.

medical legal work

medical file reviews

physiatrists

medical necessity

disability

treatment plans

insurance companies

attorneys

hospitals

credible opinions

Washington D.C. area

turnaround times

expert witness testimony

diversify practice