Supporting Tools for GENESIS Workflow, developers admin tool. office use only.

1. Overview

• Purpose: This section integrates with the GENESIS workflow to dynamically challenge adjusters’ baseless claims using NCS Zaps and state-specific compliance rules.

• Capabilities: Provides pre-formulated language for rebuttals, compliance resources, and templates for handling adjuster challenges efficiently.

2. NCS Zap Repository

Organized by claim challenge type:

a. Liability Disputes

• Example: Liability causation challenges without evidence.

• Zap Response: “Liability has been established through causation language provided in the demand package. Disputing liability without evidence violates the Unfair Claims Practices Act (UFCPA). Please provide documentation supporting your assertion.”

b. Medical Specials Reductions

• Example: Unsupported reductions without an IME.

• Zap Response: “Reductions to AMA-guided assessments without an IME are unjustified. Genesis confirms no IME was conducted, shielding these assessments from reduction.”

c. Pain and Suffering

• Example: Arbitrary valuation.

• Zap Response: “Industry standards are subjective. Please provide a detailed valuation breakdown supported by jurisdiction-specific precedents.”

3. State-Specific Compliance

Organized by state with links to relevant resources:

State Folders

• Florida

• Georgia

• Kentucky

• Texas

• South Carolina

Each folder includes:

• Regulatory Summaries: Key UFCPA violations and GENESIS’s counter strategies.

• Claim Templates: Pre-formatted compliance statements tailored to state regulations.

• Litigation Risks: Examples of how undervaluation practices expose adjusters to risks under state laws.

4. Dynamic Zap Integration

Workflow Integration

• Automatic Insertion: GENESIS identifies opportunities to apply NCS Zaps based on adjuster responses.

• Customization Options: Adjust Zaps dynamically based on claim specifics.

5. Supporting Documentation

Resources Provided

• Unified Template Document: Pre-linked for zapping liability causation language, ICD-10-based calculations, and other claim-specific rebuttals.

• Reference Guides: Instructions for systematic handling of adjuster challenges.

6. Examples of Use

Scenario 1: Adjuster Disputes Pre-Existing Condition Re-Aggravation

• Zap Response: “The Eggshell Doctrine protects these claims. Please confirm the basis for denial.”

Scenario 2: Adjuster Ignores Whole Person Impairment (WPI)

• Zap Response: “Failure to conduct an IME invalidates disputes to WPI assessments, which remain authoritative under AMA guidelines.”

7. Design Considerations

• Streamlined Access: Use collapsible menus for NCS Zap categories and state-specific folders.

• Search Bar: Enable quick retrieval of zaps or compliance resources by keyword.

• Real-Time Updates: Sync with GENESIS to incorporate the latest Zaps and compliance templates.

Negotiation Counter Strike:

MIST PROTOCOL:

In response to any reference you may have raised in regard to minor injuries or soft tissue claims, we present the following:

1. Crash Severity Is Not Determinative of Injury Severity:
   The assumption that minimal vehicle damage equates to minor or non-existent injuries is not supported by credible evidence. Biomechanical studies, including [insert study citation, e.g., “Correlating Crash Severity with Injury Risk”], demonstrate that soft tissue injuries often result from the dynamics of the collision rather than visible vehicle damage.
2. Treating Physician’s Assessment Holds Greater Weight:
   The claimant’s injuries, diagnosed under ICD-10 code [insert code, e.g., S13.4XXA for whiplash], have been thoroughly evaluated and treated by a licensed medical professional. Absent an Independent Medical Examination (IME) or a contrary expert opinion, the treating physician’s findings must be given the greater weight of evidence.
3. Soft Tissue Injuries Are Legitimate and Documented:
   These injuries, though often less visible in imaging, can result in significant pain and require ongoing treatment. Dismissing their validity undermines both the claimant’s experience and medical standards of care.
4. Bad Faith Risk in Ignoring Evidence-Based Practices:
   Continuing to undervalue this claim based on assumptions such as the MIST Protocol may constitute bad faith handling. If necessary, we are prepared to pursue this matter through litigation, highlighting biomechanical evidence and regulatory guidelines that refute your approach.

We respectfully request that the claim evaluation reflects the documented severity of the claimant’s injuries and the professional assessment of their treating provider. Reliance on unsupported assumptions about crash severity is neither appropriate nor aligned with industry standards.

INFERRED USE OF CLAIM IQ:

GENESIS is designed to identify any pattern within the audit progress that may be attributed to use of inhouse automated tool Claim IQ. Whilst we cannot prove such an assertion now, we are confident that through litigation, the discovery phase, and the production of documents could expose the likelihood of such use, through ALOG notations, the tracking of adjuster ALP metrics, and value ranges set out in the negotiation strategy screen

 

CHALLENGING EXPERT MEDICAL ASSESSMENTS WITHOUT AN IME:

Assessments include Whole Person Impairment, future medicals and Re-aggravation of Pre-Existing conditions.

1. Reliance on Treating Physician’s Expertise:
   • Legal Principle: Without an IME, an adjuster lacks the required medical authority to discount or refute the findings and recommendations provided by the claimant’s treating physician. Courts have generally held that treating physicians, by virtue of their direct care, have the most reliable insights into the patient’s condition, necessary treatments, and related costs.
   • Case Law Support: Courts often rule that only an independent medical examination, conducted by a qualified expert, can contest a treating physician’s assessment. Without it, any attempt to discount treatment costs is speculative and unsupported by medical evidence. For example, Sullivan v. Saint-Gobain Corp. and Scott v. Safeco Ins. Co. emphasize the credibility and weight of treating physicians’ testimony in the absence of opposing expert medical testimony.
2. Medical Necessity and Legal Authority:
   • Standard of Medical Necessity: Adjusters and insurance companies generally must substantiate claims that treatments are unnecessary or inflated by expert medical testimony, such as that from an IME. Without such expert validation, reducing medical bills or questioning treatment necessity lacks foundation, as adjusters are not licensed medical professionals and thus lack the expertise to make such determinations.
   • UFCPA and Industry Guidelines: Under the Unfair Claims Practices Acts (UCPA), arbitrary reductions without medically substantiated grounds (like an IME) may be viewed as bad faith. Industry best practices dictate that insurers provide clear, factual evidence for any adjustments to medical expenses, which typically requires an independent medical opinion.
3. Inadmissibility of Non-Expert Opinions in Medical Disputes:
   • Legal Principle: In litigation, courts routinely exclude non-expert opinions regarding medical treatment, recognizing that only qualified medical experts can credibly dispute a physician’s diagnosis or treatment recommendations. Adjuster opinions on medical necessity, without an IME, would likely be inadmissible in court.
   • Pain and Suffering: Industry standards are highly subjective and must align with jurisdictional precedents and the specifics of this claim. Please provide a detailed breakdown of how the valuation was determined, or clarify if external tools (e.g., Claim IQ) were used.

RE-AGGRAVATION OF PRE-EXISTING CONDITIONS and the Egg Skull Doctrine: Industry standards are highly subjective and must align with jurisdictional precedents and the specifics of this claim. Please provide a detailed breakdown of how the valuation was determined, or clarify if external tools (e.g., Claim IQ) were used.