Lapse greater than two weeks between the accident date and the first
date of treatment.
in treatment, treatment more than 3 times per weeks.
Treatment longer that 3 months in duration.
Medical or therapy provider visits greater than
15 non-managed care settings.
Pre-existing medical problems TMJ, dental, chronic diseases or multiple medical issues.
Diagnostic procedures that appear excessive.
Unusual multiple medical providers or “doctor
attendance for medical or therapy appointments.
Accident history that is minor compared to complaints.
Care that seems to be unrelated to the accident
exaggeration or bizarre complaints.
Inpatient hospitalization greater than 5 days.
Catastrophic injuries such as brain/head injuries, spinal cord injuries,
or major burns.
psychological treatment for minor injuries.
Intensive use of addictive medications.
Injuries causing prolonged disability exceeding
Wage loss greater than 7 days.
Essential services greater than 2 weeks.
Billing for durable medical equipment which exceeds $250.
bill is greater than is “usual and customary” for the location, or shows indication of unbundling or creative
Charges seem redundant, duplicated or unrelated.
Chiropractic visits greater than 12.
Inpatient hospitalization exceeds 2 utilization
management concurrent reviews.
Post-discharge need for home care or physical therapy services.
Poor employment history or limited vocational options exist.