Disability Claims Solutions, Inc. Communicating With Your Doctor About Your Disability By Linda E. Nee, BA, HIA, DIA, DHP

Transcription

1 Disability Claims Solutions, Inc. Communicating With Your Doctor About Your Disability By Linda E. Nee, BA, HIA, DIA, DHP

2 Introduction Welcome to Disability Claims Solutions! The most important task related to filing a disability claim is obtaining signed periodic (often monthly) Attending Physician s Statements (APS) from all of your doctors. Attending physicians are critical to the disability process. It is estimated up to 30% of a physician s medical practice involves treating patients with one or more claims for disability benefits. The busier the physician, the more crucial it is to discuss your claim with him/her at each visit. Disability Claims Solutions, Inc. understands the dilemma physicians face when asked to complete multiple medical forms for their patients. We want to help by providing you and your physician with the information contained in this booklet. Please review carefully and share the information with all of your doctors, therapists and counselors. This booklet is relevant for both private disability claimants and Social Security Disability Income (SSDI) Applicants. Private disability insurers generally include companies such as: Aetna DMS, DMA Metropolitan Life The Berkshire/Guardian Prudential Financial Principal Liberty Mutual Unum Group CIGNA Northwestern Mutual Mass General The Standard Reliance/Standard Sun Life Financial It is very important for both you and your physician to understand the importance of providing medical forms and patient records to the insurance company in the event of a disability. If your physician has any questions, please ask him/her to contact DCS, Inc. at: Disability Claims Solutions, Inc. 60 Hicks Rd West Newfield, ME Tel: (207) Fax (207) lindanee@metrocast.net 2

3 The Attending Physician Most attending physicians are genuinely concerned when it becomes medically necessary to suggest to a patient they should stop working. Absent an accident or sudden medical event (such as a heart attack), disability is the inability to perform the material or substantial duties of a job or occupation for periods of time defined in a disability policy contract, or by federal law as is the case with SSI and SSDI. The typical disability claimant: 1. Suffers from one or more medical conditions for which job accommodations have already been made by the employer for a period of time; or, 2. Has tried their best to stay at work with a worsening condition which makes it more and more difficult to sustain productive work on a full or part-time basis; 3. Is being treated for a disease which produces unpredictable symptoms such as migraine headaches. 4. Has been diagnosed with a disease while working in a stressful environment and is now at the point of having secondary depression, panic or anxiety attacks. 5. Suffered a sudden and unforeseen medical event such as a heart attack, stroke, or accident. 6. Is not expected to have the physical or mental capacity to return to work in the foreseeable future (12 months for SSDI). In most instances, attending physicians have had a history of clinical treatment with the patient and can review the totality of a patient s medical history to determine if disability is the best medical treatment at the time. Placing a patient on medical disability should be part of the attending physician s overall treatment plan for the patient. What this means is that going out on disability should not, in most instances, come as a surprise to the attending physician. Complete cessation of gainful work is most often recommended by the attending physician after a considerable period of the patient s best efforts to manage symptoms and stay on the job. This means it is NEVER a good idea for an employee to make an independent decision to stop working. Disability status is determined by a physician. Unfortunately, most people who are having difficulty staying on the job, just stop going to work, and find themselves in their doctor s offices with paperwork saying I need to go out on disability. Physicians who are caught off-guard like this may not be as supportive as you d like them to be, particularly attending physicians whom you ve consulted with less than

4 months. It is the physician who determines the date of disability by documenting in his/her office notes the recommendation to cease work. If the claimant just stops working and consults their attending physician after-the-fact, any disability claim filed could be denied, or the elimination period will be extended because of a later date of disability. It is not advisable to take that chance. One of the biggest problems disability insurers have is in the determination of a date of disability. In the absence of a physician recommended date of cessation of work, the insurance company will use the day after your last day worked as your official date of disability. The point is, there is a process involved in applying for private disability benefits or Social Security Disability Income benefits, and it is not just walking off the job without discussing it with your attending physician first. Nearly all physicians focus on medical diagnosis and treatment of patients which is very different from making determinations as to whether patients can remain productive in their jobs. Unless an attending physician has extensive experience in evaluating worker s compensation, for example, physicians generally do not have a great deal of time to spend filling out disability forms on a regular basis. In fact, many doctors tell us at DCS, I m in the business of the treatment of patients, not in filling out disability forms. It is important for disability claimant to understand this is an accurate statement. Although physicians are required by the insurance industry to certify disability, it is not regarded as a major part of what they do. Disability forms are often given to medical business managers and nurses to complete so that the doctor can have more time with his/her patients. This is how it should be. Therefore, it is important for all disability claimants to understand attending physicians are often placed in the awkward position of having to spend considerable time filling out disability forms which in turn limits the time spent with other patients. Several groups of medical care providers are well-known for their refusal to certify disability or sign forms: These are: Physical Therapists Pain Management Clinics or Sports Medicine Acupuncturists Orthopedic Surgeons after surgical post-op period * Athletic gyms for aquatic or water therapies Alternative Medicine (ND) unless they also are an MD The above groups of medical providers should never be solely relied upon to provide medical certification of disability. These services require management by physicians with specialties directly related to the claimed cause of disability, or those physicians on which you rely for prescriptions for medications. 4

5 Here are a few suggestions to those considering a claim for disability as well as claimants who have been receiving benefits for some time: Talk often with your attending physician about difficulties you are having sustaining work, or performing certain duties of your job. Avoid catching your doctor by surprise with a sudden walk-out from your job. Once your physician recommends disability ask him/her how he wants you to handle bringing additional forms to the office. Ask for input and assistance in helping you document your disability on an on-going basis. Ask your doctor if he charges a fee to complete disability forms and offer to pay for the time. Monthly patient records and APS forms are the patient s responsibility to obtain and provide to the insurance company. It s only fair that your doctor be compensated for extra time spent on the forms. Bring your disability forms to your doctor at the time of your appointments, do not just fax to the office and expect them to be completed. Try to develop a cooperative relationship with your physician by respecting his time and that of his/her staff. Develop a friendly relationship with your doctor s business manager, nurse or receptionist so that you have a cooperative point-of-contact if there is a problem. Provide all of your doctors with a complete job description and point out specifically what you are unable to do. Physicians are not mind readers. Unless you tell them about your difficulties doing certain tasks at work, they may not ask. Do this even if you ve been on claim for a while. Go prepared with written notes on each appointment. Inform your physician he/she is not restricted to the size of the boxes on the disability forms and that other information can be provided on an additional sheet if necessary. Claimants should request a copy of the most recent office treatment note to send along with the Attending Physician s Statement. This is how you stop frequent requests for patient records. Sometimes you may have to wait a week before the note is transcribed or becomes available, but, sending in the most current office treatment note with the APS form is a very good idea. Obtain all medical records yourself. DCS does NOT recommend trusting the disability insurer to obtain medical records used as proof of claim. While we do understand the insurance company pays for the records if they request them, we are of the opinion the insurance company may not follow up with future requests thereby placing the claimant in a risky position of not knowing which records were received and which were not. In addition, physician offices do not function at their 5

6 best when multiple requests for patient files are received as frequent requests for records creates busywork no one in the office has time to do. Nearly all doctors offices ask patients to sign a HIPAA release and authorization form. DCS recommends that insureds specifically state on the office authorization form they are to be contacted when the doctor receives requests for medical records from the insurance company. The suggested wording for a physician in-house HIPAA authorization is: I give (your doctor) permission to release my patient records to outside third-parties only when I have been contacted, and informed of the request, and have provided written consent to the release of medical records. Further, I do not authorize physician verbal exchanges, by phone, or in person, with any insurance representative or doctor concerning my medical condition or treatment without prior consent and knowledge. This is not a refusal to provide medical information when requested to do so by an insurance company, only that I be informed of the request, and have an opportunity to give my consent prior to the release of my protected health information. This should be handwritten on all of your doctor s office HIPAA authorizations. When you turn in the forms, you should point it out to the office nurse or receptionist. You probably won t be able to remember the exact wording so it might be a good idea to either write it down or take this booklet with you. DCS takes the position that all individuals should have control over the release of their medical records. As a client of DCS, Inc., when sending in medical information on your own, documents should be sent to the insurance company with a confirmation of receipt. This also applies to faxed documents for which you should obtain a printed confirmation receipt from the fax machine. is never a good option for communicating with any disability insurer since e- mails may not be printed and/or placed in the official record. Medical and other private information generally shared with an insurance company cannot be safely protected. Therefore, we do not recommend communicating with your insurance company by or other electronic means. Insureds should not do the following: Tell your doctor you want to go out on disability because you want to retire. Cancel appointments without proper notice. Insist on consultations over the phone. Give open-ended office authorizations. (See above) Fail to comply with the doctor s treatment plan and prescribed medications. Insist on appointments right away or at the last minute. Call the physician s office frequently. Engage in doctor shopping to find physicians who agree with a self-diagnosis. 6

7 Without signed APS forms and patient records there will be no payment of benefits on a regular basis. No medical proof of disability no claim. All disability policies require the submission of updated medical information as continuing proof of claim. It may be once a month, once a quarter, every 6 months, or every year. Therefore, it only makes sense that the insured seek out the assistance and cooperation of the doctors with whom they consult on a regular basis, and especially those who are willing to complete medical form. Appropriate and Regular Care Disability claimants are expected to seek medical treatment from physicians who have a specialty in the specific area for which they have a claimed disability. Insurance companies spend a great deal of money hiring physicians with medical credentials which they hope will lend credibility to their file reviews. Insureds should always seek out and pay for the physician with the highest and most prestigious credentials in the area of specialty they can afford. Appropriate care is defined as medical care and treatment provided by a physician with a specialty directly related to the insured s claimed cause of disability, and which represents generally accepted and recommended care prescribed by a medical authority. This definition of appropriate care contains two parts: 1) the doctor treating you must be appropriate to the disease, and 2) treatment given must be generally accepted as standard medical practice by the medical community. (MDA, CDC etc.) Regular care refers to the frequency of treatment that is reasonable and appropriate to the impairment. Only a treating physician can determine what regular care is, but in doing so, the physician must be very careful to document what he/she believes to be regular care in the patient records. An example of regular care might be: Patient is currently at maximum medical improvement and requires only quarterly office visits with yearly MRI. Patient is asked to make appointments every three months for her regular clinical consultation. Patient has reached a point where monthly consultations are not necessary. I ll see her back every two months for follow up. Patient is to continue bi-monthly office visits and continue to take medication as prescribed. Patient is recommended back to her family physician for quarterly office visits and followup with me yearly. Patient has been compliant with her monthly medical appointments, however, she has now reached the point where appropriate follow-up care is only needed every 6 months. 7

8 Sometimes claimants are not well informed of what actually constitutes appropriate medical care sufficient to support a disability claim. Obviously, physicians specialized in family practice may not be the appropriate physician to treat depression and anxiety on a regular basis. It is very important to make sure you are treating with a physician appropriate to the claimed disability. Let s take a look.. Generally accepted appropriate care for a few problematic impairments include: Fibromyalgia Monthly treatment with a Rheumatologist combined with bi-monthly therapy sessions with a psychologist, psychiatrist, or MSW. This impairment is often described as a two-level symptom-to-recovery impairment. This means that the appropriate care for fibromyalgia consists of medical treatment, as well as regular and on-going counseling, with a qualified therapist. Sometimes patients may be asked to attend support group meetings, or join a pain management program, and continue exercising as able. The insurance company will look to see if the above treatment is indicated in the record for fibromyalgia. Lyme disease Documented recent Western Blot test, CD-57 with positive results for Lyme or related bacterial infection. Treatment suggested with on-going trial of antibiotics with followup lab reports. Physician should be an Internist with a specialty in Infectious Disease. Currently, long-term Lyme Disease Syndrome involving joints is not generally supported as Lyme disease by most insurance companies. Cervical Herniated Disk or Back/Spine Problems Physician should be Orthopedist or Orthopedic Surgeon for evaluation with baseline MRI and yearly follow-ups to gauge any change in condition. Recommended treatment may include a Neurologist if it is determined there is nerve damage or involvement. Post-surgical follow-up should include physical therapy, exercise as able, and pain management. Myocardial Infarction (MI) Heart Attack Diagnosis and treatment by Cardiologist with pre and post cardiac stress tests and evaluation of EF (ejection fraction) and performed METs. Stress tests generally document whether ischemia exists. Appropriate care and treatment include medication management, and exercise with participation in a cardiac rehabilitation program lasting 6-12 weeks. Multiple Sclerosis Diagnosis supported by identification of white matter lesions of the brain with MRI and spinal tap followed by continuous recordkeeping of severity and frequency of exacerbations. Treatment should be given by an Internist with specialty in Infectious Disease or Immunologist. Quarterly follow-up with a Neurologist with yearly MRIs is considered appropriate care and treatment. 8

9 DM I or II (Diabetes) Supported evidence of elevated and uncontrolled blood glucose levels by a qualified Endocrinologist and Dietician with quarterly A1C, urine protein tests to determine level of blood sugar control. Treatment should be with an Endocrinologist quarterly with monthly follow-up of family physician. Yearly visit to a Cardiologist is often recommended. Journal records should be maintained documenting daily blood glucose readings. Depression, or Anxiety Attacks bi-monthly therapy sessions with a qualified Psychologist, Psychologist, or MSW consisting of various forms of clinical treatment. Support group intervention may also be recommended with behavioral therapy. Family physicians are not accepted as appropriate care providers for depression, anxiety or panic attacks. In general any diagnosis contained on the DSM- IV (Diagnostic Manual) should be treated by a qualified mental health provider. Alcohol or Substance Abuse Combined in-patient and intensive out-patient treatment in a qualified medical substance abuse facility by Psychologist with specialty in addiction. (Addictionologist) Weekly attendance for meetings and counseling, support groups and therapy is a commonly accepted treatment for substance abuse. In general, family physicians are not considered to be appropriate care for alcohol or substance abuse. This should give you some idea of what is meant by appropriate care. Disability insurers will review your medical records for proof you have been receiving appropriate care. Oftentimes, the insurance company s medical staff may attempt to steer, or direct you, to what it considers to be appropriate care. Bottom line, only treating physicians can determine what appropriate care should be for their patients. Since the insurance company s medical resources do not provide medical consultative treatment, and have no actual medical history with the insured, the insurance company could actually endanger the health and well-being of the insured by dictating what treatment is acceptable to the approval of any disability claim. Having said that, it is also important for the claimant to realize it is their responsibility to seek out appropriate care when receiving disability benefits. Physicians should be asked to document in the patient record what he/she believes is appropriate care for disability or social security claimants. Comments about appropriate care are often contained within the physician s documentation of his/her recommended treatment plan. A treatment plan is a description of your doctor s current, and anticipated future treatment with a prognosis, and overall plan to improve the general health or well-being of the patient, or cure disease. This type of documentation is very important to the disability claimant since it gives the insurance company an idea of how long you may be on claim, and the methodology your doctor plans to use to improve the patients health and well being. Please note that disability insurers generally do NOT accept certification from alternative medical providers such as Homeopaths or Naturopaths unless the person is also a Medical Doctor. 9

10 The Attending Physician s Statement All private disability insurers require insureds to complete a form called the Attending Physician s Statement or APS on a monthly basis, or at some specifically defined interval. Benefit payment decisions are often based on the information physicians provide on the form, and in most cases it is the insured s responsibility to provide the APS form to their physicians and pay a reasonable fee if asked to do so. NOTE: If your physician is contacted directly by the insurance company, the disability insurer is responsible to pay your doctor a reasonable fee for completing forms, or making and sending copies of patient records. Reasonable physician fees for completing forms ranges from $200-$500. Please make sure your physician understands that he can charge the insurance company a reasonable fee when contacted by the insurance company directly. The most important part of the Attending Physician s Statement is the questions related to medical restrictions and limitations (R&Ls). For the purposes of private disability and SSDI medical restrictions and limitations require the physician to state specifically what physical or mental activities the insured may never do (restrictions), and those activities the insured may do, but only to a limited extent (limitations). In other words, the insurance company is requiring your physician to inform the insurance company why their patient can no longer do certain physical or mental activities related to their job, any other job, or occupation as it is performed in the national economy. Although your physicians may be not be aware of the significance of insurance terms, the words restrictions and limitations have very specific meanings to an insurance company. Some physicians avoid writing R&Ls because they really don t know what the questions are asking, and are too busy to review a great deal of patient records in order to fill out disability forms. For example, a physician may write Patient is totally and permanently disabled. Although perfectly acceptable for SSDI applicants, those with private disability insurance will find this wording unacceptable on an APS form. Statements such as the above do not specifically document medical restrictions and limitations needed by the insurance company to evaluate your claim. Instead, the physician should have written: Patient is restricted from engaging in any physical activity during exacerbations of severe fatigue or muscle weakness. Another restriction might say: No lifting, kneeling, bending or stooping during surgical post-op period of 6-12 weeks. 10

11 The more specific your doctor can be about what you can and cannot do, the more useful the APS form will be to the disability insurer. And, the more unlikely the insurance company will be to make repeated requests for records to your physician s office. Limitations, on the other hand, might be written: Patient is limited to not > than 1o-15 minutes of repetitive keyboarding or fine manipulation involving hands, arms, or upper torso. Patient is unable to sit >10-15 minutes without frequent rest periods; no walking > minutes; patient has limited endurance and is not able to sustain full or part-time work. Restrictions and limitations are always related to your job/occupational duties; therefore, one of the first things you need to do when going out on disability is provide your doctor with a copy of your job description. Your doctor will need to make a determination as to what job tasks you can reasonably do (if any), and those you cannot do at all. This is difficult to do without a review of your job description. Without accurate and thorough medical restrictions and limitations written on the Attending Physician s Statement, insurance companies will either: 1) continue to call your physician until they obtain the information they are looking for; 2) send your doctor a long narrative of questions to answer: 3) ask your doctor to participate in a doc-to-doc call on the phone; and/or 4) deny your benefits stating the physician did not provide restrictions and limitations clearly outlining why you can t work at your job, or any other job. Without specific, identifiable medical restrictions and limitations certified or signed-off by an attending physician, private disability insurers will NOT likely pay benefits to you. Properly written R&Ls can make the difference between payment of monthly disability benefits or a claim that is denied. NOTE: Comments written on the physician statement should NOT include: Patient cannot work. Same as last report. Restrictions and Limitations block on APS form left blank. Patient is retired and is unable to work. (This is very bad.) Out of work. Out until further notice. Not able to assess patient s ability to work. We don t do forms. Patient reports this diagnosis.. Patient has a longstanding history of Lyme disease therefore we will treat him/her for Lyme. Can t work. 11

12 Patient Records Most insurance companies will request, and actually prefer to obtain, copies of actual office treatment notes and patient records for the following reasons: 1. Consultation notes record dates of treatment as well as descriptions of the attending physician s treatment and treatment plan. Actual office notes show proof of appropriate and regular care preferred by many disability policies. These records show when you actually attended an appointment for treatment and who treated you. The Attending Physician s Statement does not prove you were in consultation with your attending physician. 2. Office treatment notes can be used to engage in a practice referred to as snatching. Snatching is an egregious claims practice whereby the insurance reviewer snatches key phrases from the patient records favorable to a claim denial, while at the same time ignoring all else favorable to the insured and continued disability. Claims are often denied because the insurance company snatched phrases such as: Patient looks good today ; Patient reports improved symptoms ; or, Patient may be thinking about returning to work. Although later on in the record the physician states: Patient is recommended to continue on current medication, rest, and report back in three weeks, the insurance company will ignore that statement and point to Patient looks good as a reason to say the insured can work. 3. Physician notes may contain statements different from what the physician has been documenting on the Attending Physician Statement. These inconsistencies of report can be used in a doc-to-doc call to intimidate the attending physician into agreeing with the insurance company that the patient can work, and should be released to return to work. Once a physician makes a mis-statement in patient records, it is nearly impossible to recant at a later date. 4. Patient records can be subject to interpretation by paid medical reviewers employed by the insurance company. The objective of internal insurance physicians is to evaluate the restrictions and limitations provided by your physician and render an opinion as to whether the actual patient records, lab reports, MRIs, etc. support those restrictions and limitations. Although physicians do not make decisions whether to pay or deny claims, their overall review and documentation is key to the liability decision. Insurance physicians are often paid monetary incentives to rubber stamp business decisions with their medical documentation. 5. Patient records may not be legible. When this occurs, the insurance company has two options: 1) return the records to the physician s office with a request the notes be transcribed; or 2) deny benefits claiming the notes provided were not legible. 12

13 NOTE: Physicians charge from $100 to $300 to transcribe their own patient notes. Usually, the task is completed by the office or business manager so the fee is to help cover administrative costs. Frankly, some disability insurers are too cheap to pay the fee to have the notes transcribed, and as a result this is a fee the insured may consider paying if the office notes are essential to the disability claim. It is not the purpose of this booklet to discuss patient s rights under HIPAA; however, there are many resources on the Internet that will give you the basics about your HIPAA rights and the electronic transmission or sending your patient records. It is important for you to know that your patient records are just that YOUR RECORDS and should be provided to you upon request. There are many amendments to HIPAA concerning psychotherapy notes and mental health records. If you have any questions concerning your rights to protect actual psychotherapy notes as Protected Health Information please contact us and we will be happy to discuss your personal situation with you. Doc-To-Doc Calls One of the many ways in which insurance companies manage medical information for claimants on disability is to request what is called a doc-to-doc call. It is quite common for an attending physician to feel obligated to speak to an insurance physician when, in fact, he/she has no real obligation to do so. Physicians do have the right to refuse to speak to any insurance physician verbally, or on the phone. It is important to communicate this to your doctor and offer him/her the option of asking the insurance company to submit their questions in writing. Doc-to-Doc calls are pre-planned by the insurance medical department with specific goals to accomplish the following: 1) Intimidate the physician with higher credentials or reputation- place the attending physician in a situation of submission. 2) Convince the attending physician to support the insurance company s point-of-view that the insured can work in some capacity. 3) Document a return to work release in the shortest amount of time. 4) Create a document signed by the attending physician which supports the insurance company s medical review in order to support a claim denial in the quickest amount of time. 5) Obtain a written return-to-work release from the attending physician. 6) Obtain a prescription or verbal release to perform a Functional Capacities Evaluation. Usually, the insurance company will send the physician a letter with a request to schedule a doc-to-doc call. Then, after the call, the insurance company will always follow-up with a confirming letter stating, if you agree with the basis of our conversation, please initial or sign the letter on the bottom and fax back to us. 13

14 The Problem: Insurance confirmation letters do not state the basis of the verbal conversation honestly, and actually attempts to take advantage of the physician s busy day to obtain a signature on the document that does not accurately reflect what was actually said. It is very important for the physician to know he/she is under no obligation to speak to an insurance physician on the phone on behalf of any patient. If the physician agrees to participate in the doc-to-doc call, it should only be done with the full knowledge and consent of the patient and a record of the call should be made and placed in the patient file. Then, the physician should document his/her own confirmation letter rather than signing the one submitted by the insurance company. A typical response to the insurance company from your physician might say: Dear (Insurance Company): I received your request for a telephone interview to discuss your insured, and my patient (name the patient). Although I am very happy to provide you with information regarding the restrictions and limitations of my patient, I prefer to do so in writing. Please submit any questions you have to my office and I will respond to you in a timely fashion. The above answer is appropriate for any request made by an insurance company for a doc-to-doc call. If the questions are answered by the doctor in writing, there will be NO question as to what he/she actually said about the patient s condition. In fact, the doctor eliminates the opportunity of being misquoted. Anytime a doctor speaks to an insurance company physician there will be a risk of being misquoted. Unfortunately, the attending physician can attempt to recant what was said later, but it is nearly impossible to do so. The gotcha initiated by the insurance company takes advantage of the attending physician and the insured in order to manipulate a work release signed off on by an attending physician. It s important for the attending physician to realize the insurance company has an intended objective of obtaining information needed for a work release. The insurance physician would NOT be calling the attending physician if the insurance company agreed with the reported restrictions and limitations precluding work. Coming out the gate, then, it should be clear the insurance company is contacting the doctor because it disagrees with his/her medical opinions. Physician Note: It is expected doctors will submit invoices for their time in filling our written narratives, or participating in doc-to-doc calls. Fees range anywhere from $200-$500. Please make sure you invoice the insurance company for your time, anytime you are approached by an insurance company for additional information. 14

15 In conclusion, it is important to share this document with your attending physician. Good communication between doctor and patient and respect for the physician s busy schedule goes a long way to having a cooperative relationship with a physician. It is crucial to go prepared with notes about your condition to each appointment and request the treatment notes before you leave the office. It is also important to remind the doctor s office that they are not to be intimidated by the insurance company s requests and that the doctor can charge a fee to the insurance company for any requests for forms, narratives, phone calls etc. which take considerable time to complete. Physicians often do not realize the power they have in communicating their opinions to an insurance company and frequently take the path of least resistance fearing they might be hurting the patient. In reality, physicians can be very assertive in stating their medical opinions. Many times when physicians take the proactive approach, the insurance company stops vexatious requests for information which interrupt a busy office. Please Note: Attending physicians can communicate with the insurance company by: 1. Completing the Attending Physician s Report on a monthly basis clearly documenting medical restrictions and limitations precluding productive, consistent work. Additional pages can be added to the APS when required. 2. Providing a written narrative describing the patient s medical history, treatment plan, prognosis and ability to work. Although narratives are credible presentations of the physician s opinion regarding the patient s condition, the same information placed in office treatment notes is more credible to an insurance company. 3. Completing a written series of questions received from the insurance company referred to as a narrative in lieu of actually speaking with an insurance-paid doctor on the phone. Functional Capacity Evaluations and IMEs Most insurance companies include policy provisions which allow the insurance company to have patients examined by physicians who are paid by them to render reports claiming the insured has work capacity. Based upon these IME reports, disability insurers will deny future benefits. As part of the IME process, disability insurers will also send the primary care physician a copy of the IME report and ask for an opinion. If the insured s physician fails to respond and does not submit an opinion in opposition to the IME report, benefits may be denied. Please note, detailed information concerning the IME can be found in DCS newsletters or other written brochures. 15

16 It is extremely important all primary care physicians understand the importance of taking the time to respond to insurance IME reports in a timely fashion, and in a very detailed manner. For example, if the physician responds with a two line comment, I do not agreed with the report and my patient remains totally disabled, the insurance company will not view the opinion as credible and will reject it entirely. The average IME report written by an insurance physician is approximately 10 pages long. There are typically six sections to the report such as: 1) Introduction; 2) Documents Reviewed; 3) Patient History; 4) Physical Examination; 5) Medication; and 6) Impression. Psychological IMEs may include another section for the Axis I-V diagnosis and Global Assessment of Functioning. When responding to an insurance IME report the goal of the primary care physician is to prevent the insurance company from having a consensus of medical opinion as to the ability of the patient to work, and from making a diagnosis without having a history of medical treatment with the patient. If the primary care physician does not, speak up and respond appropriately, that is exactly what will happen the insurance physician will document an adverse opinion in the IME report after having only seen the patient once, and only for approximately 45 minutes. IME: Therefore, it is important to do the following when the insurance company demands an 1. Speak to your physician and let him/her know the insurance company may send the IME report to their office with a request for a written opinion. 2. Ask your doctor to notify you of the receipt of the IME report and to provide you with a copy. (Psychological IMEs are rarely provided directly to the patient. In this case, the IME would be provided to DCS, Inc. directly.) 3. Ask your doctor how much he/she will charge you to write a comprehensive report opinion disputing the IME conclusion. Be prepared to pay your doctor the fee for responding to the IME and ask to see the response before it is sent in to the insurance company. 4. Offer to pay your physician for any extra time spent preparing a report to refute the conclusions of the IME. If the primary care physician refuses, or fails to send in a comprehensive opinion refuting the impressions made by the insurance physician, benefits can be denied because the insurance company only has one opinion its own. Therefore, it is important to discuss the possibility of an IME with your physician in advance, and be prepared to pay for extra services rendered. 16

17 Physician Note: Insurance companies often look for what we call medical consensus of opinion. The only way an insurance company can achieve this is when primary care physicians leave their opinions out of the disability certification process. It is highly recommended physicians take a firm stand on diagnosis and treatment plan when questioned by an insurance company. On those occasions when a physician remains silent, the disability insurance company assumes the doctor agrees with it. The Issue of Surveillance Insurance surveillance is an out-of-contract risk management activity wherein an insurance company attempts to observe and record the insured engaging in activities which the primary care physicians have certified the insured cannot do. This is called inconsistency of report and is only useful to the insurance company to bolster an otherwise weak position for claim denial. In other words, no disability policy allows for the denial of a claim as a result of surveillance. But, the insurance company CAN attempt to persuade the primary care physician with surveillance that the insured can work and therefore no longer meets the definition of disability in the policy. It is customary for the disability insurer to send a copy of the surveillance CD or DVD to the primary care physicians for comment. The disability insurer is looking for the doctor to agree with the insurance company s opinion that the insured can work based on catching the insured in an activity the doctor previously reported his/her patient cannot do. Underlying the actual request for an opinion of the surveillance is the knowledge that, like everyone else, physicians do not like to be made a fool of. The insurance company is hoping the doctor will feel betrayed by the self-report of symptoms told to him by his patient, and will retaliate by releasing the patient back to work. It is surprising just how many physicians actually fall into this charade, and the results can be tragic to the insured. Some of the effects of using surveillance against the insured can be prevented by asking the doctor to clearly define his/her treatment plan and medical restrictions and limitations as discussed earlier in this brochure. Therefore, the insured should be well aware of those activities the doctor has recommended he/she not do at all, and those that can be done only to a limited extent. Then, the insured should not do them. Reports of surveillance are excellent opportunities for physicians to support previously defined medical restrictions and limitations with an insurance company. For example, a psychiatrist was recently sent an insurance surveillance CD showing a person diagnosed with Depression walking for several hours in a Mall. 17

18 An appropriate response to the insurance company by the psychiatrist might be: I have reviewed the surveillance CD recently sent to me concerning and have found no indication my patient is engaging in any physical or mental activity for which I have assigned medical restrictions and limitations. Further, as part of my medical treatment plan it has been recommended to that she engage in any physical or mental activity to which she is able and to attempt to engage in outside social activities. However, remains mentally and physically unable to perform the duties of her regular occupation for an additional months due to depressive symptoms, feelings of sadness, and occasional fatigue. This type of response from a primary care physician accomplishes several things. First, it informs the insurer his/her patient was not observed engaging in restricted or limited activities; 2) walking and engaging in outside activities is a normal recommended activity for depression; and 3) re-states the physician s medical restrictions and limitations. The worst thing a physician can do with a surveillance CD from an insurance company is ignore it. Remember, anytime a physician is asked to render an opinion and fails to do so, it is presumed by the insurance company the physician agrees with it. Some physicians are so angered by the act of surveillance upon a patient, they just refuse to deal with it, which is the worst thing a physician can do and may jeopardize a patient s benefits. Physicians should always respond promptly to a surveillance CD in writing including the following points: A statement the insured was NOT observed on the CD performing mental or physical activities which the physician previously certified as restrictions and limitations. Or, the observed activities are NOT indications the insured cannot do their job, or any other job (if the insured is in the any occupation for group claims.) A description of the physician s current treatment plan which includes some or all of the activities observed by the surveillance. A description of the patient s current medical restrictions and limitations and why the patient is precluded from performing their own or any other occupation. A conclusionary statement informing the insurance company the insured is in compliance with all medical treatment recommendations and/or activity limitations. 18

19 Ultimately, an insured should not be performing any activity which has been restricted by their physician. Unfortunately, there isn t much DCS can do when a client with a back injury is observed nailing tiles on the roof of his house. Common sense dictates all medical restrictions and limitations given to a patient by a physician should be adhered to by the patient. Predetermined Impairment Denials In order to reduce risk and pay fewer claims, disability insurance companies target certain impairments for which the medical community has differing opinions; or, an agency such as the Center for Disease Control (CDC), has announced diagnostic criteria which determines the presence of disease, or the lack of it. Disability insurers have always targeted certain diseases which are selfreported. A self-reported medical disability is defined as the inability of a patient to work due to patient reports and clinical diagnosis rather than having actual objective data, such as x-rays, lab reports etc. which prove a person has what they say they have. Disability contracts actually limit the payment of benefits in most group policies to 24 months. In most recent years disability policies often define a self-reported disability as: SELF REPORTED SYMPTOMS mean the manifestations of your condition which you tell your physician, that are verifiable using tests, procedures or clinical examinations standardly accepted in the practice of medicine. Examples of self-reported symptoms include, but are not limited to headaches, pain, fatigue, and stiffness, soreness, ringing in ears, dizziness, numbness and loss of energy. Not surprisingly, many of the predetermined impairment denials are diseases which are typically classified as self-reported by disability insurers: Fibromyalgia Chronic Pain Chronic Pain Syndrome Migraine Headaches Fatigue Cognitive impairment (not organic brain disease) Blurred Vision Other targeted for denial impairments include: Lyme disease Multiple Sclerosis Lupus Reflex Sympathetic Dystrophy (RSD) and Complex Regional Pain Syndrome (CRPS) Panic Attacks 19

20 PTSD Chronic Back Pain or Failed Back Syndrome It is very important for the disabled patient and physician to include the following documentation when certifying disability for any of the above mentioned selfreported impairments: 1. Length of treatment history and clinical observation of the patient indicating total number of visits to date. 2. Specific restrictions and limitations precluding work capacity after having reviewed a copy of the insured s job description. 3. Whether or not the patient meets the conditions of diagnosis of the American College of Rheumatology or Center for Disease Control, or any other medical agency publicizing diagnostic data. (DSM-IV for mental health disorders.) 4. Fibromyalgia diagnoses MUST always include the number of positive tender points out of 18 identified by the American College of Rheumatology. 5. A diagnosis of Chronic Fatigue Syndrome MUST always include whether or not the insured meets the criteria supported by the CDC. 6. Multiple Sclerosis diagnoses MUST include results from MRI, spinal tap or neurology consults showing clear diagnostic data supporting MS. Documentation should always include statements relating to fatigue levels of the patient in conjunction with the ability to consistently sustain full or part-time work. 7. Diagnosis for Lyme disease MUST include a recent positive Western Blot and or CD- 57 test with proof of treatment of antibiotic trials for a period of 1-2 months. Physicians supporting Late Lyme Disease Syndrome should include statements relating to the time period of infection to the delay or misdiagnosis of Lyme. The above impairments often include on-going reports of pain in some fashion. Although there are no clear diagnostic criteria to measure pain, the pain scale of 1-10 with one being the lowest level of pain to 10 the highest, is the most reliable measure of describing pain to a doctor. Even so, pain in its purest sense is self re-reported. That is, pain can only be described and reported to someone else as it is being experienced by the person having it. In addition, pain varies from one patient to the next. Therefore, journaling is becoming more essential in verifying levels and locations of pain particularly in the treatment of fibromyalgia, chronic pain syndrome, and Lyme. It is always a good idea for patients to keep journals describing pain levels, locations on the body, and when relief is obtained and for how long. 20