Monday, February 07, 2005

The right way to report a patient's disability?

Dude, are you ever wrong! Well, OK, some of your advice is reasonable. I should know, I review medical records submitted in support of disability claims for a living.

Don't provide copies of your patient notes. Rather, provide a summary letter report. Office notes are often your "shorthand," may not be understandable to anyone else, and copies are often illegible. Notes also reflect only a snapshot of the patient's condition at the time of your examination. Without a full explanation, the insurance company might not fully understand the extent of your patient's disability.

It's OK to send a summary letter report. But the advice to avoid sending the actual office visit notes (OVN's) is horrible. The summary letter is basically meaningless without support from the contemperaneous OVN's. I appreciate the additional explanation, but don't try to tell me that the claimant was in great pain and couldn't walk in a letter if your OVN's don't describe this.

Rather than saying, "The patient can only sit for four hours at a time," describe the impairment in broad terms. Use "The patient cannot sit consistently or reliably."

What does "consistently or reliably" mean in terms of ability to perform occupational activities? I don't know and I can assure you the vocational analyst doesn't. As the Attending Physician (AP), you need to specify. I suggest, "Ms. Smith can sit for only 30 minutes at a time with a 5 minute break in between sitting." Or examples, such as, "Walking can be performed incidentally, such as walking to a photocopier infrequently. However, walking as a primary duty, such as delivering interoffice mail, is prohibited." Be as specific as possible. These restrictions will be compared to a job description to determine disability.

A patient who's unable to work could become destitute without the disability benefits to which he or she is entitled.
If appropriate, give your unqualified opinion that the patient is totally disabled and cannot work. It may be helpful to discuss with the patient the duties of his job and bear in mind the definition of disability in the policy.

It is not the job of the AP to determine to what benefits the claimant (patient) is entitled. If you haven't read the contract, you may be unaware of issues such as residual benefits, own occ vs any occ and the dreaded job vs occ issue. Frequently, the definition of disability in the contract is based on "National Economy" or how the job is done across the nation. In the specific job held by your patient, as an administrative assistant, for example, she may be required to deliver interoffice mail. However, in the National Economy, an administrative assistant may not be required to do this activity. Is this the case? I don't know, do you? Disability is a decision that is based on the contract issued, not just the claimant's medical condition. Impairment is a medical issue, but not disability. Do not render an opinion regarding disability or fitness to work unless you are intimately familiar with the claimant's contract and the material and substantial duties of the occupation, not just your patient's job. Describe medical support for specific restrictions and limitations, but not an opinion about fitness to work. How do you know that the employer will not accomodate a specific restriction?

Some good points:

  • Without a full explanation, the insurance company might not fully understand the extent of your patient's disability.
  • Describe your credentials and attach your CV to establish your expertise in treating the patient's condition.
  • Carefully prepare any Attending Physician Statement or other form provided by the insurance company. Attach your CV. Take the time to prepare a thorough response.
  • Most importantly, provide thorough answers. You're not limited to the space provided; attach a separate sheet if necessary. (Great point, the more info the better.)
  • By providing clear and accurate information you are decreasing the likelihood that your patient will have to fight for his claim.

My Recommendations:

  • Don't be offended if a reviewing physician doesn't agree with you. If you take the advice of this attorney and obfuscate the issues, this disagreement is more likely.
  • Don't take it personally. Don't become invested in the outcome of the claim. I don't mean to say that you should not advocate for your patient, strongly if necessary, but remember that there may be issues in the decision with which you are unaware.
  • Provide clear data. Don't try to hide info. I am constantly surprised when medical records arrive with sections blacked out. The claimant has signed a consent releasing all information.
  • Restrict your opinions to medically indicated/supported restrictions and limitations. Realize that your patient may not describe the actual occupational duties completely and accurately. It is not uncommon that I talk with an AP who has stated simply, "She can't work," only for him to find out that the job described to him is not the one his patient does.
  • Don't tell your patient, "You can't go to work." List what activities your patient can and can't do and let the employer decide whether they are willing to accomodate. You might be surprised.

Feel free to e-mail me with any questions.