I don't know if I should whisper now so that, you know, people can recover or to speak louder. Exactly. Exactly. So thank you all for being here. We mighty few who stuck it out and yay. My biggest thanks is for early evening flights. So they're just stopping now. Hopefully they won't say that for the next 15 minutes. We'll see. So again, I'm grateful for late afternoon, early evening flights so that everybody can hang out for just one more hour. So thank you very much for being here. I'm going to talk a little bit today about disability benefits, something near and dear to my heart. I've been in the disability world for just about 14 years now, and I'm very excited to continue in it and to share some information. Part of the information I'm going to be sharing is about social security disability and some of the history for that, but I'll also try to work in some of the workers' comp issues and everything as well for that. So this was supposed to be a picture of me, but I guess my folks forgot it. No worries. I'm here. Dr. Tracy Hamill, I am a family medicine physician by training, was in clinical practice for 10 years, doing everything including OB for the first five and only outpatient for the last three. So in 2009 is when I transitioned over into insurance medicine and haven't looked back since. I'm currently medical director at Sun Life over the group claims area. That involves the long-term disability, short-term disability, life waiver as far as our products are concerned. So I'm going to talk a little bit today about some of the things that I've learned since I got into the insurance industry and some things that I really wished someone had taught me previously when I was in practice. So again, going to go over a little bit of the history of disability benefits. This is really mostly related to social security disability. I love history, so I apologize that there's quite a few slides about the kind of progression of disability benefits through the government and really what those show are kind of what we've ended up with as far as private insurance industry. Going to go over some differences in definitions. This will include again some of the workers' comp issues that were asked about earlier. And then finally, I'm going to wrap up with some of the things that really would make my job easier as far as getting information from you all and hopefully will make things easier for your patients as far as trying to kind of maneuver the world of disability benefits. So 1935 is when the Social Security Act was enacted. And again, this is the traditional social security that we think about retirement age. Really was designed as a social safety net to make sure that people who were older than 65 had something to live on and wouldn't necessarily have to rely on savings that they might not have had. And 1946 is when they incorporated disability benefits. It was thought about, seriously, is how it was phrased in the government website, is it was thought about initially in 1935, including for folks that had disabilities as well as retirees, those older than 65, but wasn't until 1946 that it was established. And again, the amendments that were there gave both a definition of disability, an initial definition, and again, provided the benefits to disabled workers. In 1949 is when they first moved towards the states. So instead of having it centrally located in the federal government, the states were designated as the representatives and funds were given to them to kind of distribute as they saw fit for these disability benefits. 1954, really there was just a couple of different changes. The first change that was made was that someone was physically or mentally impaired, so adding the mental impairment was something that happened in 1954. And the definition included considered to be of long duration or continued or indefinite duration as far as how long the impairment was anticipated to last. The disability freeze that's listed here was basically saying that if you received disability, you wouldn't be penalized for those benefits when you got to retirement age. So basically those years don't count towards your retirement amount, benefit amount. And that's something that continues and we'll talk about a little bit later. In 1956 is when monthly benefits were first established, and again, trust fund was set up to be able to pay for these, and it was all monies that, again, were sent to the states and they had developed individual goals and rules and regulations as far as which persons would qualify for the benefits. This is the same trust fund now that, yep, slowly dwindling. So the other things for my standpoint that were interesting about the 1956 amendments is that it also established a six-month waiting period. So someone needs to be out of work for six months because of their impairment in order to get benefits. And then after that, they're going to, again, be anticipated to be out long term or for a long duration. The recent and substantial attachment to the workforce is something that I, again, was not aware of as a treating provider. You have to have a certain number of quarters is what it's called in order to qualify for disability benefits and have been employed for enough quarters or enough time in order to be able to apply. This does result in some people not qualifying for Social Security disability benefits. If they don't, they still could qualify for benefits from an employer, which is the types of insurance that I deal with. And then finally, one of the interesting things that was incorporated in the 1956 amendments was that the states could enforce the need for rehabilitation, the need for vocational assistance. And if a person refused to participate in that, they could be denied benefits. This is something that some contractual language has been used for private insurance at this point, not as much as far as the federal government any longer, but interesting that it was there to start out with. So in 1955 is when the government finally decided, okay, we need to have some overall rules and regulations. We need to set some standards. And a medical advisory committee was formed in order to give that guidance about what would qualify as a disability and for, you know, what types of diagnoses or what types of findings, et cetera. And then those were distributed to the states in order to be able to be utilized. And again, one of the things that was looked at at this time was that you, or thought about at this time was thinking about things like education, experience, age, and whether or not those play a role as far as disability is concerned. From a social security standpoint, there was ultimately a decision that, you know, greater than age 55 is advanced age. So I'm not there quite yet. Two more years. So and they do make vocational decisions based on age, the Social Security Administration does. Generally, the disability insurance that's provided through an employer is not age related as far as trying to make a determination of impairment or not, but there are cutoffs as far as how long those benefits last. So between 1959 and 1960, when they originally moved or added the disability benefits, it was defined between age 50 and 65 only. And so in 1959 is when they expanded it and had for anybody who was impaired or disabled, so removed that 50 years of age requirement. They also established a trial of work period, which again for my purposes is something that's interesting and is persistent today, which not a lot of people are aware of. If you are receiving social security benefits, you can have a trial of work. And if you are not making as much money as one would anticipate, or if, you know, after six months you're no longer able to do that, again, it's not held against you and you're still able to go back to your original benefits. And this is something that, again, in the private industry we've been utilizing to kind of give incentives for trials of work. So we know that we do have people who have social security disability benefits. We have other, you know, contractual language that we're trying to adhere to. And so we want to make sure that they're aware and their doctors are aware that they can have trials of work. And if it doesn't work, their benefits are still intact. So the definition changed, again, from the indefinite duration to at least 12 months. So the definition of disability, instead of being a forever thing, was in 1965 looked at more as a long-term thing, but one potentially that could get better. 1967 and the amendments at that time were interesting to me as I was reading through these because, again, the first sentence there was concerned for the definition of disability eroding over time. That meant the courts got involved. And so really what happened during the early 60s is that there were a number of different court decisions that came from various states. And again, everything's still being managed by the states at this point. A number of different court decisions that did things like put the burden of proof onto Social Security Administration as far as defining jobs, whether someone could get a job. They even had a person who that in the case, and I think it was Leftwich versus Greenwich was the case where someone was working full-time in a gainful occupation, meaning they were earning as much money or more money than they would have made on disability. And the court still said they were disabled. So these were a number of rulings that happened. And as a result of that, there was an effort to, again, more clearly define what disabled meant. And that meant that even with your physical impairment or your mental impairment, you were unable to sustain functioning in a work environment and make a gainful wage. And again, gainful wage is another one of those variable and contractual issues. Usually it means around 60 to 80% of what you were making before you went out on disability. So around that. And what this said is that the Social Security Administration in particular didn't have to demonstrate that there were jobs available or that an individual could get a job, just that there was jobs that the person would qualify for in the national economy. So that was a big change and really something that was embraced by the private insurance industry to get more clarity as far as what is the barrier, what is the goal that we're looking for as far as return to work. So in 1972, Medicare and Medicaid protection was added to Social Security disability benefits. Usually it's a two-year timeframe before they qualify for those benefits, but they can get that health insurance after those two years if they're still on disability. One of the big things to think about for this is that really this is another emphasis on the fact that Social Security is a safety net and not just income replacement. And we'll talk about that just a little bit more. Also in the 1970s, lots of dollars were spent on Social Security. So there was really, it was underestimated how much, how many people would be on the roles and how many people would need benefits long term. And so really what happened in 1980 and the Social Security amendments of 1980 was there was a revision and all of the state rules came back to the central government. So the federal government took over all of the Social Security disability for the state's enacted regulations and made sure that everybody was following the same basic rules and guidelines. You had a question? Oh, sorry. And then finally in 1984, there was more, again, of an emphasis to put this standardization in place and to make sure that we were getting all of the states under the same guidelines. And really for my purposes, this is one of the big things that came out of the 1984 amendments was subjective symptoms. The Social Security administration had previously indicated we need to look at everything. We need to look at physical, we need to look at mental, we need to look at all of the things in combination. So however many potentially impairing conditions this person has, we need to look at that. What this says is we still need to take into account symptoms. We still need to think about the subjectivity of an experience of symptoms, including pain. But we are allowed to look to see if those reported symptoms are consistent with medical information that we have. So this was a big issue when I was coming into the disability industry, you know, trying to think about objective versus subjective. Prior to my time in the industry, objective findings were kind of the key. If you didn't have objective findings, you didn't have impairment. Fortunately, I came in kind of the golden age when people were re-looking at that, probably because of things like the, you know, multi-state settlement agreements that several companies had, which meant they needed to look at all of these things a little bit closer. We needed to take into account if people are having symptoms and still looking to see though if they're related to underlying medical conditions. So as I said, this is where I come in and talking a little bit more about the private insurance. And just like the Medicare, Medicaid versus private medical insurance, there's a juxtaposition between state or federal benefits, disability benefits, and private insurance. And again, private insurance benefits generally are provided by an employer, similar to how people generally get their health insurance if it's not through the government. So there are some differences, though, as far as how each of those are managed and kind of what things we're looking for. So overall disability insurance, we can break down into two main categories. Individual disability insurance is purchased usually by an individual, sometimes by a small company or organization, but usually by an individual, protects for specific things regarding your occupation. These are very highly modifiable, meaning that there's a lot of variability between these different contracts and is something that this is paid out-of-pocket, post-tax for people who have individual disability insurance. Group disability insurance, which is what I work with, is usually provided, again, by an employer. There are some smaller companies that provide group-type insurance, like Aflac is one that provides group-type insurance, even if you're not buying it directly through your employer. This really, for our purposes, is broken down into two different types, short-term disability and long-term disability. And yes, we still do say STD all the time. And so my daughter is now saying STI, so she's in college now. So I said, okay, good. We can at least speak at work and not freak the new people out. So short-term and long-term disability. The differences between the two of these generally involve both the elimination period, the length of benefits, the amount of dollars that someone receives, and the definition of disability or what we look for to see if somebody is impaired or not. Short-term disability is the quick hit. People are going to be out and they're going to be coming back to work fairly quickly. For short-term disability, generally, there's a very short elimination period. An elimination period means a time that you're out of work because of your impairment, but you don't get paid. So for some companies, it's the first day you're out of work. For others, it's seven days, up to seven days. Usually that's the time frame that you need to be out of work prior to triggering these benefits. Length of benefits, these last generally 180 days. For six months, it's usually what STD benefits are for. We have a number of contracts at Sun Life that are 90 days, so a shorter time frame. These are based on a person's ability to perform their job. So it's how their job is defined by their employer. That means if in their job they have to lift 72 pounds on a regular basis, that's what we're looking at or trying to get them back to when we're assessing their function while they're on disability. The good thing, again, as far as short-term disability is this is a quick turnaround. Most people go out for a specific reason and they go back to their own job. They go back to their own employer. They get the benefits and there's hopefully not too much hassle with all of that. The long-term disability is a different animal in that it's a longer elimination period. So people are out of work from anywhere from 90 to 180 days prior to qualifying for this benefit. Now, that means if they don't have short-term disability through their employer, which does mean sometimes people have to elect short-term disability and or long-term, and it's not an automatic. If they don't have it, they have no pay basically for that 90 to 180 days. So this is something that's obviously very challenging. Fortunately, most people do have both benefits. So it's one transitioning to the other. In general, these types of claims are defined based on the occupation in the national economy. So we have vocational consultants who evaluate the dictionary of occupational titles. There's other software resources that are utilized to say, okay, this person is a nurse. What does that mean? And what do they have to do in the national economy? So by the time someone gets to long-term disability, if they, for example, in their job had to lift 72 pounds on a regular basis, but per their job description in the national economy, they should only have to lift 20, that's the goal that we change to is what the definition is in the national economy. Disability also does definition in the national economy, workers' comp in general looks at their job, what they needed to do to start out with. So length of benefits for this can range anywhere from two years where they just get a flat two years through their contract. It can extend to retirement age for many people. The definition of disability, again, is their own occupation, how it's performed in the national economy, but that can also change over time after that two-year period. So short-term disability, think quick hits. Pregnancy is the biggest factor that we, or the biggest diagnosis that we get in short-term disability. People are out for their pregnancy, they're out for their recovery, and they go back in six to eight weeks. Most contracts that for pregnancy still have the six to eight week time frame as far as recovery for benefits, but there's several states, I think 12 states now, who have additional parental leave, other paid family medical leave that's there that can extend those times. So what we get from the employer is the job description, and really what we get from you all from treating providers is what's their diagnosis, what do you anticipate that they're unable to do, and when are they going to be going back. In reality, the when are they going back is the one that is used most frequently by the claims examiners for this short-term because it's a high turnover, a large volume. There's lots of cases that these claims examiners are touching on a regular basis that if you say this person needs to be out until X date and it's medically reasonable, it's within standard guidelines including the MD guidelines, they're paid through that date in general. It's really the exceptions, you know, the things that are outside medical guidelines that are longer recoveries than we would anticipate or somebody who had a return to work date initially that didn't return to work and there was an extension. Those are the things that we need some additional information about. So forms, the attending physician statement, that dreaded form, two or three pages with the checkboxes and the lines that I've been trying to change for the last 14 years in my various companies. I'm going to get there one day. Those are helpful, again, if you only fill out three things, diagnosis, what they can't do and when they're going to return to work. Those are the most important things, the most important information that we can get on that. And then again, if it goes outside guidelines, that's when we're going to contact you. That's when we're going to be requesting medical records or explanation looking at office visits to see, you know, was there a complication? Is there something else that's going on? So long-term disability, again, occupational demands are defined by our vocational consultants. We have master's level vocational consultants are the ones that do these evaluations pretty much across the board, across the industry. And so these are folks who have been trained both to assess occupations, to assess what a job's duties will be, but also trained to counsel people as far as getting back to work. So counseling and making sure that people understand that they can get back to work, that they're not necessarily going to lose their benefits. That if they go back to work and then can't, you know, have something happen later on where they can't continue working, they're going to, you know, within a short amount of time, they're still going to be able to utilize those disability benefits. Generally because there's that change in definition, we gather more medical information. So these are when we're getting those forms again. And sometimes, yes, they do look exactly the same as they did previously, and yes, we understand why you put, you know, the same exact things that you put down the first time. But again, really what we'd be looking for as far as long-term disability, and most of the time, you know, you'll know that it's long-term because of the fact, number one, how long somebody's been out of work, but also it's on the paperwork. So it's listed on there as well, short-term versus long-term. And really what we're looking for is more specific information about what your patient can or cannot do. And so this is the time when we think about what is the max capacity going to be? What can they do? Lots and lots of times I get, you know, files that I look at where people have a rotator cuff injury, rotator cuff repair, improved but still don't have a good range of motion, still don't have the strength that they did. And for their occupation, they need to be able to frequently reach overhead and occasionally exert up to 50 pounds. So they can't do that. So they will continue to qualify for benefits. But just because they can't do that occupation doesn't mean they can't work. And that's one of the other pieces that's difficult both for our company, for you, for your patients is the fact that really what, you know, we're trying to figure out is what can they do and to give some assistance in that. One of the big things that I always tell or had to tell my family members when I started this work was, yes, it's an insurance company but we're a good one. We are a good one. We're one of the good guys. We're not the ones that's denying care. We really want to get people back to work and we really want to help out. Absolutely. I will grant you it is a money-making industry just like all of them. But I've been very fortunate to work with people who really care and really do want to get people back to work. And so that's why, you know, one of the big reasons that I'm here is just to explain some of the information that can be helpful. So the detail for this is what's helpful. Again, the same person, you know, with the shoulder rotator cuff injury, say there was a different person who had a metacarpal fracture. For that person, no use of left hand would be a great restriction because they can't use their left hand while it's healing or not use it appropriately. No work is something that's not as helpful because of the fact that, yes, we understand that your patient is telling you that they can't do their job. We get that. We also get that, you know, they're having to prove to us that they can't, you know, that they are owed benefits. And that constant filling out of forms and talking to people and trying to explain why they can't do something can be very disheartening and really can get to the point where people are just trying to justify getting benefits versus necessarily even admitting, you know, that they have some capacity to do other things. And for me, that's something I'm also hoping to change is that, again, if there's more discussion early on, what types of things can you do? Is your disability company going to help you do something else or talk with your employer about doing something else? Then we definitely want to try and facilitate all of that. So details are very helpful as far as, you know, what types of things they can or cannot do. Someone with a fractured shoulder, for example, could they be a nurse? Could they, you know, be moving patients and all of those things? Could they do my job, you know, sedentary work where they're just typing? Yeah, absolutely. You know, it's something that, again, as long as the fracture is stabilized, they can do all of that, you know, desk height, reaching, handling, and fingering. And I say things and definitions like sedentary, I throw out these words and you all know what they mean, but I didn't know. I would never have been able to define what a light occupation is or a medium occupation when I was in practice. And so as a result of that, when I got these forms and these checkboxes that I was never instructed about how to think about, those were not my top priority. And I think I did, you know, a number of my patients a disservice by just, you know, for example, if it was a Social Security request, put the little sticky note, said, find to send records. And then it's off my desk and I don't have to think about it again. For my patients, it would have been more helpful if I had been more specific or clear about what information, you know, what things they could do so that a better assessment or evaluation could have been made. And that's one of the things that, again, I'm hoping that all of you, you know, continue to understand is that really making sure that we're giving that information about capacity is important. So some other definitions here as just a pause. These are some of the definitions that come into play a lot of times at the long-term disability and are things that you might hear about. So PRE-X is something that, and I put it in brackets because I wasn't sure that I was going to put it in here because it can be kind of a touchy subject for not so much anymore, but can be kind of a touchy subject as far as health insurance is concerned and whether or not something's covered. What I would like for you to understand as far as disability is concerned is that pre-existing clauses or pre-existing provisions in a contract generally are for people who have been employed for just a short amount of time, usually a year, which means they were hired, they're eligible for benefits, and then within eight months they go out of work. What we're looking for and what the actuaries put these dollar amounts in for is to make sure that they didn't have an illness or injury all along that, you know, when they first got that job or first got the insurance. And so pre-existing for disability means not that you just had a condition or not that you were diagnosed previously with a condition and it was written down somewhere. It means that you sought care or treatment, so medications, office visits, evaluations, care or treatment for a condition during an identified time period, usually about three months before you started work. So sometimes it's up to 12, but usually it's three months before you started work. And if you did see a doctor or take a medication for a condition that later became impairing and went out in the first year of work, then you would be denied benefits. If you go a year and a day, you get benefits. So again, this is one of the things that was difficult for me was thinking about the contractual language and having to kind of suspend reality a lot of times when I'm looking at files because unfortunately there's a reason that things are priced the way they are and this is one of them. There's contractual language there. Own occupation, again, is something that we define, our vocational consultants define based on standardized resources and in general that own occupational time frame. So you will be eligible for benefits for your own occupation for about two years. We get to the change in definition at that point. A change in definition means that you are then able to perform any work for which you're qualified given your skills, training, all of those things. And the big thing to think about or the good thing about this is we are trying to get people to think about it early. So if we know somebody has, again, no capacity to return to their own occupation, so a nurse for example, has a knee replacement, it's not doing well, she's still having pain symptoms, still is not walking well, we know she's not going to get back to her job as a floor nurse. But at the change in definition, she would potentially qualify to be a triage nurse, to answer phone calls and those types of things. And in this day and age we're definitely getting more of those being gainful, meaning they're giving a good wage for those types of occupations. So what we're trying to look for is, number one, can they do their own occupation? Can they do the demands that we list for you or that we explain to you? And number two, if they can't, are they going to get back to it? What are the things that we're looking for as far as getting back to their occupation? The goal for a disability company is always to try and get someone back to their employer. That's the person that's paying our premiums, but it's also a win for the employee as well. They don't have to be retrained, they don't have to interview for a job, they're back into an environment that they're used to. And then the employer also doesn't have to invest in retraining. So the vocational rehabilitation services that we have and many companies have are really beneficial in talking with employers to try and figure out are there other things that someone could do, are there other activities that people could be doing while they're recovering from their surgery, for example. So and I'm going to move along a little bit quickly here since we had the 15 minute noise interruption, so I'm going to move on here to really ways that you all can help. And from a disability carrier perspective, this is income protection. But just like, you know, Social Security has offsets for workers' comp or state disability, we have those as well. So if someone has workers' comp, then that amount is removed from the benefit amount that we pay. So they only get a max of the amount of benefit that we would normally be assigning. So the income protection is, again, different than the social safety net that Social Security is. And income protection through an employer is different from workers' comp in that anything can happen that can lead, that anything that happens that leads you to being unable to perform your job or your occupation will qualify for disability benefits through your employer, whereas workers' comp is, again, only if it occurs on the job or associated with work activities. Really again, from a disability carrier perspective, it's a win-win if we get people back to work, period. It's best for the employer, for our client, if we can get them back in their own job. Next best, if we can get them back doing something else there so that they can, you know, don't have to retrain. And then for us, the next after that is getting them back to work anywhere. And that's where we can get some additional services. And really for me, the reason that this was I'm not a bad guy insurance person was the fact that there is quite a substantial amount of literature that indicates indirectly that people are happier, healthier, and live longer if they have work. And so that's one of the things that I am trying to get to and one of the things that I encourage the nurses that work with me and the claims folks to understand is people do better and are healthier when they have work. So what do we need from you all? Again, details is really the big key. Specific things that someone can or cannot do is what we need to hear. So if someone cannot use their arm, say they cannot use their arm, cannot use right arm because of a fracture, cannot because recovery from surgery or any of those types of things. The no work again is really not as helpful. One of the things to know is that we do keep in mind not only the occupational demands again of their job but trying to figure out what else they might be able to do either with their employer or with someone else. So as much detail as possible about what types of things are problematic for your patient. Because again, we're trying to get people back to work, trying to get them back to productivity and really what we find is that a lot of this is very patient driven. Patient driven in the fact that there's people who stay at work and keep working until they fall down basically. We call some people the working wounded and they're driving the boat because they're wanting to stay at work. I'm wanting to make sure that they get their benefits that they're due if they finally just stop, if they can't do it anymore. And so as much information as possible, how things changed over time definitely helps as far as documenting in medical records, how often they're complaining or reporting symptoms. If they're having issues with chronic pain for example, documenting every time they come in if they're bringing it up is very helpful. The other thing too is that they don't necessarily have all of the information regarding the contract that's overseeing their disability payments. And so that's when we need to get involved or discuss things a little bit more, explain kind of some of the other issues whether it's vocational or otherwise. And because they don't know that information, we need to have this relationship develop better than those little checkboxy sheets because it's really not, it's not helping the patient, number one. So listening to your patient, absolutely. The thing we want you to do, recording whenever possible, documenting any changes in function, specific changes like inability to grasp or lift or walk or stand, all of those things that people have to do occasionally, frequently or constantly, we need to hear about. Our claims resources include both our claims managers, the people that manage the files that talk with your patients regularly, but also we have clinical folks that again understand those sedentary light medium definitions that understand that there's distinct timeframes that are associated with occasional or frequent in order to be able to relay that information to you. So what we're trying to do is to have as much communication as possible. And what I've been trying to do in my end is try and make things as clear as possible, meaning that we are now sending more occupational specific narratives, letters that say, this is what somebody has to do. Can they do it? And one of the best pieces of information that we get back from one of those letters is no. No, they can't do it and this is why. And voila, we're done. And that person gets their benefits and that's one of the things that for me is most helpful, is making sure that we're getting as much information as possible. If they can't do their job as defined or what can they do? Is there something else that we can help with? And that's where our other resources, our vocational counselors come in. They do things like help with prep for their CVs, those types of things. They also have preps for talking for interviews and those types of things. They go through different places or different resources that states might have. So we have a lot of resources that we can put to bear and again, trying to work together. So these are the things I would like to kind of wind up with as far as, let's partner. Let's try and make sure that we're sharing information as much as possible. The more information you document, the more I'm going to see. I generally see a lot more information maybe than you do because I get all of the records from the specialists, whereas you might just get a report or a letter. So when our folks call, we're trying to clarify something specifically. We will send letters. So if a letter is easier, just have your front office person or your nurse say, please just send a letter with questions and we can do that. We want to get as much information from you as possible. You know the patient best. We want to assess their, again, max capacity. What are they able to do now? What can they do in the future? Are they going to get back to their own job or occupation or not? And we can work with any of those. We just need to be able to understand that. And then successful return to work for us is any return to work. We have lots of folks that go back sometimes only part-time and that's the most they can ever do. And that's great because they're getting, if they're working part-time, they generally get an extra incentive or extra payment from disability. So once you start to go back, you get some extra payments for that. If you're trying to find a job, a lot of times you'll get extra benefits or extra payments during that time while you're trying to find a job. So all of those things I think are beneficial, again, for our clients. They definitely want to make sure that they're retaining their good workers and make sure that they don't have to retrain. And that's, you know, again, over the past couple of years something that we're seeing more and more of that people just are not staying in their jobs and the effort to retrain at this point is pretty costly for them. So I will end there, but we'll leave things open for questions. Thank you very much for an excellent presentation. I just wanted to dig down a little bit further into the workers' comp situation. So as an occupational medicine provider, I'm mainly working with acute injuries, but I do have a sizable number of patients that have had work disability for six months or longer. And I haven't routinely been asking them about group or individual disability insurance. I will start to do that more, but I'm just wondering what is our responsibility as a healthcare provider in coordinating workers' comp disability and group or individual disability? Is that out of our league? Do we need not worry about that? And what are the legal ramifications? That's a great question. And in general, as far as workers' comp is concerned, they have their own regulations and so have specific physicians that they need to see specific information. They have rules as far as doing exams. We also, from a group standpoint, have the capacity to perform exams or IMEs, FCEs, those types of things to assess capacity. Really for both of those, again, it's providing the information as it's presented to you. So you know, it's not something that in general, if something is being denied that you think is really squirrely, you know, if someone is not getting paid for something and you think this is weird, I don't understand why, sending a letter to the insurance company, especially with the group disability insurance, sending a letter to the insurance company can be very helpful, but it's not final because unfortunately, again, all of these are really contractually based. So workers' comp has their rules and regulations that they need to follow. We have contract language that we need to adhere to. And so even if someone is impaired on occasion, they won't get benefits. So do you work with workers' comp insurance companies for a disabled worker or is it two totally different worlds? Separate, completely separate. You know, again, we have an offset for those, but we don't, we get information from them, we get, you know, their independent exams when they do them, but we're completely separate. And our benefits are not reliant on them. It's an offset, but if once workers' comp ends, then they get their full benefit at that point. Hi, thank you so much for your lecture today. I represent an employer, a multinational corporation, and being on the VAT side, there's often difficulties extricating mental health disabilities from performance issues. Could you share any best practices that you've used over the years and how you do that and how do you also then manage those leaves in the proper way and obtaining the right information so the employer can adjudicate those claims? And then secondly, how in your world have you experienced related to individuals with, as employers start to hire more individuals on the autistic spectrum and how disability and mental health can relate to performance issues as well? And do you have any best practices there that you can share? Thanks. No, those are great questions. You know, as far as what to do from a provider standpoint, from a treating provider standpoint, for people who have behavioral health issues and have mental health challenges at work, that really what we need to think about is again that they're in regular care. That's what I look for. So if an employer is saying, this person just has a bad attitude and they're being a jerk and I don't want them around anymore and so I'm going to put them on a performance improvement plan and get them out of here. But you know that the person has other stressors at home, has a history of depression, is not being adequately treated. Getting that person into care and documenting those medical issues really is what's most important for the disability standpoint. If we don't have the documentation that yes, there's a problem that's being assessed and is being treated or that treatment recommendations are being made, unfortunately the benefit of the doubt goes to the employer then. So we need to have that documentation that's there. And that's again with anything. If there's something that's bothering your patient, it needs to be, if you're documenting it, then we can take it into account. If it's not documented, it doesn't happen. And so as far as the behavioral health issues, fortunately there's a lot more emphasis now on accommodations and the ADA's been around for a while, but it's becoming more and more of a focus. And so for folks who have issues, starting that process of asking for accommodations, sometimes that's the best way to keep somebody employed and keep everybody happy. Because there's some adjustments made, whether it's this person has to work in an office versus out in a queue because they can't take the noise that they have to deal with, or this person needs to come in at a different time because they have other issues that are coming on. Those types of discussions are mandated by law. They have to occur. And so if you're giving or encouraging your patient to start those discussions, that's important. And on that same encouragement tact, that's also for the working wounded, the people that are out there that have some issues as far as impairment but are pushing themselves through. It's absolutely okay to bring things up and say, is this something you've thought about? Is this something you need to do? Have you investigated? Do you have these benefits? That's why they're there, so when people can't perform their own jobs. Behavioral health issues, absolutely a huge issue in the disability world. Difficult in the group disability world because a lot of contracts have a two-year limitation, which means someone's truly mentally, mental health impaired. And obviously there's lots of people out there that are. For those folks, our main goal is trying to get them Social Security because that will be long-term. So yes, difficult. Good day, Dave O'Brien. My question is, it's kind of an extension of the question we just asked, maybe a little bit broader. How do you address the patient who has an impairment? They really can't go back to work in their current status. Their primary treating physician has referred them for some additional either consultations or therapy or evaluation, and they really don't follow through on that. So technically they have an impairment, but they're not really taking care of business. I agree. That's an issue, and certainly not following through in care is one of the details that we look at from an insurance standpoint, from a carrier standpoint, to say basically that the resulting opinion is, well, if you weren't bad enough to go get this treatment, then it's not that bad. And so yes, I agree. It becomes an issue for treating providers because there's a lot of times when you absolutely can say, yes, this person is impaired. And so what I would advocate is saying continue to document that, continue to recommend, continue to document, to demonstrate again all of those objective things that we kind of touched on a little bit, all of those findings that are there. Because unfortunately with things like electronic medical records, things can get kind of carried over or glossed over, meaning that either you can have something that got better five years ago still listed, or you can have a problem that's still going on now as far as decreased range of motion or problems with spasm, those types of things that's not listed every time the person comes in. And if that's something that's seen every time, it should be documented every time. And it is something that, again, it will potentially be used against them, but the best you can do is just keep recommending. Don't stop recommending is the bottom line. It's great talk, but can you make a comment on the family medical leave? Because I've seen that normally often they will apply for both, the children's disability and the FMLA. So do we apply, I mean generally look at the application, do you apply the same criteria in terms of when you accept one, you basically accept both, or you basically, sometimes you can't accept one but on the other? That's a fabulous question, and certainly it's something that I will give kind of a glossy answer to, and the glossy answer is there are two separate things. What insurance companies such as mine generally do is to utilize the information that's on the FMLA form, and if that qualifies for disability, we don't need to bug you about it. But if it doesn't, then we bug you. And so there's definitely, one of the things that I used to tell patients when I was in practice was, I have control over FMLA. I can get you an FMLA. I can't necessarily get you payment. I can't necessarily get you the disability benefits. So what we do is again, the FMLA is job protection, but it's not income replacement, whereas disability is income replacement. So there's less stringent rules for the FMLA than there are for the disability. So they are definitely completely separate. I can give you an example from my past. As I said, I did OB for the first five years, and so I had a pregnant person. She had a medium-level occupation. She said she had back pain. There was nothing on exam. She was walking normally. There was nothing else that was there. There was no additional treatment that she received. I filled out her FMLA forms, indicated that she was having back pain and reporting consistently, which she did. She qualified for the FMLA, but when they looked at all of the other information for the short-term disability, FMLA usually doesn't have medical records that they're looking for. They're just looking at the forms, whereas short-term disability looks at your medical records, if there's a question. All right. Yay! Everyone made it! Thanks for coming. I appreciate it, and safe travels.

disability benefits

social security disability

short-term disability insurance

long-term disability insurance

patient impairments

patient limitations

disability claims

collaboration

mental health disabilities

workplace accommodations