I want to thank all of you for coming this morning. I'm finding as you are finding welcoming and seeing old friends and old colleagues has been a rewarding part of coming to this meeting. And not only old friendships but new friendships can be made and this is what I really value about this community. So I'm Jonathan Middleman, Medical Director at Group Insurance of Prudential and with the background in certification as you are in occupational medicine. In particular in my career I've been supportive of first responder community. Pardon? Thank you. Can you hear me better now? Better now? Okay. Anyway, I was supporting the first responder community as well as serving in volunteer fire departments in Connecticut, Maine and now serving the Northern California firefighter community with firefighter rehab. I want to give credit to Dr. Tracy Hamill for excellent presentation last year in regards to the history development of disability coverage in the U.S. and I want to introduce my colleague. Good morning everyone. Can you hear me? Well okay. My name is Dr. Karen Wardlaw. I am also a Medical Director, Vice President at Prudential working with Dr. Middleman. I actually have my career started in the pharmaceutical industry. I also have experience working with hospital medicine, private practice and finally I'm here with doing long-term disability reviews with Dr. Middleman. So I don't have a slide for this but I do have a disclosure because I worked for a pharmaceutical industry, an employer that I do have some of their stock in my retirement. So I was asked to mention that that I could potentially have a conflict of interest. So we just want to go ahead and get started. So I just wanted to talk about some of the session topics as you can see there. I'm not going to read all of them but we just wanted to give you a glimpse of what happens behind the scenes or in the journey of someone who applies for short-term and long-term disability. Our focus is actually just on long-term disability. So we just wanted to make sure that we reiterate to the audience and I'm quite sure that a lot of our audience members have had some exposure with the disability process either completing forms, delegating the completion of forms or having the accountability and responsibility to the C-suite for the costs that are incurred when your patients go or employees patients go out on disability. So I observed treating patients both in private practice and under workers compensation that dealing with disability insurance were totally different things. My approach to this was inspired by Dr. Jennifer Christian who most of you know and unfortunately is not able to make it to the meeting this year. One of the things I noted was I was astounded at how poorly primary care physicians were really taking care of their patients in terms not the medical care so much as supporting them through the disability process and making it very difficult for us to in turn to support their disability. We are medical subject experts we're not insurance company experts. It is the role of the claims managers and vocational rehab specialists who help make these decisions. So this presentation should give you insights to the nuts and bolts of disability insurance make it easier for you and your day-to-day practice in terms of helping your patient through what is a very difficult process. So I just wanted to ask or to poll the audience if anyone cares to contribute what are the benefits of work? Would anyone care just to shout it out or? Sorry? Socialization. Money. Yeah. Any other any other thoughts on the benefits of work? Self-esteem. Wow. Self-worth. Wow. Great. Any others? Purpose. Is that what I heard? Great. Benefits. Yes. That's nowadays with you know it's it's it's important benefit. Okay so I'm just going to go on so it's just some of the things that we have here as was discussed with your responses. Financial and health insurance. Security. Sense of identity. Connection to the workplace. I know we have different work forms now workplaces but improved cognition. One of the other things that I've heard a leader state while working in an environment that promotes creativity. So with teams and ways to to move ideas forward. As well as social connectiveness and enhanced mental wellness. So I don't have a slide for this but some of the challenges that we have especially in you know in occupational medicine. We talk about absenteeism, presenteeism. Now with the new forms of the the workplace working remotely and there's hybrid workers. So in some instances employers have mandated that employees come back to work certain days of the week. So there's still some kind of hesitation with that. Some of the benefits that we see with telemedicine, telehealth, telephone consultations. For our purposes when we review charts for long-term disability. There's just a scarcity of objective physical findings. Physical exam findings. So that's kind of a one of the challenges that we that we face. As well some of the challenges just dealing with remote workers. You know the question if someone works remotely are they impaired to the point where they're not able to work. So there's no commute but they're but they're working from home. So that's just kind of a I guess maybe a sort of rhetorical question but that's one of the things that we we also look at. I'm just going to talk about the likelihood of return to work and as we can see there the the earlier of an absence or incapacity the higher the probability that that that person will return to work. The longer they're out 70 70 days it's about a 35% chance that they'll return to work. I just wanted to switch now and then talk about financial implications. So we know that when someone takes long-term disability their salary is cut by about 50 to 60 percent. And so there's always the incentive to get the person back to work. Whereas with short-term disability there's the possibility of them not gaining or losing about 10% of their annual income. Just to just an aside I'm going to pull the audience again. Does anyone have an idea of how much insurance fraud costs per year to the consumers? Does anyone care to render a guess? 30 billion? I heard any any other? 30 billion that's a that's a about a tenth of what it actually costs. So it's about three hundred and eight point nine billion dollars that's insurance fraud. And the repercussions are that the consumer makes up for that. So that's a it's astounding amount. So I'm just still going to leave it on here on this likelihood of returning to work. I just wanted to take a few minutes to talk about the process. You know we talk about you know again if we've in this audience if we've dealt with primary care or workers comp we know we have those forms the disability form. So it's not I'm not going to just talk about the forms but it's the information that we receive on the forms. And I just wanted to talk about who the players are as well in this process. So we have the patient who we in the insurance industry refer to as the claimant. Their responsibility is to get the paperwork in to everything with authorizations into the disability claims manager. Now this is a person who's the one who processes the claim and does all of the legwork administrative work for for the claim. So they're not medically trained person personnel but they do have knowledge of the medical condition. So their response their responsibility is actually knowing the ins and outs of the policy. And Dr. Miniman will talk more about the policy and how that applies to the disability whether how it's processed whether it's approved or there if there are any delays in the in the process. We also have clinicians like we're physicians and we also have nurses who if the paperwork that comes in is not clear understandable for the claims manager legible there can be some ambiguity there can be difficulty in just understanding what's there. And so then it gets escalated or if it's just a complex case it gets escalated to the clinician review again nurses or physicians and physicians I should say. And then also in the process we also have a vocational specialist who work with the claimant and work with the disability claims manager to get them to a point where they can work. So what I'm saying is really that the information that's necessary on these forms is about functionality. What is the capacity of the person who's who's out. Thank you Karen. I want to get into sort of the nuts and bolts here. So as you see from the slide we're talking about you know timelines of how all these various plans intersect. One of the important pieces here that I didn't realize until I got into this job was the elimination period which is usually seven to a hundred and twenty days depending on the type of policy. Now your patient needs to be continuously impaired during that whole period for anything to be covered. If they recover from let's say from surgery and then subsequently have an auto accident if there is a gap in time they are not covered for that auto accident because they were not they had finished their disability coverage for the surgery. So this is the importance of an elimination period and it's very often very confusing to claimants. So anyway a typical long-term disability policy starts about six months after the individual stops work and usually covers them for the first two years for coverage for their own occupation and this is again part of the critical thing about we're talking about when we send out forms doctors fill it out and say well they can't work full-time or they can't work at their occupation. We understand what they're meaning because that's for their job coverage but what we're interested in knowing is whether they have any capacity at all and whether in the long term whether they would be able to be retrained for something else. Now there's another piece here about partial disability is probably underutilized and go on to has to do with again part-time capacity. Now we've seen this sometimes employers don't want their employees to return to work in anything less than a hundred percent. I've seen it many many times but your responsibility is to identify those people who could go back and this is where again our vocational specialists will help again in seeing if they can work with the employer to accommodate them and get them back to work and the benefit of this is often very good in terms of financial coverage because not only will we pay them we'll give them an incentive to return to work they get their ordinary pay and the disability coverage so they're making out very well while there were their partial disabilities being covered but not all policies have this and not all employers are willing to go along with this. So again in terms of nuts and bolts here there's provisions and policies that again as physicians we really had no idea until we got into this so you may wonder why all of a sudden claims get shut down and but there's reasons for these. Most physicians have ONOT coverage so we're covered if we cannot do our own specialty and this usually is a lifetime or until retirement coverage if you cannot do your own specialty but most groups have limitations they're there to reduce the financial risk to the insurer which is then passed on as cost savings to the employer for paying the policy. In general for the first two years employees are covered if they can't do their own job as defined by their job description and in the general industry general occupation. After two years there may be a change in definition. This means that the vocational expert will review their capacity as we define it, their background, their training, what they can do and whether they can make a gainful job with the skill set that they have. What this means is somewhat confusing. Gainful is usually defined at 60 percent. In Louisiana it's 80 percent of their pre-disability earnings but they have to have a job that's commensurate. In other words as a physician we're not going to have you be a greeter at Walmart. So it has to be something for which you are trained. So this is the importance of getting this information during that first two years. If it looks like your patient is not going to be able to get back to work then there's an opportunity for retraining. If somebody's been in a manual laborer and having had a fusion is not going to get back, well let's think about that earlier on and see if we could pay for and get that person in school and get some training done. This is what we do. So another limitation is a behavioral health limitation. I don't know why this was developed but for the most part this is usually a two-year limitation. I guess they assume that behavioral health can be treated successfully within two years. So that at the end of two years then behavioral health considerations, extreme depression or anxiety, no longer play a role in determining whether somebody has capacity. So where this comes in to you is that at this point you will see your patient coming in saying, you know my back is really bothering me now. I really need to you know be seen for this and to deal with this because now this is what's impairing me, no longer my anxiety or depression. So the thing is is that while they're covered under their behavioral health criteria, if they develop an impairing diagnosis during that time period they would be covered. So that's their incentive. Another piece is what we call the look-back period. I know we got rid of pre-existing exclusions for medical care which was medical insurance which was great but this is a different entity. What we look at is if somebody's newly employed we look back and see if they had developed symptoms or were treated for a condition which then became impairing. So this is again one of those risk reduction issues and they could be excluded and unfortunately sometimes this you know means people who have developed serious diseases will not be covered but this is again part of the policies for group insurance that people need to be aware of. And then as I pointed out earlier that if they're not entitled to benefits such as you know as a defined for example pre-existing then no longer any further conditions that have developed will be covered. So to help assess these issues that you know the history and free text discussion that we really rely on to get insight to your thinking is really critical as Dr. Wardlaw will discuss. So I just wanted to just take a few minutes to talk about taking your patient's history. So I'm not trying to stand up here and tell colleagues how to take a history but I just want to explain or reiterate things that are important when we review the chart. Well when we review the chart what we're looking for from the from the claims review perspective. So all of us have learned how to take a medical history and the medical history is essential. Things that are important when you have like just an example someone comes in they've had an injury February now you're seeing them in September. So documenting when the symptoms started is important that kind of gives us an idea. So one of the things so in that particular example the person worked they had the injury and they were still working and for some reason they came in in September. So we really try to look to see what happened. Is there something was there another injury? Did they you know did they get better from that initial injury and then subsequently do something that worsened their symptoms. But that timeframe in terms of when it occurred, when they went out of work, what were the other circumstances? Were there any relieving factors? Were there aggravating factors? Sometimes people will have an injury that may have not occurred at work, but their work, their history, or what they self-report, that work is aggravating a prior symptom. And so that's all important in looking at the information. What we look for as well is between the individual provider and inter-provider documentation. So we look for the three, we call it the three Cs. Is there consistent information? Is it credible? And is there consensus? So those are things that are important as well. In history, again, I talked about self-reporting. We'll see sometimes that a doctor will write, and I have an example here, my patient cannot sit for more than 15 minutes at a time. Why? Sometimes we'll see from the records, radiographic findings, they have a mild or a small disc herniation. So people will take that, or patients, I should say, sometimes take that. Well, I have a disc herniation, I can't sit. But then there's no documentation or absence of documentation of the severity. Objectively, I'll talk about that in a second about examining your patient, but really just kind of getting that information. And so other things too, when we talk about credibility, that example, someone can't sit, or they say that they can't sit for 15 minutes, but yet in another provider's records, you see they traveled for 12 hours overseas. So those are things that, and believe me, that's not, I say that, but those are the type of things that we do see. So if the doctor is then stating on the form, they can't sit, this is what my patient says, I document what my patient says, but their exam is totally normal. And then sometimes we see that the HPI is consistent every month or every visit, it's the same. The physical exam is the same, but yet their subjective or their self-reported symptoms show there's a severity that they can't work. So those are the type of things that we see. And it's important with taking the history to write, and again, to write exactly what they say, but then when we come to the physical exam observations to document what you see. And I talked again about the challenges of telemedicine, there's limitations in the objective findings, and as well with the EMR, sometimes there's a rubber stamp forward where you see a full physical exam for a telehealth visit. So those type of things we have to try to really decipher through. Another thing we're taking the history is occupational history. A lot of times, I think sometimes that falls off and a lot of primary cares, I know I'm talking to occupational medicine docs here, but with primary care, you don't see an occupational history that comes through or it's not captured. And I just have an example of, there was one claim that I was reviewing, it was a claimant who has an underlying history of asthma. He was exposed to fire, they worked in an industry where there was metal being used, had an exposure, wound up having laryngeal burn, but then I'm reviewing, because he's still out, and I'm reviewing this two years out, because what we do, if the person can't return to their own occupation, as Dr. Middleman was mentioning, the claim can run for that two-year period, but we still get updated information. So every so often, the claimant is responsible for submitting that additional information to support that impairment. And then in this particular case, the claimant still had persistent shortness of breath, dyspnea and exertion, a self-report of desaturation with ambulation. So the treating provider sent this claimant to a pulmonary specialist. With that workup, turned out he had some, appeared like interstitial lung disease. And then from the occupational history, they were able to establish that he may have had beryllium exposure, and then wound up sending this person for occupational medicine consultation. So I'm bringing this up to show that what I'm looking at is someone who has a diagnosis of asthma and they're still out for two years, and there's a self-report of desaturation. I didn't see documentation that they had it in writing, it's just that report to the doctor. So what wound up happening, I was able to give my opinion that this person still has ongoing workup, and then the claim was able to be extended. So we're waiting for that additional information to come back to see the initial injury, and then is there a secondary condition, Dr. Middleton was talking about, continuous impairment, that allows this claim to be extended within that period of time. So I mentioned about functionality. Some of the things that we, in filling out the forms, and some forms are more in-depth than others, some you just check, and some others that there's a lot of area for a free text. It's important to put as much observational information as possible. Examining your patient, the document, the pertinent positives and the negatives, as well as, if someone is self-reporting pain, that's 10 over 10, and they're sitting comfortably. When we reviewed the chart, it's like, how much, are they in distress? Is it credible with the physicians, with normal exams? So that's important. Do they have problems walking in? Do they come in in a wheelchair? So if that's what you see, really document that. Is there problems coming from a seated position to getting on the exam table? So those are important. Narratives, free text, as much as possible. I know it's probably difficult with the schedules, but as much free text as possible, that would be important. So the exam should show objective findings to support the capacity limitations. So anything like Waddell's, and also when we talk about neurocognitive. So there are patients that come in saying that they have brain fog, or just can't remember. So using a mini mental status exam, that would be helpful, because a lot of times we'll see that, and then there's no mental status exam. They just say, well, we'll refer to neurology. And so at that time, there's sometimes a disconnect where we're not really able to review, or we don't see objective evidence of neuropsychological problems. And in that instance, some instances, the claim may not be approved, because there's lack of objective findings. Thank you, Karen. The session before this, I was in a concussion session, and it was an excellent discussion about what was subjective and what was objective several months later. And the presenter pointed out that if there are ongoing issues, that if you look for the findings, they will be there on physical exam if you do the appropriate exam, but that most of the complaints are subjective. So again, this is a case of making sense. So the diagnoses drive the disability claim, but they don't constitute impairment in and of themselves. When somebody who's had a bilateral lower extremity amputee climbs Mount Everest, how impaired is that person, really? So one claimant I had to that point was a young man who unfortunately became paraplegic after a motor vehicle accident, was doing his job, which was a seated-type job, which we would expect, and be able to do, but he developed pressure sores, which required treatment with him in a recumbent position, and he was not able to sit. So we would say that that person had no limitations in the ability to do their job, but they were restricted from being able to sit. And so this was an impairment that led to his coverage. So this is why these are the details that are important for your documentation. Another consideration is licensure. Some of the policies with companies, airline pilots, mariners, truck drivers, that licensure, loss of licensure due to disqualification is covered as a disability. So with these folks, it would be, again, there would be no limitations. Somebody had a stent put in, or they had a cabbage, and they have to wait, what, six months. But that's a restriction on their license. So that's the difference, again. So we look for inconsistencies overall. We compare the activities that they're doing at home and the activities they report they're not able to do. For instance, someone who says that they have a seated job, but they're taking online classes and taking care of their baby at home, that lends some issues to credibility. So it's our responsibility to make sure that the limitations and restrictions make sense, make sense based on what we see from you. And think of impairments, we look for your descriptions of activities they can do and cannot do. Those are the limitations, what they're able to do. And for restrictions, think of things they should not do because it would worsen their condition, just like the young man with the pressure sores that needed healing. So for example, if someone has uncontrolled seizure disorder, they should be restricted from safety-sensitive jobs, right? No driving, operating heavy machineries, or working at heights. But during and after a seizure, your patient clearly cannot work. If they're otherwise controlled, and they have no side effects from the medications, that they would be limited from working for 24 hours, I usually say, after a seizure, but they would not be otherwise limited, but they would always be restricted from safety-sensitive work. Another example is, say somebody with a severe L4-L5, herniated disc causing radiculopathy and foot drop with pain with walking and sitting. Then we say the claimant has an impairment due to that disc herniation, causing back pain and leg pain and weakness. So I conclude that they can walk occasionally due to foot drop and right lower extremity pain with walking and they could sit frequently during the day, but they would need to be able to change position as needed. If you have a patient, let's say, with bone-on-bone left hip osteoarthritis that needs a total hip replacement, you may document your patient can walk occasionally or less due to the pain, but you would not document that they can't use a computer because there's no documented impairment in regard to use of the upper extremities. The puzzle has to fit together. Sometimes patients will indicate on their intake form that they can never perform any work whatsoever. Please apply some common sense here. So if you check never for most activities, ask yourself, are they bedridden? What's their overall condition? If they have a focal impairment, like a herniated disc, then you can pretty well describe overall what their limitations are. If there's issues causing global impairment, think of stage four cancer, chemotherapy, post-ICU syndrome, ALS, horrible pain, then it affects their global ability to work or their sustainability to perform work. Even if, let's say, they're not limited, we see many cancer patients with fairly normal exams through most of their treatment, but what is happening is the fatigue from the chemotherapy or neuropathy that they've developed, these things affect their sustainability, and that's what needs to be commented on. We need to hear from you and the medical records. The drop-downs in the EHRs are your enemy in terms of helping your patients. Free text is your friend, and we really rely on that. So we need to know, again, the story, what they do day-to-day, are they having difficulty doing their day-to-day activities such as housework and taking care of children, are they dropping objects, the normal sorts of things. Now, again, as I alluded to before, during the first two years of coverage, we'll want to know what the prognosis is for return to their own occupation. So if, honestly, you think that they're not gonna make it back, this guy's a construction worker and he's had a fusion and still has some pain, I don't think he's gonna make it back, let us know that, because then that's where specialists can come in and start with training, because at the end of two years, he would be in a position of potentially losing his disability coverage because they would find that there would be an alternative occupation that he could do in a seated job. But if he doesn't have the training for it, if we're not proactive in dealing with it, then that's to your patient's decrement. So, again, as we talk about the medical history, we look for changes. What happened? Did the change make sense? And also, looking at how people are functioning at work. Do they have a new boss they detest? Do they feel stressed? And then they end up with disability paperwork. That also tells us a story. So the vocational review is very important, and we need to use a common language, and that's where these definitions that you see occasionally, frequently, and occasionally are determined by the Department of Labor in the way jobs are described, and this is what vocational specialists do. They're able to pigeonhole certain jobs in certain categories, and that is the way we basically judge whether somebody can or cannot do their job. So, we go to the next. So, in defining these jobs, we look at sedentary work, for example, exerting up to 10 pounds. Think of clerical work here. Seated-type work. Light work, usually sales. Assembly work, light manufacture. Medium work is where our nurses usually are classified. And then heavy work for construction workers, and I think truck drivers are usually between medium and heavy work. For Dr. Hartenbaum, I think heavy work would be the requirement in most cases. So, this is where the use of language is important. For you to use the similar words as occasionally, frequently, and constantly, this is where the use of terms such as repetitive are not necessarily helpful. We know what it means when we're looking at the use of developing carpal tunnel or developing tenosynovitis, but this is not something vocational specialists are familiar with, and so if you use the word repetitive, they really don't understand. The other confusing word is full duty or light duty. Full duty is doing the job that they did before. That's clear to everybody. But light duty doesn't mean the same thing to everybody. So, what can they do? That's what we need to see. Because just using the word itself is vague and doesn't tell anyone what they can do. Just means they can't do their prior job. So. So, you can see that it's very important here that your patients often don't really know what their job description is. We get a copy of their job description, but it's interesting when you actually ask them what they do, it doesn't seem to always correlate. Experienced claims examiner told me a few months ago that they want doctors to know that it doesn't help to write down on the disability form. They cannot do their job. I mean, that's fine for, as I pointed out, first two years, but it doesn't, but this opinion is usually based on what your patient tells you. And let me give you an example. Your patient is an administrative assistant and has that L4 or L5 disc herniation, and they tell you they cannot lift 50 pounds. Fair enough. You agree with them, and document they cannot do their job. But what administrative assistant ever has to lift 50 pounds? So, our vocational experts evaluate the regular occupation and come to the determination that in national economy, that job is performed at the sitting or sedentary level. So, don't document they cannot do their job. Document what they can do. They can walk occasionally, sit frequently, and allowed to stand as needed to manage symptoms. When we ask whether someone can work full or part-time, we're asking whether your patient has sustainability to work five days a week for 40 hours. If there's a current capacity for part-time work with a ramp-up plan, please mention that. So, this is important where you have to document what they can lift, not what the patient tells you necessarily, and to get that through their history. First of all, all these points are doubly important. If a patient is denied for proof of claim, or because a reviewer felt that your patient had capacity for performing some other job, we do have an appeals process where a separate group of experienced claim managers will interact with the claimant and try to see if their claims were properly evaluated. This usually involves a second level of review and a review by a different physician, a different clinician. As I said, medical school, if you don't write it down, it didn't happen. The same thing is if your records don't document things for your patient, what they're capable of doing, it can't support it. So, go to Karen. So, I just wanted to go back to that example that Dr. Middleman had given about the patient that had an L4, L5 injury or radiculopathy. So, I'm just gonna expand on that. So, we have two nurses that have the same symptoms. They may have had a MRI. They may have had the EMGs that show there might be some compression. They have two different, one nurse is a rehab nurse and may be required to lift up to that 50 pounds. There's another that may be more sedentary that their job has frequent lifting to 10 pounds. So, as the treating provider, you assess that there's going to be a 20 pound lifting restriction. So, when we look at it from the claims perspective as a reviewer, that nurse that's required to lift up to 50 pounds has a lifting restriction of 20 pounds. So, that limitation exceeds what their usual and ordinary job is. So, that particular person, once that claim comes through with all of the clear, concise information, that claim will be approved. And that person will go on to receive the disability benefits. For the other nurse who may be a case manager, has more of a sedentary position, the 20 pound lifting restriction is really not applicable to this person because they are only required to lift up to 10 pounds. So, in that particular instance, when that claim is processed, that would not be approved. So, when we talk about capacity, the job descriptions, that's why that specific information is necessary of what they can do. And as Dr. Middleman mentioned, not that, well, they can't do their job. And so, also with the considerations, as so, things that I just mentioned, or as Dr. Middleman also mentioned, a never never for any, for all of the activities, is not helpful for the claimant. Because what will wind up happening is as that claim is reviewed, the never, if we, and one of the other things that we do, if it's escalated to the clinician level, physician level, we have a differing opinion process. So, if the doctor is stating they can't do this or that, or it fills out some information, but it's not correlating with the physical exam, the objective physical exam findings, we, as a reviewer, will either contact the physician by phone, by letter, which is faxed to them, asking for clarification. Doctor, this is what we found, and this is what we see, in terms of objective information. How can you support that impairment that you're writing for? So, that's one of the things. Also, just to mention briefly about long COVID and brain fog, as I mentioned before, as I mentioned, the objective exam is helpful. With either the mini mental status exam, or any of like the MOCA, or the SLUMS, which is the Montreal Cognitive Assessment, the SLUMS or the St. Louis Mental Status Questionnaire, and then the mini mental status exam. I just wanted to give an example of one of my colleagues had a case. It was a physician who had long COVID, and actually was able to have the benefit of a neuropsych testing. So, from the results of the neuropsych testing, it showed that the claimant was cognitively intact, but just had some mental fatigue. The differing opinion process was followed, and actually, it was a peer to peer discussion. The reviewer was able to speak with the claimant's physician. Now, when we have these discussions, we don't advise on how to treat, we have conversations about clarification. From that discussion, the physician was actually able to send the claimant back to work part time, with the limitations of working in the morning, and then having the afternoon off because of the mental fatigue. That was one of the success stories. So, how can you help your patient? Again, understanding the role as an attending physician. I know we're Occupational Medicine, our intention is to roll this discussion on how to complete the forms, the information that's necessary to the broader physician audience. Patients listen to your opinions and recommendations, using clinically based rationale, when placing limitations on the assessment, and not just based on self-report of what they can't do, but really just with taking all of that into correlation with the activities of daily living, what they fill out on their questionnaires, what they can do, and then just getting that information from the patient as well. And then being realistic and supportive with patient outcomes, letting us know if, again, what the prognosis is, are they at maximum medical improvement? Are there surgeries planned? That's the other thing that we take into account as well with reviewing the claims. And then if capacity cannot be assessed, functional capacity evaluation, also notes from occupational therapy and physical therapy. We've used those that had maybe a little bit more detailed information about the actual capacity than one of those rubber stamped telehealth visits. So I just want a full disclosure here. I have no certification for behavioral health, so this input was from our neuropsychologist who's been very helpful. She wanted, so I asked, how can we help physicians understand how to support their patients with their behavioral health considerations? So here's some points here. So the takeaway is that simply because somebody has a diagnosis of depression or anxiety, that does not in and of itself preclude a patient from working. So a higher acuity of care and or symptoms are generally required to support impairment. Consider asking about personal, social, or work settings to better understand why your patient may be asking to be supported for impairment. It's important to understand that job dissatisfaction is not a disability. Work stress is not a disability. Interpersonal conflict with managers is not a disability. Life stressors are not considered disabilities. And dependents at home are not a disability. So are they on FMLA for a loved one? These are all parts of your history. Other non-medical factors to consider or ask about may be in cases of motor vehicle accidents or where there's pending litigation. Workers' compensation is a separate evaluation of impairment with a causal relationship and is separate from LTD evaluations, but there may be overlap in the way a patient presents to you. So I just wanted to mention one more thing about continuous impairment and comorbid conditions. What we look at is the, if someone, and I'll just give an example. I had a physician write in a report. They went out for back pain, they had surgery. They actually, from the records, had improved. And there was a comment that the doctor wrote, well, since this person, since my patient is having carpal tunnel syndrome, I'm sorry, carpal tunnel surgery in another month, we will leave them out until after they have their surgery. So just to kind of reiterate, the impairment is based on the diagnosis. And if a comorbid condition is not impairing, it's not going to be covered. So just wanted to kind of just mention that. So we're just gonna come to the conclusion. So we just really wanted to try to give you a quick glimpse of the behind the scenes when a patient comes in and they are impaired to the extent that they have incapacity. Just the process, getting the forms in, it's concise, it's legible, and as much narrative that can be put in regarding the claimant's capacity and functionalities, the word that we use, and their workability. Just behind the scenes, how important it is that we have proactive management of the case with either knowing that they're either at MMI, what the prognosis is, the objective physical findings that correlate with the self-reported severity of symptoms, and as well, working with the vocational specialists earlier or sooner than later, and really trying to get your patient's claimants through this process so it can be as seamless as possible and that there aren't delays or unnecessary denials early because there's not enough documentation that comes in or there's not enough specific documentation that comes in. So with that, we wanted to just conclude and see if there are any questions that we can answer. Thank you. In terms of, I'm gonna repeat it if I'm hearing it, you're asking a question about depression, and in terms of a claim review, how do we deal with that? Okay, so that would be reviewed. We have clinicians who are behavioral health specialists, nurses with training in that area, and we also have a psychiatrist and a neuropsychologist on staff. And there are forms, behavioral health, capacity questionnaires, questionnaires that go to discussing and asking for input on mental status and their exams and so forth. So I know from our discussions with my colleagues that what they look for is, as I said, a higher acuity of care. Somebody's just not seeing their PCP for depression on an annual basis, but rather under active care. Are they in psychotherapy? Are they on two or more medications? Are those medications, the dosage being changed and so forth? Are they needing a partial hospitalization program? All of these are factors which would help promote or help support somebody's incapacity due to a behavioral health claim. So does that answer your question? Yes, so if a patient is not stable, it seems like we have the unstable, clinically depressed patient. Exactly, I mean, the instability is, the documentation of the instability that's supported by the acuity of care, the frequency of visits, the changes in medication, all of that will go to support that claim. But it needs to be documented. Intensity of care. Yeah, intensity of care. Can you use the mic? Because I think it's being recorded. I'm sorry, yes. Hi, how would we recognize and let you know that we've recognized someone needs some vocational help and retraining early in the course? Do we do a referral for vocational rehab? Yes, that's an excellent question. And actually that is the last question on our fourth we send you, saying can vocational rehab be helpful for this patient? And so we do ask that. Early on, how would we let you know? Well, that would be part of the process. In other words, the claims manager should send you a form, that form on which you would indicate where their limitations are, what restrictions they have, and whether they would be amenable to vocational rehab. And then also, if they're unable to return to their usual op, that's one of the things that would come across as the physician, you would provide that information that they could be referred to vocational earlier. Good morning. Good morning. How do you recommend getting a functional capacity evaluation through the Department of Labor? I'm gonna defer to Dr. Middleton. When the employee is an employee of the Department of Labor? When their case is being reviewed by the Department of Labor and you have to use those providers, is it physical therapy? I've never seen a functional capacity evaluation when I'm looking for a physician. They are physical therapists, yes, who do the, yes, yes. A specific one? Well, there are as many different, I gotta say, I've seen a lot of different FCEs, different quality of FCEs, and I usually, at these conferences, usually there's firms in the exhibits that will tell you about them and what their company can do for you. So I would go to those exhibits and get that information. All right, thank you. You're welcome. Hi. So I'm wondering if the clients that you've worked with, if you have any best practices for interactions with the occupational medicine practice with this whole process, because oftentimes, at least for our institution, we have community providers that are filling out this paperwork that don't know what our people do, and I have found at our institution, it really is in a vacuum, and the occupational medicine practitioners are not involved at all in this. So if you have a client or a model or a best practice, that would be really helpful for those of us who don't necessarily have an integrated approach to bring back to our employers. Interesting. So you're talking about a hospital-based system? So now, so we're employer-based, so I work for a DOE contractor. Okay. So yeah, so we have an on-site occupational medicine clinic, but benefits operates over here and occupational medicine operates over here. Boy, that's a whole, yes, I see your problem, and I don't have an immediate solution. I wish I could think of one, but it's, the best thing, what we're trying to do is get this talk out to PCP. So actually, one answer would be is that if you have a particular group of practitioners you would like us to address, do a quick lunchtime thing, we'd be happy to do it. Maybe we'll start with our benefits department. Thank you. Okay. Thank you very much. I think one of the last slide, you did advise that we should not rely on self-reported data. So I was just thinking, where do we bring in questionnaires like who does lower extremity functional scale, dash, you know, that clinicians use to, you know, find out, you know, in terms of disability? Where do you put that in? And actually, that's, it's helpful. So if that's part of, say, your usual assessment or if you're trying to get more information on their functionality, anytime, because if, in examining them, if you feel that they're not improving and then really just trying to get more information to support your opinion or your assessment on their capacity, that would be helpful. So it's a long, I think it's probably more along a spectrum, but if it gets to the point where, if you feel that they're really not going to be able to get back to, say, that particular position, but just trying to get a sense of what they can do and cannot do, that would be helpful because we review that and take that into, you know, we take that into consideration with their functional ability. Yeah, plus your comments of how your physical exam correlates with the findings on the questionnaires. So that's the consistency piece that we look for. Good morning, thank you. How does the medical accommodation process fit in with a determination of disability from completing the assigned job? It's the one thing that we do see forms that have accommodations, and so in some instances that may not get escalated to our review level, and that's from the claims manager, they may take that information to the specific employer and say, in the case where, if they need to be sedentary for back pain, the claims manager works directly with their contact with human resources, and in some instances that cannot be accommodated. So that person would remain on disability, the claim would be approved throughout whatever duration that that particular accommodation can be lessened, or if, you know, but they'll still have reassessments to see if, you know, again, if the employer can't accommodate then it will continue on disability. But if there's partial, under the partial disability piece, that is, say somebody's pay is reduced because now the job they have has a lesser pay rate, then they can actually pay that difference. If they're back at work. Importance of keeping them at work is critical because that keeps them engaged and so forth. So socialized, all the functions that are important. So if we try every means possible to keep people back in the workplace with these partial payments. Well, thank you everyone for attending. Thank you for having me. Thank you. Thank you. Have a great, have a great lunch. And a great conference. And a great conference. Thank you all for coming.

disability claims evaluation

medical professionals

detailed documentation

objective assessment

limitations and abilities

vocational specialists

common language

comorbid conditions

mental health instability

functional capacity evaluations