Medical provider trying to claim disability

[mgriffiths]

Disclaimer: I HATE disability with a passion - far too many people are on it, and the vast majority of my patients on disability could easily work a job - therefore it is strictly fraud

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I had a patient the other day who is a medical provider (yes, I am leaving out pertinent details such as PA/NP/MD/DO, gender, specialty, etc. on purpose) who is claiming an injury from several years ago that has now disabled the patient.  I personally don't believe the patient (real injury or otherwise), but of course it is the generic "back pain."  I often employ "Waddell Signs" in these situations, but being that the patient is a provider the patient is aware of these (even making a comment about them during my exam, something to the effect of: "Now don't go charting positive Waddell Signs or anything, hahahaha!").  The exam was essentially benign.  The patient had pain with specific maneuvers but then did not with other maneuvers that test similar areas.  In my professional opinion, the tests where the patient expressed pain were truly negative, but the patient verbalized pain - why I hate the generic "back pain."

Needless to say I am suspicious.  I know that the patient's youngest child just graduated college - and I am concerned that the patient  is simply just trying to retire early and have some extra slush fund from the government for disability.  I started with XR (came back with some mild to moderate DDD), prescribed NSAIDs, referred to PT.  I plan to have the patient complete a functional assessment - which is where I catch the majority of ridiculous disability claims, but I'm concerned that being a medical provider this individual will be able to game the system effectively.

Anybody have any other ideas for stopping the ridiculousness - not just in this situation but with other patients as well?

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PS: I do understand that disability has its place.  I have a few (please note: A FEW!!!!) patients who are absolutely disabled and I have no problem with them being helped, it is just too d*** easy to get onto disability.  It's basically to the point where if you hire a lawyer you will eventually win and be placed on disability.

[Reality Check 2]

A functional capacity evaluation with a licensed PT is by far the best route. Those tests have fail safes built in to find inconsistencies and malingering.

If this person is pursuing a personal disability policy then the company paying for it might have something to the equivalent of an IME - Independent Medical Evaluation - at its disposal which could take you off the hook for the final determination.

If this person is pursuing SSDI or SSI then you might be out of the process entirely as they collect your records and use their own convoluted and time consuming method and folks usually fail 3 times as a rule. 

Said provider might be smart enough to hire a disability attorney to guide through the process.

I would just document what little you find and that you are employing outside testing such as FCE etc. Try to distance from the final decision if possible - let the insurance company duke it out with him/her. 

I wholeheartedly agree that folks get disability way too easily and frequently. I have patients missing limbs from combat who still go to work everyday despite a pension/disability available to them. They want to feel useful and have a purpose and schedule. 

All disability patients should be followed by an investigator with a camera in my opinion. My Workers Comp guy carrying a couch up stairs and the guy with neck problems backing up a car with his neck craned are the ones who need to be caught. 

Keep the high road and keep your ethics.

My old crusty 2 cents

[GetMeOuttaThisMess]

I’ve often wondered why folks looking for disability don’t go the psych route? No painful tests/injections or surgeries to deal with. That’s the route I’d take.

[Guest UVAPAC]

I don't understand why this "medical provider" is on disability.  

What is his working diagnosis?

Degenerative Disc Disease Mild-Moderate, Lumbar strain, SI Joint dysfunction, Piriformis Syndrome, Disc Herniation, Spinal Stenosis?  

I would get an MRI of whatever aspect of his back, and go from there.  Even if he needs some restrictions or accommodations certainly he/she is able to work in some capacity?  

I always tell my patients YOU DO have a work capacity.  Maybe you cannot lift 50 pounds today, but certainly you can file paperwork or answer phones all day long.  

[Gordon, PA-C]

IMO 95% of the people on disability are fraud artists.  The only people who should be approved for disability are:

 

1.  100% wheelchair bound persons.  If you can take at least 10 steps at a time without sitting down, then you don't qualify.

2.  Legally blind, WITHOUT the ability to fix the condition with glasses/contacts/surgery.  

 

Everybody else who doesn't fall into one of those categories can work.  Period.  Our disability system is an absolute joke.

[Cideous]

Ever had a Migraine?  4-6x per week?

 

Yes there is a lot of fraud, but there are reasons to grant disability that don't involve being in a wheelchair or blind...

[ArmyPA]

1 hour ago, Cideous said:

Ever had a Migraine?  4-6x per week?

 

Yes there is a lot of fraud, but there are reasons to grant disability that don't involve being in a wheelchair or blind...

I know there are people who actually have debilitating migraines, however I find that headaches is a diagnosis that can be easily faked or exaggerated with no way of proving otherwise. I have a family member with 80+% disability rating from the VA who calls in sick to work for migraines quite often...conveniently they have them the day after an all night bender at the bar (read: hangover). The sad thing is most of this persons co-workers know it but wont say anything because they are a Vet...

[Cideous]

And then there are those with Migraines that spend their days puking, in a dark room with total silence.  Any light or sound makes you want to kill yourself.  So bad they are willing to have electrodes installed sub-Q that with a remote can fire the occipital and trigeminal nerves in an attempt to offset some of the pain....

There is fraud everywhere.  You can not judge everyone based on someone you know who is not legit.  Each case needs to be reviewed with an open clear NON-BIASED MIND.  Something in very short supply by providers today.

[mgriffiths]

21 hours ago, Reality Check 2 said:

A functional capacity evaluation with a licensed PT is by far the best route. Those tests have fail safes built in to find inconsistencies and malingering.

If this person is pursuing a personal disability policy then the company paying for it might have something to the equivalent of an IME - Independent Medical Evaluation - at its disposal which could take you off the hook for the final determination.

If this person is pursuing SSDI or SSI then you might be out of the process entirely as they collect your records and use their own convoluted and time consuming method and folks usually fail 3 times as a rule. 

Said provider might be smart enough to hire a disability attorney to guide through the process.

I would just document what little you find and that you are employing outside testing such as FCE etc. Try to distance from the final decision if possible - let the insurance company duke it out with him/her. 

I wholeheartedly agree that folks get disability way too easily and frequently. I have patients missing limbs from combat who still go to work everyday despite a pension/disability available to them. They want to feel useful and have a purpose and schedule. 

All disability patients should be followed by an investigator with a camera in my opinion. My Workers Comp guy carrying a couch up stairs and the guy with neck problems backing up a car with his neck craned are the ones who need to be caught. 

Keep the high road and keep your ethics.

My old crusty 2 cents

Yep, I plan on a functional assessment.  I also know I won't be the one making the final determination, but my office notes will be used to either support or oppose this individual's disability claim.

Any other thoughts anyone?

[SedRate]

On 7/31/2018 at 5:35 AM, mgriffiths said:

 I started with XR (came back with some mild to moderate DDD), prescribed NSAIDs, referred to PT.  I plan to have the patient complete a functional assessment - which is where I catch the majority of ridiculous disability claims, but I'm concerned that being a medical provider this individual will be able to game the system effectively.

Anybody have any other ideas for stopping the ridiculousness - not just in this situation but with other patients as well?

https://nccih.nih.gov/news/press/08112015

"...An estimated 25.3 million adults (11.2 percent) experience chronic pain—that is, they had pain every day for the preceding 3 months.

"Pain is one of the leading reasons Americans turn to complementary health approaches such as yoga, massage, and meditation—which may help manage pain and other symptoms that are not consistently addressed by prescription drugs and other conventional treatments."

Consider referral to PM&R, spine, counseling/psych, and/or pain management. As above, there are alternatives out there for pain, such as dry needling, aqua therapy, marijuana, massage, etc. 

Good luck. Disability is a frustrating concept for both the provider and patient. Try to be objective and not let your past experiences cut your treatment short. 

[LKPAC]

17 hours ago, Cideous said:

 Each case needs to be reviewed with an open clear NON-BIASED MIND.  Something in very short supply by providers today.

As a provider, I resent this statement.  I think most of us are capable of judging each case individually in a non-biased way.  I disagree that this ability is "in very short supply."  I still think that most providers are caring, intelligent people who want to do the right thing.  The right thing is neither a rubber stamp of approval, nor an indictment of patients in true need.

[SedRate]

Here are some interesting articles I found during a quick search on chronic pain statistics, disability, and possible malingering:

https://www.sciencedirect.com/science/article/pii/0304395993900762

"...16.4% of the subjects with chronic pain were depressed compared with 5.7% among those with no chronic pain."

 

http://www.painmed.org/patientcenter/facts_on_pain.aspx#hhs

Among the major adjustments that chronic pain sufferers have made are such serious steps as taking disability leave from work (20%), changing jobs altogether (17%), getting help with activities of daily living (13%) and moving to a home that is easier to manage (13%).

Women were more likely to experience pain (in the form of migraines, neck pain, lower back pain, or face or jaw pain) than men. Women were twice as likely to experience migraines or severe headaches, or pain in the face or jaw, than men.
The percentage of person experiencing migraines or severe headaches was inversely related to age. Twenty percent adults aged 18-44 years experienced a migraine or severe headache in the 3 months prior to the interview compared with 15% of adults aged 45-64, 7% of adults aged 65-74, and 6% of adults aged 75 and over.
Adults aged 18-44 years were less likely to have experienced pain in the lower back during the 3 months prior to the interview compared with older adults.
When results are considered by singe race without regard to ethnicity, Asian adults were less likely to have pain in the lower back compared to white adults, black adults, and American Indian or Alaska Native (AIAN) adults.
Adults with a bachelor’s degree or higher were less likely to have migraine headaches, neck pain, lower back pain, or pain in the face or jaw, compared to adults who did not graduate from high school.
Adults in poor and near poor families were more likely to experience migraine headaches, neck pain, lower back pain, or pain in the face or jaw in the 3 months prior to the interview than were adults in families that were not poor.
Among adults under age 65, those covered by Medicaid were more likely to have migraine headaches, neck pain, lower back pain, or pain the face or jaw than those with private insurance or those who were uninsured. Among adults aged 65 and over, those covered by Medicaid and Medicare were more likely to have migraine headaches, neck pain, lower back pain, or pain in the face or jaw than those with private insurance or only Medicare health care coverage.

 

https://www.ncbi.nlm.nih.gov/m/pubmed/12650234/

Base rates of malingering and symptom exaggeration

Twenty-nine percent of personal injury, 30% of disability, 19% of criminal, and 8% of medical cases involved probable malingering and symptom exaggeration. Thirty-nine percent of mild head injury, 35% of fibromyalgia/chronic fatigue, 31% of chronic pain, 27% of neurotoxic, and 22% of electrical injury claims resulted in diagnostic impressions of probable malingering. Diagnosis was supported by multiple sources of evidence, including severity (65% of cases) or pattern (64% of cases) of cognitive impairment that was inconsistent with the condition, scores below empirical cutoffs on forced choice tests (57% of cases), discrepancies among records, self-report, and observed behavior (56%), implausible self-reported symptoms in interview (46%), implausible changes in test scores across repeated examinations (45%), and validity scales on objective personality tests (38% of cases).

[ventana]

get the insurance company to hire a PI and video tape them doing all the things they say they can't

 

 

[narcan]

It's worth mentioning: stopping these folk from getting disability is not your job. Be objective, fair and honest in your assessments; do the right tests to find the right answer. Don't end up on disability yourself, wheelchair bound from a massive stroke, because you let the malingerers drive your blood pressure through the roof.

[AbeTheBabe]

Is this a work injury? When I suspect someone is faking it, I will send them for a "Functional Capacity Exam" which tests their capabilities and if they really have pain by monitoring blood pressure and heart rate. Also, the work comp insurance will also follow and video tape patients they think are lying or check their social media.

[Reality Check 2]

The wildest disability I have encountered was a 60ish veterinarian who suddenly became deathly allergic to cats.

He had some sort of disability policy and he filed for SSDI.

My main question was why couldn't he limit his practice to dogs, or rabbits or iguanas or birds or something?

He got disability, played golf, tore his rotator cuff and thus I met him in the ortho practice.

Weird.

We can all do SOMETHING at any point in our lives.

Yes, I am a trained PA with years of experience. If I became disabled perhaps I couldn't earn the salary that I make now - disability is roughly 60% of normal income or even less if I remember correctly. Depending on my physical state I think I would consider something I COULD do to stay mentally active and perhaps earn more than a disability check. But, that's just me.......

[sas5814]

I'd like to think I'd do the same as long as my brain works (spare me the comments) but people are people. A long time ago I learned to stop saying "if that was me I'd" or "if that was my kid I'd" because I really don't know what I might do in a given circumstance.

I've also learned when it comes to money, especially "free" money, people change into something different.

[mgriffiths]

1 hour ago, Reality Check 2 said:

I would consider something I COULD do to stay mentally active and perhaps earn more than a disability check. But, that's just me.......

The frustrating part is that A LOT of SSDI patients earn income "under the table" (I know it is not all, and likely isn't even the majority, but a lot do).  I reported a patient a while back who was on SSDI, but was actively running a small engine repair shop out of his garage.  The best part was when he threatened to sue me he wrote the note on the back of his business card!!  He is currently in jail.

[Guest UVAPAC]

2 hours ago, mgriffiths said:

The frustrating part is that A LOT of SSDI patients earn income "under the table" (I know it is not all, and likely isn't even the majority, but a lot do).  I reported a patient a while back who was on SSDI, but was actively running a small engine repair shop out of his garage.  The best part was when he threatened to sue me he wrote the note on the back of his business card!!  He is currently in jail.

Playing in a summer softball league last year I asked the umpire what he did for a living... Told me he was on "total disability due to osteoarthritis" in his knees.  Stated "I umpire under the table to make some extra income, it doesn't pay much, but it pays for my beer!" and laughed hysterically to himself for a good minute or two.  

[GetMeOuttaThisMess]

Non-SSDI pays out depending on who pays the premium, thus I’ve always carried my own. Personally paid is eligible for up to 70%. Employer paid is 60%. I elected employer coverage for first time this coming fiscal year since it is >50% cheaper. Two reasons primarily, 1) I don’t need the “can’t perform professional duties” clause any longer which would’ve paid out if I couldn’t practice but still could’ve worked in some other capacity, and 2) I’ll be out/retired in two years and if push came to shove I could cover the difference in income with savings already set aside till retirement date. I’ll be going from $260 to $100/month premium expense. I won’t be moving to a new professional position.

[rev ronin]

The only thing I love more than busting fraudulent patients is helping all my other workers' comp folks.

Our justice system is supposed to be set up such that we let many people go free rather than imprison an innocent person.  Doesn't always work out that way.

My panel is currently about 50, with all but 5 of them injured more than a year ago, some as many as 12-15.  I have seen as many legitimately injured people denied care as I have fraudsters.  When I suspect fraud, I do order FCEs, or call the claim manager and suggest that an investigation may be in order.

For every fraud, I can give you 10 stories of legitimate long-term disability cases that are heartbreaking.  Almost all of my patients lose their spouses or long-term partners.  They all lose whatever they had in a 401K or other retirement plan, the equity in their own home... I've watched claim managers impoverish people through their own intransigence just to close cases.

I hate fraud.  I hate it because it takes away money that should be going to my legitimately injured patients.  But there's plenty of the latter.

Seriously, if anyone is in Western Washington on a Friday, come shadow me for a day, and hear my patients' stories.  Hopefully, seeing some of the legit folks will soften some of the above attitudes towards disabled injured workers.

[Cideous]

7 hours ago, rev ronin said:

 

For every fraud, I can give you 10 stories of legitimate long-term disability cases that are heartbreaking.  Almost all of my patients lose their spouses or long-term partners.  They all lose whatever they had in a 401K or other retirement plan, the equity in their own home... I've watched claim managers impoverish people through their own intransigence just to close cases.

I hate fraud.  I hate it because it takes away money that should be going to my legitimately injured patients.  But there's plenty of the latter.

 

And this is my only point on this thread stated much better by someone who does it every day.  Thanks Rev.  It's a tough job in medicine but we need open minded providers like you to continue the work of helping people.