Hi. Good morning, everybody. Thank you for coming. Thank you for coming to the meeting. Just a quick reminder, cell phones and audio-video recording. Please silence your cell phones as this is being live streamed at this time. And also, please fill out your evaluation forms for individual sessions as they will help with future planning. And of course, evaluations can be found in the American Academy mobile app, the online platform, and the online learning portal. And please visit the PM&R Pavilion downstairs if you haven't already. My name is Mark Ellen. I'm the session director for today's session on insurance, what every physiatrist should know from the inside. We have two other wonderful speakers who have had a lot of clinical experience and have made the flip into the insurance world. Our first is Dr. Alan Novick, who is the vice president and medical director at New York Life Insurance Group Benefit Solutions. And he'll start out on disability insurance, your patient can't work, now what? How to avoid pitfalls. Thank you, Mark. And thank you, everyone, for attending those both live and live stream. So I hope you're all having a good conference. Where is the... So, as Mark said, I'm Alan Novick, I'm a vice president at New York Life Insurance. Only disclosure I have is that I work for New York Life Insurance, but the opinions are mine based on my clinical and administrative experience. I've been in this role for about three years now, and before that I had over 30 years clinical experience in a kind of diverse practice. I did inpatient rehab as well as pretty robust outpatient clinic with workers comp, musculoskeletal. And I say that because I used to joke I was 50% inpatient, 50% outpatient, and 50% administrative. So I had no time to fill out forms. When a form came to me, it would just make me cringe, and I was like, oh, why? So I'm hoping over the next 20 minutes or so I can give you some insight and make it easier so you don't get so many forms. Let's see how it works. Whoops, wrong way. So there's some great, we'll start off by talking about some great myths. Loch Ness Monster, a myth. Unicorns, a myth, although went to the zoo yesterday and saw a rhinoceros, and if you just squint just right, kind of looked a little bit like a unicorn. The Miami Dolphins can win the Super Bowl, absolute myth. And I made this, I started this slide carousel before the beginning of the season while we still had hope, but gone. And the last myth and the one I really want to talk about is insurance companies want to deny all claims. When I was on the clinical side, I sort of believed that, and that is just not the case. New York Life was founded in 1845, so if you have almost 180 years of existence as a company, you have to be doing something right. You have to have customer satisfaction, and you're not going to get that if you're sweeping, all claims get denied. The company has a lot of actuarial data, so they know the anticipated loss. They're not looking to deny every claim. They know they're going to pay on claims. What they're looking for is information on how to process the claim correctly and in a timely manner, because disability is a highly regulated industry where there are set timeframes. The company has to make decisions about the claim within certain time periods. So we need that good information, and we get that information from you guys. So what's the fundamental problem? Well, most physicians have no training regarding disability insurance. These forms are thrown at them, they've never seen them, and what do we do? You have no knowledge of the differences in disability policies, which really impact how you could complete a form, and really don't even understand their own role in the whole process. So what's the solution? Well, physiatrists are trained in function. What better specialty than us to talk about disability? When I got to New York Life, I was the first physiatrist. Now we have three in our team of physicians. But we're the perfect specialty, but in order to do this, if you want to be involved in this and help your patients, you need to know the rules. So let's talk about some of the rules. What do you need to know? Well, fundamentally, you need to know what disability insurance is. Disability insurance is income protection. It provides a portion of your income if you become sick or injured and are unable to work. There's usually an elimination period, so it doesn't start day one. You get hurt, and 30, 60, 90 days later, if you still can't work, then you're going to get a payment to replace your income. So if you're retired, you're not getting an income, you can't collect disability insurance. But if you choose not to work, you're not collecting an income. There's two types of disability insurance. You need to understand that a little bit, too, before you can complete forms or work in this arena. There's short-term disability that's typically six weeks to two years, and there's long-term disability, usually with an elimination period of about 90 days or more. And the duration of the disability is based on the individual policy. Now, within long-term disability, there's two types. There's own occupation or any occupation, and it's really as simple as it sounds. Own occupation means you're going to get paid as long as you can't do your own job. Usually higher-earning people, physicians, lawyers, will have an own occupation policy. And then there's the concept of any occupation, meaning if you can do anything, you can go back to work. You don't collect, basically, if you can go back to work in any capacity. Usually individual policies are sort of what you buy. Do you buy your own occupation? That's going to cost a little bit more, or do you buy in any occupation? With New York Life, we sell group policies, so if your hospital offered all their employees the ability to buy a disability policy, that would be a group policy. And most of our policies, the way they work are you have one or two years where you're covered for your own occupation, and then it becomes an any occupation policy. So when it changes from own occupation, if you as the physician have said they can't do anything, well, now the policy changed. You might get new forms, and we'll talk about that a little bit more. So what's your role in this whole process? You could either be a treating provider or you could be an independent medical examiner. As the treating provider, you provide proof of loss. For a patient to claim disability insurance, they can't just walk in and say, I'm disabled, pay me. They need a physician to say, yes, you're disabled, need to discuss the physical and functional abilities of the patient, the restrictions and limitations, and their ability to return to work or not. It's really that straightforward. As an independent medical examiner, you've got a lot of you who do in the musculoskeletal workers' comp world are so used to causation and what's the treatment. Those don't play a role in disability because we have to accept the claim as it is. We're not concerned about the treatment. We're not concerned about the cause. It's all about can they work or not. As an independent medical evaluator, if you tell us about causation, it may not help us and then we might have to ask you more questions, which we don't want to do. So it's really all about function. In order to fill out the forms correctly, you need to know the vocabulary. There are very defined terms for each physical demand level. The Dictionary of Occupational Title talks about different work levels, sedentary, light, medium, heavy, or very heavy. They're defined as 10, 20, 50, 100, or greater than 100 pounds on an occasional basis. Often this gets very confusing for people because I'll see where somebody's had three or four back surgeries and the doctor says no heavy lifting. It's clear they meant something lighter, 10 or 20 pounds, but by definition, heavy is 100 pounds. I know that isn't what they meant, but I have to clarify it. I would say if you don't want to remember the sedentary, light, medium, just put the weight in. We'll figure it out from there. Don't trap yourself by using the wrong terms. One of the important things here is that 10 pounds occasionally because that defines whether a patient can do sedentary or not. If they have in any occupation policy, you're really looking, can they do at least sedentary or not? That 10 pounds is going to be scrutinized. If you write they can lift one pound, probably you're going to get questioned unless it's really a clear reason why. Just something to keep in the back of your mind, that 10 pounds is sort of a critical if it's any uck. What's the process? Well, patient files a claim. That will go to our nurse, and this is a very simplified kind of overview, generalization, but it will go to our nurse case manager who collects and reviews the medical records. Usually you're not seeing anything yet. Your staff is sending records. No big deal. If the documentation is sufficient, claim manager will make a claims termination, yes it supports or no it does not. If it's insufficient or inconsistent, the nurse case manager will attempt to get the necessary clarifications, so they're going to be sending you a letter. Depending how you answer that, if they don't get sufficient clarification, then it's going to be sent to me as the medical director or one of my team members, and we attempt to get clarification. That's going to be possibly another letter to you or a peer outreach. We want to try to avoid that. I don't know, how many of you have tried calling a physician's office? It's not fun. I spend way too much time on phone trees, you know, press three if you are this, press two if you want this, press one, you're put on hold, and then, you know, 12 minutes later you get disconnected. So the last thing in the world I want to do, thank you for laughing at that, I appreciate that, the last thing in the world I want to do is call you. So if we can beat that process, all the better. But if I get clarification, or if I don't, then I wind up giving my opinion on what the patient could do based on the documentation provided. Sometimes if there's no physical exam, and that's what I was trying to get clarified, if there's no clarifications, then we may need to send the patient for an IME. So what do we use to support a claim? Well, we have both medical and non-medical documentation. Non-medical, we use a patient disability questionnaire and social media searches. You know, when the doctor says they can't do any work, they can't stand for more than two minutes, and then you see that they just wrote on their Facebook page they ran a half marathon, something doesn't jive, you know? And then we have medical documentation, and the single most important part of the medical documentation that we look at is the physician progress note. If it's in your progress note, we're not sending you extra forms. We don't want those delays, and we really don't want to bother you. But unfortunately, a lot of times it's just not, the information we need is not in your progress notes. So then we'll typically send a medical request for information, and in that we'll ask for a diagnosis, factors impacting return to work, restrictions at work and home, and a return to work status. Great. If we get that filled out and it's clear, no problem. But a lot of times we'll say, you know, restricted sitting and standing. Oh, what does that really mean? Is it restricted to two minutes? Is it restricted to two hours? You know, same with lifting, no heavy lifting, what do they really mean? So if we don't get that clear, then we may send what's called a physical abilities assessment form. And I think probably most of you have seen this type of form. This is not actually ours. This is one I just pulled off the internet. But it will have the different physical activities, sitting, standing, walking, lifting, carrying, and frequency. This is not set in stone. You know, these are categories. But if you think, and the frequency is basically in thirds, occasionally, frequently, and constantly. If you don't think this is the right amount or the weight's listed there, cross it off and put five pounds, put, you know, 25. But fill it out. It's so helpful. And one of the things you want to do, remember to date and put your name on it. You'd be surprised how many blank forms we have and not really know, did the physician fill it out or what it was about. So kind of here's the overview if you really want to prevent requests for more information. The first thing, put the work status and restrictions in your progress notes. Now, I know when I was in practice, I'd see the patient, write my whole care plan, dictate my note, they'd walk out, and then a week later, I'd get the form sent to me. Too lazy. I'm not going to dictate another note, you know. It really will save you trouble in the long run if you just say, sent disability forms, information can't work because they can't lift more than five pounds, boom, you know. It's good to have it in there, but that will save you more hassles than anything. So then if we have to send the medical request for information, write legibly. You know, I feel so stupid when I get a form and the doctor took the time to write it out and I can't read it. I'm really good at deciphering chicken scratch. I'm really good. But if I can't read it, I've got to call. Now as far as the medical request form, the diagnosis, this sounds really stupid, but include the disabling diagnosis. I'll get forms, diagnosis, hypertension, chronic kidney disease, hypercholesterolemia. I'll get a list of 10 diagnoses, kidney stones, hangnail. And they forget to put the lumbar radiculopathy on it. It's not more makes it better. It's the correct one to make it better. So please try to do that. And then there'll be usually something that says like factors impacting return to work. Don't restate the diagnosis. That's obvious. If you say the diagnosis is lumbar radiculopathy, then under factors impacting work, say sitting increases pain or something to that effect that shows what's limiting them. And then it comes to the restrictions. And if you put one of these, guarantee you're going to get more forms or more calls. Don't put not applicable. I guarantee you it's applicable. If we sent you the form, it's applicable. They've applied for the disability insurance. We want to try to see if it can get approved, but we need the information. Don't put retired. If they're retired, they're not making a salary. There's no salary for the disability insurance to replace. So technically they are not retired. Don't put can't do their job. You know, you don't know the majority of the times whether this is in any occupation policy or their own occupation. So that can be a real problem. And don't say see progress note unless it's really in your progress note. I guarantee you, you know, we look at your progress notes before we reach out to you. So we've seen them. Maybe not the most recent, but we're pretty real time. More often than not, it doesn't say the information we need in that progress note. If it's there, go for it. But usually it's not. And then there's the different restrictions at work versus home. You know, somebody will list can't lift more than 10 pounds, can't walk more than 50 feet. And then they say they can't work. Well, why can't you work within those restrictions if they can't? Put a reason why. But otherwise it doesn't make sense to give restrictions and not allow them to work within those restrictions. As far as the physical abilities assessment, kind of the same rules go. Certain things, you know, if you write not applicable, it just doesn't make sense. If you check all the categories, there's no activities. You know, these people at home are walking around their house. They're sitting in your office when they come. Don't just check no on everything. Inconsistencies between the physical abilities assessment form and physical exam. You know, if you put normal gait in your physical exam and then on the physical abilities assessment say no walking, it doesn't jive. Same thing with the documented progress note and the physical abilities assessment. If you say that the patient started walking as an exercise, they're now walking 30 minutes four times a week, but then say they can't walk for work, it just doesn't make sense. And also changes in subsequent physical abilities assessment. If you said in March they could lift 20 pounds occasionally, but then in August or September you say they can't lift anything, but they have the exact same complaints, the same visual analog pain score, and nothing's changed on their exam, then why did it change? And we're going to have to ask you about that. So that being said, let's look through some examples real quickly. The first one's a 58-year-old who was involved in a motor vehicle accident, sustained a carotid dissection and a CVA with right hemiplegia. Claims manager did an interview with the patient. She couldn't understand the patient at all. She had to start talking to the husband. Patient questionnaire was completed by the patient's husband, and he specifically wrote on the form, wife can't write. It sounded like an aphasia. So what's the problem? Well, all of the PCP notes for two years, with the exception of the most recent note, said right hemiplegia doing well in the history of present illness, but under physical exam said alert and oriented times three, normal speech, normal strength, normal sensation, normal gait, and normal memory. Just didn't make sense. By the way, these examples are real. Each one of these are real, and if any of you in the audience were the doctors who did this, I'm sorry ahead of time. So the most recent note though, the PCP office note said here to complete disability paperwork, and at that point said the physical exam abnormal strength, abnormal sensation, abnormal gait, but gave no specific details. Was the strength one out of five? Four out of five. Makes a big difference what they could do. And so we had to send, when we had this kind of lack of information, we had to send a medical request for information, and the response we got back was based on my 30 years of practice she can't work. Okay. By virtue of having MD or DO behind your name, you are experts. We don't question your abilities. I don't need to know that you're 30 years old. It's not about you. It's about what the patient can do. So instead of saying, yeah, patient had an aphasia and we would have been done, I had to call them. And I did a peer outreach, and the doctor said, oh, yeah, I'm sorry, man, those were templated notes. She's never had a normal exam. He did say her strength was three out of five in the uppers, four out of five in the lower on the hemiplegic side, but that she had a severe expressive aphasia. No brainer. She can't work. But he could have saved himself a lot of problems if he had documented the aphasia. Let's go to a second example. 56-year-old construction worker with back pain rating the left lower extremity. Pain improved 80% with the lumbar epidural steroid. Pain was worse with standing, lifting, and bending, but now able to sit more comfortably. Normal gait, strength, sensation, reflex, it did have a straight leg raising on the left and decreased lumbar flexion. Well, we had to send the request for information. Diagnosis was good. Lumbar verdict. Factors impacting return to work. They said can't sit, stand, or walk. Well, they just said they could sit more comfortably. Kind of didn't, wasn't consistent. And restrictions at work, no lifting greater than 20 pounds, occasional standing, walking, no bending, but at home they could do as tolerated. How can you stand at home but can't do it at work? It didn't make sense. And then they said unable to return to work, can't do his job. This was in any occupational policy. We weren't concerned about him going back as a construction worker. I had to do a peer outreach, could return to sedentary work. So that was a way to save some effort. Third example, low back pain in a 38-year-old diagnosed with spondylosis, decreased lumbar range of motion, positive facet loading, normal strength, sensation, reflexes, negative straight leg raise, but did have an antalgic gait. We had to send for information. Chronic low back pain was the diagnosis. Okay. Factors impacting return to work, pain with standing or walking, good. Restrictions unable to sit, stand, or walk greater than five minutes. Seems a little odd. I'm not sure how you can do that. And they said unable to work, permanently disabled. Well, apparently this physician was into motorcycles because he wrote a very detailed note how the patient rode their motorcycle to Sturgis, which is a big national motorcycle rally. I'm not a motorcycle guy. And was able to enjoy the rally. So I had a Google. I was so, you know, so curious. It was a greater than 10-hour drive per Google. At every five minutes, what, would it have taken them a week? You know, it didn't make sense. So I did a peer outreach, and unfortunately the provider did not respond to me. And I had to make a determination based on the information, which was not to this patient's advantage. The last one, 49-year-old, bumped their head getting into a car, no loss of consciousness, difficulty with attention, memory. And apparently I have a little issue with attention because I put attention twice. It was supposed to be concentration. The exam, the doctor did a nice thing. Said they came to the office unaccompanied. No distress, alert and oriented, normal speech, intact, remote, and recent memory. That doesn't sound too bad. Decreased attention and concentration, but really no subjective or objective data to that. And had a mini mental status exam, 29 out of 30. Seemed not too bad. But their diagnosis was post-concussive syndrome and unable to work due to impaired cognition. The patient completed the questionnaire and said they were able to read, drives about 40 miles a week, manages their own finances, and uses a computer or cell phone daily. Kind of doesn't seem like significant TBI. Now, in their HBI, won her election to city council and has been serving without difficulty. Now, regardless of the election, whether you're blue or red from earlier in the week, hard to imagine that if you can serve on the city council and run an adequate election, that your post-concussive syndrome is so bad. These are real cases, guys. I did a peer outreach and the physician did not get on the phone with me, but through his staff said he still feels the patient can't work. So, you know, we just had to go with what data we had. The last thing I want to real quickly go is preventing requests for more information. With the IMEs, as I said, it's all about diagnosis, physical exam, and function. We're not concerned with causation or treatment. Couple of examples that I've seen in the last three weeks, this is why this slide got added, we had one where it was multiple trauma with TBI asked to assess chronic pain, TBI and cognition. We use different vendors to send out our IMEs and they find the physicians. We send questions so they know what we're asking for beforehand. And yet, despite asking to assess chronic pain and TBI, the physician said defer cognition and TBI to other providers. He only wanted to address the pain. Well, you know, shouldn't have accepted the IME if you're not going to answer the question. You have to understand if you're going to do IME, who is your customer? Your customer is not the patient. Your customer is the insurance company. Now, and that being said, we don't want certain answers. We don't care what the answers are. We just need answers. And if we ask you a question about assessed TBI and you don't do that, you're not serving your customer. Had another one, chronic back pain, and this was the best IME. It was all good, except they made a statement that said, that the patient said that walking made their pain better. This was an own occupation policy, and it was a security guard who had to walk from site to site. And he said, walking makes him better. So I asked the doctor to clarify, and we got the response, the claimant can walk occasionally due to the history, my examination of the claimant, and the FCE. So what he said was, my opinion is based on everything my opinion should be based on, without saying really why. You got to answer the question, why couldn't they walk? It would have been easy on the exam. They had an antalgic gait. You know, just say, because of the antalgic gait, altered biomechanics, although we feel, you know, walking could intensify the pain. Done. We would have supported it. So finally, you know, your documentation makes a difference. Filling out the paperwork can help your patients, but it's not mandated. So you have to, you know, if you want to help your patients, you got to do it. Unlike workers' comp you're going to hear in a minute, where you have to fill out the forms, you're doing this to just help your patient. Don't assume the patient's going back to their prior job. Answer the questions that were asked. Identify function and work status. You know, don't do not applicable, retired, see notes, and use the correct terminology. And by all means, be consistent. That's the most important. So thank you for your time. Well done. Well done. Where were you 33 years ago? I could have used you. All right. Our next speaker is Deborah Weiss. She's a physician down in, also down in South Florida. She is currently an assistant professor of PM&R at FAU and is also, I'm going to just let you take it because I don't want to go into the red hot mess thing. So I'm, where would my slides be? You're going to queue them up? Weiss, that's me. Okay, so I actually have currently been a medical consultant or medical director to the Zenith Workers' Comp Insurance Company. I've been doing this for over seven years, so I'm going to give you some vignettes on how you can get through this system, maybe. Is it post the right one? Yeah, well, do we need a new battery? It was. Wait, maybe I'm holding it upside down. Let's try that. Other side. Yeah, no. I think it's this one. It's OK, there's ways to get through this. What did you do? I'm always breaking things. Just so you know, I'm always breaking things. It's how it goes. And if it's not me, my dog's eating it, just so you know. Second thought. See? I can empathize with you. OK, that looks like the first slide. So anyway, I'm either a consultant or a medical director to the Zenith Insurance Working Group. This one that is the colors worn off of, right? So I have no financial disclosures, although I wish I did. And so as Dr. Novick said, are you the kind of person who likes paying attention to details, paperwork, and challenging cases? If so, workers' compensation patients are for you, right? I did this for many years, and now I'm on the other side. And honestly, as much as that nice speaker said yesterday that we are the enemy, I am not the enemy. I am not even that scary. I can barely see over the podium. So yep, that's what everybody thinks. Work injury claim denied. All workers' compensation insurance companies want to deny the claim. True or false? Well, the Zenith doesn't want to deny the claim. It's false. But what our goals are are to have a quick diagnosis as it's related to the mechanism of injury. And that's really important in workers' compensation. Does the injury match what happened? Quick initiation of care. Is it a catastrophic case? We have a catastrophic team. If it is, reach out. We might be able to help you. We've been doing it a while. Diagnostics. I know there's a lot of guidelines. You shouldn't get this too soon. You shouldn't get that too late. But in reality, we want diagnostics to rule in and rule out. Are there underlying degenerative conditions that you're going to treat? Is that really the problem? Was that caused by this injury? And adequate care and adequate follow-up care. I can't tell you how many times the injured worker is seen, and then they're not seen again by the physician for three months because all of their PAs and nurse practitioners are seeing them in between. And nothing seems to change in three months. And returning to work. So let's talk a little bit about the workers' compensation system. It came into being to provide wage replacement for workers, medical care for workers and employees, who had injuries in the course and scope of employment. The system was designed to protect the employees and the employers. And it was supposed to be really easy to navigate. Let me tell you, not so easy to navigate. And I've been in it for seven years on the other side. Workers' compensation came around in the late 1800s to early 1900s. It was fashioned against the European model. And it was adopted in a state-by-state fashion, which is why every state is different, which is also what makes it so confusing. Who's eligible? Full-time, part-time, seasonal workers. And it's really important to understand that workers' compensation covers accidents that occur because of work, not just accidents that happen at work. So for example, you have somebody who's working in a kitchen. They have a sinkable episode. They hit the floor. In certain states, the floor is not a hazard. That would not be compensable. But on the way down, they hit their head on a fryer, that is compensable. Or you have somebody who walks outside on the property and they're stung by a bee, not compensable. But if they were a landscaper and they were asked to remove a beehive, very compensable. So you have to sort of understand what's going on. The claims process is supposed to be easy. The employee tells the employer, I got hurt. The employer sends them off to medical evaluation. Sometimes this includes a drug screen. If this is a drug-free workplace, that claim might get denied if they're positive for THC. The employer files a claim with the insurance company, hopefully in a timely fashion. And then the insurance company begins to investigate, just like if you were in a car accident. They have the ability to investigate these claims to see if they're real. We have some people who are professional claimants. And they have between 14 and sometimes 120 days based on the different diagnoses that come up in various states to determine whether they're gonna accept this claim. What's covered? Well, that's easy. Fractures, falls, cuts. But repetitive stress injuries and cumulative trauma, that gets a little confusing. And what about an occupational exposure? A pipe breaks and everybody's exposed to carbon dioxide or carbon monoxide and half the people go to the hospital. But one of those claimants has asthma and it triggered their asthma. At what point is it no longer the exposure to that, you know, that exposure, that occupational CO2, and now it's back to their baseline asthma? You are gonna be asked to determine this. So that's important. These are two really important legal terms that I see get confused all the time. The lawyers grab onto these, so I want you to understand them clearly. Exacerbation is when a pre-existing condition is temporarily made worse by the injury. So for example, you have tricompartmental osteoarthritis of the knee. I like to use that one because everybody can picture it. And you fall on it. Now you have a contusion, maybe a sprain. But the underlying condition is the tricompartmental disease. Are we treating the contusion or the sprain? Or does this person, do they get a total knee replacement? So no, we're treating the contusion, the sprain. You may have to do something for that OA before you send them back off to work, but you're not gonna treat it forever. Now an aggravation is something that's permanently changed. So you think of that patient who may have had that small back injury with a bulge and an annular tear, and now they go off and they're working for another employer and they lift a 200-pound piece of wood, and now that disc herniates and has an extrusion of disc contents into the canal. Well, that may be an aggravation because it's permanent. The worker's compensation history and physical, I can't stress this enough. It's a little bit different. We want you to talk about the mechanism of injury. Ask yourself, does this story make sense? Is there a translator that might not be telling you the story correctly? And how long have they been doing this activity? Are they new at it? We had a lot of people who went out during COVID doing jobs they shouldn't have done, and they really got hurt. How long has the patient been doing this? How long have they worked for the employer? A week, five years, 25 years? Are they a valued employee? Did they have immediate symptoms or did they come to you three weeks later with symptoms? Does it make sense? We know you're pressed for time, but we need this information. Do they have prior injuries anywhere on the body? Because they may try to bring in old injuries and things. And also, are they doing concurrent employment? A lot of people need to work two jobs. Which job really caused the injury? For us to cover things, we're gonna find that out one way or the other. And if you can find it out, it might help you to help that person get back to work. Diagnostic, do they have old MRIs? Do they have new MRIs? And red flags. A lot of times you have to fill out forms like DWC-25s in Florida or RFA forms in California. It's okay to write undetermined the first time you see the patient and then say, oh no, this was definitely from work. If you really don't know what's going on, pick up the phone, call a claims adjuster. They have the story, usually from the employer and the employee. And please do a full exam. These focused physical exams don't help your patient. They actually hurt your patient because along the way, you're gonna find out that patients may have heard other things and then it might not be covered down the road. And these people have medical literacy that's very low and they need your help. Follow-up visits are so important. We really want you to see if the employee's been compliant. Are they not getting treatment because it didn't start? Or are they not getting treatment because they just didn't go? Have there been any new accidents since the last time they were in? And although you place that patient at light duty, does the employer even have light duty? Because if they don't have light duty, then maybe put them in therapy more times a week to try to get them back to their previous job. I approve five times a week of therapy all the time. I actually have our claims managers or nurses call them up and say, there's no light duty, why don't we call the physician's office and see if we can get them into more therapy? Because otherwise we might not get them back to work. Do a new physical exam every time they come in. I can't tell you how many notes are cut and pasted from the very first visit. It's obvious, they can't be the same if they're getting better. Read PT notes. I know they don't always come in, I know how frustrating it is, but if you can get a PT note, they don't always tell us the same thing they tell you. And clearly explain your thought process and plan. So, the insurance company denied your treatment, why? Well, maybe you decided to treat a non-authorized body part. You're bringing in a body part that nobody has said could be treated. If you believe that this is part of the claim, explain why. It's all about documentation. Now, you think I'm the bad guy, I deny everything, but we don't. We have to send out every case that we think is inappropriate to a utilization review company where one of your peers is reading your records and they're trying to decide whether the treatment you asked for should be denied or should be accepted. They do this based on the ODG and MD guidelines. These are all from occupational medicine. We're physiatrists, we understand function, so I think it's really important that when we look at these things, you understand that you're not being denied. It gives the insurance company an opportunity to deny if peer review holds weight in your state. But what I've noticed is that many UR denials are never challenged. So on my side, I'm like, wow, that doctor must not really think the patient needs it. I can't tell you how many times our nurses come to me and say, doctor, you know what, this was denied. Is there any way you can overturn it? We really think the patient needs it. We think the doctor didn't document enough. So I'll ask them to call the doctor's office, or I'll call and try to do a peer-to-peer, which, as Dr. Novick said, is extremely stressful. People don't want to pick up. They think you're being yelled at. I'm actually, if I'm calling you, it's because I want to approve. I want to find a way to make your treatment be approved. I want to hear what you're thinking because you didn't write it in your note. And coordinate peer-to-peers with the medical director of the insurance company. Just so you know, the utilization review company, they're supposed to call you a few times. Now, I've heard from my side that they're going to call when your office is closed, they're going to leave a message on the wrong number, and all of these things, and it's frustrating. I've been on the other side, trust me, and it's not always fun, but honestly, I give all the physicians I speak to my cell phone. I'm like, if you have a problem with one of our patients and I'm not following them, I'll pull it up on my computer. Adding body parts. This happens all the time. Here's the classic case. The patient goes to the PCP. It's an inurgent care. They have a shoulder complaint. The PCP does a focused exam. And down the road, they get an MRI. They go to the orthopedic surgeon. They end up with a rotator cuff repair. They're into this process 18 months, and now what happens? They send them to you. They send them to PM&R. They send them to pain management. They're not getting better, and all of a sudden, there's a new diagnosis of cervical strain and sprain, or cervical problems. Now, in the history of physical, nobody complained of neck injury. The mechanism of the injury didn't talk about it. Now, if you think the immobilization of the shoulder is what caused the neck to have some complaints of pain because they were in their sling for so long and things like that, then document it because we'll allow some treatment as long as you say that this is just a result of the shoulder. But describe these things because if not, your patients aren't gonna get the treatment and it's gonna get denied. And then the real question is, since nobody did a full physical in history, which was the real pain generator from the beginning? So, treatment of injured workers. One of the things that's always so concerning is we want evidence-based treatment. Like, if you're just throwing treatment out there, it gets automatically sent to peer. The claims adjusters are not physicians, so if it doesn't make sense to them, they just send it off to be peer-reviewed and you get denied. If you're doing a procedure, describe why. What's the intended outcome? What the plan is if the treatment works or if it's unsuccessful? Where are you going with this patient? See injured workers more than one time a month because you will be able to continue to see what's going on with their care. I know a lot of times you're like, well, nothing will get started for a month, but these people are scared. They're working out in the community and they don't really know what's supposed to happen to them. Really, many of them that I see claims for are seasonal workers who really don't speak the language and they don't really know what to do, so they need your help and they need your encouragement. Cost. Some of you have in-house dispensaries. I know you think we're the big pocket, the big deep pocket, but we're taking care of hundreds and thousands of people all over the country, some of them with catastrophic injuries, so think about what it's gonna cost the patient when you're done treating them and maybe consider some less expensive equivalents for the patient. Durable medical equipment. This is one of my big pet peeves and I ask the people on my team, what can I say to all of these wonderful physiatrists? And they said, well, if some great new equipment comes into the office and they leave that pre-printed prescription pad, don't just sign off on it unless you know what you're signing off on. You could be signing off on a piece of equipment that they're gonna try to sell us for $5,000 that you only want the patient to use for about a day. And it's really important. If you think they really need it, write why. I had a physician who put an article at the bottom of his note of why he wanted it and I said, wow, this must be a great new piece of equipment. I looked it up, it was about six rats. I don't know, six rats doesn't really do it for me. And discontinued treatments that are no longer indicated. Will the procedures that you're talking about increase the patient's function? And what does 50% better mean, right? It's a Medicare term. 50% better to me, I wanna know what they're doing that's 50% better, are they able to start work? How many treatments do you wanna give these patients? Is it for life? Is there facet arthropathy that occurred over a degenerative time, something that was really the work injury? And is all unexplained pain CRPS because we are seeing a onslaught of CRPS. I don't know why, I think it's the new term. Nobody wants to tell the patient, I'm so sorry you had an injury, you have pain, you might still have pain. They're like, you know what, you must have CRPS. So, and I'm coming back to the OA of the knee. So sometimes we'll allow a patient prior to MMI to have those three or five injections of the viscose supplementation, why? And then as long as the physician says, after these injections, this will no longer be related to the work injury. Why, we wanna send them off on their way and make them feel the best they can. So, this is a case I'm gonna go through quickly, but this was a real case. We had a 45 year old, a seven month employee, mechanic twists his back while he's working on a car engine, makes sense. Everything's basically normal, except his pain's eight out of 10, strength, range of motion, tenderness to palpation, all the special tests are normal, no radicular pain, axial pain. He's placed in physical therapy. After about 12 sessions, this is what the physical therapist says, pushing and pulling greater than 40 pounds, tolerating all exercises, improved since initiation, his pain's two to three out of 10. But he keeps seeing the physician for the next four years, of which the physician makes no change in his current status, doesn't place the patient at MMI, and then the patient, a new physician takes over, he retires. Patient goes into the new physician, never tells anyone, he stopped working the day of the accident, although everybody thought he was doing light duty in the office. And I get it, you guys are gonna be told a lot of stories, but try to do your homework. The new physician now wants to initiate medial branch blocks, RFAs, L2 to S1. Four years later, this patient's not working for this company anymore. So, what would you do? You're the medical director now. You have all of this, you're Monday morning quarterback. What are you gonna do? Are you gonna allow all these? Do you think treatment after four years is gonna get this person back to work? Well, it just so happens that we found out the person was working in another place and was getting paid still from the insurance where they thought he wasn't working. So, return to work, create a plan with the patient the minute they come in. We want them back at work one way or another. We know that people who have higher BMIs who smoke who have low back pain, men between 45 and 54 account for 60% of the injured workers. Document clear and concise restrictions. Again, like Dr. Novick said, what can they do, what can't they do? Consider baby steps to get them back to work. And again, if there's no work available, consider upping what you're treating them. Give them more treatment more frequently. I don't think I have to say much about this, right? I can't drive five minutes in my neighborhood without seeing these guys on the road. Do they help or do they hurt? We know injured workers who hire attorneys stay on temporary disability longer, according to some studies. If they suddenly get worse and now they're represented, that's interesting. I went to dinner with someone who didn't know what I did and they told me they were an attorney. They told me they were going back to every one of their cases to see if someone had a headache and they were gonna tell them that they had a mild concussion and add that to the claim. So be careful. I'm not saying everybody's bad. Sometimes our lawyer friends are good. And when a case settles, did you know that most of your employees, I'd say 98%, have to resign from their position? So especially if the insured is still with the carrier. So maximum medical improvement. It's a functional term. You are a physiatrist. We define it by when somebody's not gonna improve anymore. Not all patients are going to be pain-free when they are at their maximum medical improvement. Document their permanent restrictions if they have it. Be clear and concise. Permanent impairment ratings. You know the physician best. Do your own permanent impairment ratings. We know it's gonna take time. We will pay you a little bit more if you ask. So don't be afraid to do them. Sending them off to QMEs or IMEs sometimes extends the length of the claim. The patient doesn't get a chance to move on. So think about your patient. And most importantly, tips for success. Be the physician you train to be. Be a physiatrist. Take care of your patients. They need you. Document clearly. Pay attention to detail. Speak to medical directors. We can help more than we can hurt. I don't bite. I'm not that scary. I can barely see over the podium. And these workers need your expertise and the insurance companies need you. Thanks. Thank you. Thanks Dr. Weiss. Another good talk. So, and I have my work cut out for me and I still don't know how to use the control. So I'm Mark Ellen. How do we get this? Oh, I didn't touch that. I didn't touch anything yet. Yeah, I didn't use the format, sorry. I don't want the blue background like they told me back in fellowship way back when. So I'm Mark Ellen. I made the transition of working for an insurance company about three years ago. Before that I had 29 years of basically academic sports medicine, including being a team physician at the three different universities. And three years ago, it got to be a little bit too much working for a private practice orthopedic group. And I was doing a peer-to-peer and the guy seemed so relaxed. I asked him how he got the job. And he's like, yeah, we're hiring. He could just go on the website and type in medical director. So I did. And the week later, somebody from a certain healthcare company called me and I had a half an hour interview with an in-house recruiter. And then another week went by and I had an hour long interview with one of the medical directors in Connecticut. And then a week later, and then a week later, I had a three-on-one interview and the guy leading it was a retired surgeon. And I don't think he had practiced since he was probably out of residency and he looked way older than me. And he kept calling me an old dog and asking me if I could learn new tricks because they had complicated computer program and software. So I did not get that job. Three weeks later, I'm getting yelled at by some 30-year-old MBA. On the job about something. And I'm sure I was in the wrong as usual. And feeling not great. And I got a call that afternoon from a different insurance company that I apparently applied to at the same time and I forgot about. And the lady who ultimately is my boss was on the phone and decided to hire me because she wanted to try somebody new. And so I've been doing this for about three years now. My boss, that same lady is now corporate vice president and she told me I was allowed to speak here and head up the meeting a little bit. But the opinions are expressed are mine and have nothing to do with the company. In fact, the company has no idea I'm here. They don't know what I'm saying. And it's between us and the people who are being live streamed right now. So don't blame the company. So I work for Anthem Federal Healthcare. It's a subsidiary, and I'm sure I spelled it wrong, of now it's Elevans Health. They're based out of Indianapolis. We have over 300 medical directors. About 20 or 25 of us are physiatrists. We do meet virtually like every third Monday, I think, at around three o'clock Eastern time. And we do talk about what we can do to try to help out our patients. We've pushed them for simple things on wheelchairs like just having an elevated seat on a power chair. We've pushed them to have pneumatic tires as normal things when I started. They didn't pay for pneumatic tires, which as somebody who trained in a spinal cord unit, I thought that was kind of weird. And we are direct contracted to the US federal government. So when you disagree with us, I didn't make the decision that comes from the Office of Personal Management in the US federal government. They decided what they're going to pay for. We just inform you or enforce it in some way, I guess. So you should know that the medical director will review every chart that's a no. So everything that comes to me is a no. So it's been gone up the ladder. If it's a cataract surgery like yesterday, if it has the right code, it's auto approval. I don't see anything that says cataract on it unless, I don't know, they have perfect vision and something came out really weird. We look at there's a unit within in-house that looks at all public stated. They look at the evidence. They see what different academies recommends. This is why the Evidence Committee and the committees that come out of that, Education Committee, are really important here. And these CPGs that we come up with or appropriate use criteria that we're on with other academies, white papers and latest guidelines are really important because this is what they base their decisions on. So here's the codes. It goes through auto approval. If it can't be approved, nurse level review. If the nurse can't approve it, it goes to one of nine or 10 medical directors from my division. And then we have standard ways that we have to phrase things. And this is pre-negotiated. There's a fine if you don't say it the right way. So we can say it's approved, it's medically necessary, or it's denied. And then there are three levels of denial or three different ways to deny it, not necessarily levels. We don't have enough information. And as everybody said so far today, if it's not in the note, it doesn't exist, and I don't know. I'm not allowed to read between the lines. I understand where you're going, but I can't justify it to who's ever looking over my shoulder. Then we have it's not medically necessary. And that just means for whatever reason, they're not going to pay for it. And then level of care not appropriate, which usually doesn't affect physiatrists. That's more the surgical things. It's an ambulatory event. A surgeon wants to bring them in for a week or two. And that we use different things for, different rationales. So the denial letters are all going to start out with we cannot approve. And they're written in simple, simple terms down to the eighth grade level. I get dinged on this every month because I have trouble writing on an eighth grade level. And I get yelled at all the time that I'm writing too high, like a 10th grade or something. And I don't know the difference. And I was a sports guy. I was simple terms. What can I possibly know? I thought I was like sixth or seventh grade. I got hit in the head a lot. We have to give a reason of why something's denied. So it's not just going to be a blank denial. We're not paying for this. We have to say why it's not getting paid for. And then we have a place to find rationale. So we have clinical guidelines. And these things are published. You can Google clinical guideline for anything from any company. So and that goes by diagnosis. It goes by CPT code, anything. If it's not a clinical guidelines, then we'll have a medical practice module or manual. It'll come from that. Or if we don't have any guideline on it, it's going to be a more generalized discussion in the brochure, that thing that you get every year. Like right now, it's the time to change your health care if you want. It's open season. And you should review the brochures because that'll have the general gist of what your insurance pays for, not just the price. So when you're doing a peer-to-peer, who is on the phone with you? In my company, you have to have at least 10 years of clinical practice before they would hire you. And I think in my unit, just about everybody has at least 15. I am the second or third oldest, I think, in the unit. Again, most people are going to be internist, family practice, or ER, which doesn't help us a whole lot. I'm the one PM&R for the federal government for our unit, for Anthem for the 16 states. So I do a lot more of the DME and the orthopedic stuff and the inpatient rehab. I do a little bit of SNF. But most of that, again, most of our whole stuff is going to be handled by internal medicine, family practice, ER. So what our marching orders are for insider, we're supposed to be fair and impartial. We should be transparent. Where are we getting this information from? And we should be nice to you. I'm not going to yell at you. I'm not going to call you a name. I'm not going to disparage you in any way. If there's a way I can say yes, I'm probably going to say yes, like 99% of the times, until something bad happens. So what do we use to make decisions in the fairness part? We look at the CPT code, the diagnosis, the procedure, the medication, or what the device in DME is. And again, the insurance company has a guideline for every one of these things. It's a library full of stuff that it's easy to pull now because it's all electronic. So we'll use, for my unit, published clinical guidelines, they use McGilligutty inpatient guidelines. Those are published. They're not great for inpatient rehab. That's much more for what they'll pay for surgically. And they'll have every surgical diagnosis. They'll have internal medicine stuff. I don't really do the inpatient stuff. I have partners that will swap out orthopedic cases with me. And the only inpatient cases I personally do are total hip, knee, things like that, or anything else that's complex orthopedics that I have a little background on. In-house, we have the Carillon unit now. And that discusses about what they think is where there's evidence for outpatient-based musculoskeletal and surgery. They also have a radiology section that we utilize and a sleep section. We can also use a medical policy manual, which is strictly for us, for the federal employees. And if we can't find anything or we have the ability to supersede a few things, not everything, we can just use a brochure and say, you know something, we'll pay for it based on the brochure because you've had every possible treatment. Nothing works. And this may help you. So again, who's on the phone? My pay is not linked to my decision. I haven't been yelled at yet about my decision on a peer-to-peer yet. So it's been three years. I'm waiting for the day, but I haven't done it. So all I ask is that you help me out. Give me something with some teeth that I can bite into and write a nice little ditty so whoever's looking over my shoulder doesn't bother me. Before we call you on the phone for a peer-to-peer, I've already reviewed the case a couple of times. So I basically know what's going on, but I'll still ask you, why did I deny it? I didn't have enough information. And I think that this has increased since EMR. Because in the old days, you had control of your note. You knew what you were doing. Now it's da-da-da-da-da. I mean, I finished with ModMed, and it was just like hitting circles all day long. I don't know what got printed out of it. I never saw what the note looked like. I have no idea what it captured and didn't capture. The other part is you have other people in the office doing the non-actual physical exam on the note, and you don't know what they put in ahead of time. So that's the primary thing. So probably 50% of what I see and what it denies, because I don't have enough information on it. The number two thing is that the prerequisites for utilizing something, like a drug or doing a RFA, the prerequisites that are required weren't completed, or at least I couldn't find them. And again, it goes back to lack of information. And very last, the one I hate to do, because there's no way I can overturn it, is we don't cover it. And this is the one I get yelled at all the time, as if it was my decision not to cover it. So a lack of information, note missing. So we got nothing. Sometimes nothing gets sent from your office, or I get somebody else's note. I don't get to write Payson's note. That's always fun. Where the note mentions, again, like Alan was talking about, something completely different and not what they got coded for. And again, I think a lot of times it has to do with EMR, as opposed to the old time notes. When I first started at Penn, my partner was Dr. Torg, and his notes would read something like this. 25-year-old football player tore his ACL. I'm going to fix it. That was his entire note. And he calls me into his office after my first day and asking me if I'm having a good time and stuff. And he's telling me about make sure you document everything. And I'm looking at him, and he's like, kid, I charge $25 to see me. I make everything in the OR, because I don't care how much I get paid seeing patients. He's like, you have to make a living. You have to make sure you document everything. OK, Dr. Torg. So step care, what are we supposed to look for, were they treated with meds, oral meds, did they go to physical therapy, were they braced, did they have appropriate x-rays? Everybody needs baseline x-rays before you want to order an MRI. We'll also allow for ultrasounds of the area ahead of time. For an RFA, make sure they've had their medial bundle blanched blocks times two, and have 80% improvement in their scores. I don't know how you take something so subjective and you give it an objective number. I've never understood that. So for advanced imaging, make sure there's an appropriate history and an exam of the area you actually want to image. Plain film findings should be that it's not really diagnostic on your plain films. And then, have they had treatment? Is it a really acute injury that absolutely needs to have an MRI that day? Or is it something that the plain films are negative, the history and exam shows something, you're going to treat them with an anti-inflammatory, maybe an injection or something else, and they've had therapy for a few weeks and they're not doing well in therapy? This is what the timing word means on the slide. And the company I work for asks for four to six weeks. But most of us know that if the patient's not doing well in the first two or three weeks of therapy, they're probably not going to do well on the four to six week And I'm OK with you getting an MRI at that point. If it's something like horribly traumatic, nobody's going to stop you from getting an MRI. So if we do some examples and we look at inpatient SNF, what are the important things? And this is the thing that goes through the nurses and will get thrown on to us at the end of the day. They're missing an MD note. The PT and OT were not on the same page. And the recommendations are different. The patient isn't tolerating. The therapy or not performing the therapy. And they will actually look at the little boxes that the therapist fill out, like how many 30 minutes, 45 minutes. And they'll look at that and make a decision. Well, they're not doing enough therapy. They're not doing their three hours of two therapies in acute or their one hour of therapy a day on a subacute. And they don't always take into account the holidays. So make sure that there might be a little ditty in the note that said this was a holiday. And we limited treatment on this day. They should show continuous improvement. I know and you know that nobody does continuous improvement like this. It's always like a little sine wave that goes up. It's OK to have a bad day or two. But week to week, because typically the ask is for seven days at a time. Week to week, they should show improvement. And it should be something real, not just like, they made it to the doorknob today. And I've had that argument already. It's like, dude, they've been there six weeks and they made it to the door? No. And DC planning, make sure there's something in there that they can go home or somewhere else. So for those of you in the outpatient world who are doing spine and RFAs, make sure they've had the appropriate prereqs, oral meds, exam, concordant findings on films. They shouldn't have any. If they've had a radiculopathy, make sure you clearly define that this is axial pain and has nothing to do with the radiculopathy that they have. Because that will get you a big no. They failed their physical exam. They've been re-evaluated before. That's another big thing. I never see the notes if they get re-evalved. All of a sudden, they're in for a procedure note. They've had their medial bundle branches done times two with just local anesthetic. There's no steroid. It wasn't a therapeutic injection. And they had not 50, but a report of 80% improvement. For VSCO, so you're going to do your three to six shots or five shots, depending. And now there are these VSCO centers that come out. And everybody's doing this under fluoroscopy now. Not ultrasound, but fluoroscopy. They'll do what they're calling a arthrogram. I don't know if it's really an arthrogram, but they'll do that first as a separate visit. And they'll say, oh, yeah, they have a joint there. Now we're going to go back in, and we'll do five visits of high alga, because it's a five-shot dose, not a three-shot dose. We're going to charge it for fluoroscopy and stuff. So that I've already sent up to our in-house unit for fraud. Please don't do that. So VSCO supplement, OA of the knee only. Not RA, not a meniscal tear, not a plica, not anything else. They've failed physical therapy. They've been braced or had some modalities. They've had a corticosteroid injection. Most insurances want you to have two. And they haven't worked where they failed after eight weeks. That's what ours says. I mean, I'm a little more lenient than that. My partners aren't. And don't stack the injection, meaning that you're shooting the VSCO in with the steroid. That's not what it's meant for. In 2014 or 15, I guess it was 14, we had the CPG that came out on non-operative treatment of osteoarthritic knees. And that was done by the AOS. And the AUC came out, and we were going over everything. And I was fortunate to be on the writing committee on that one. And I think there were five of us. And we went in a big circle over like 12 weeks about what was going to be in it. And VSCO had failed the CPG in 2014. And because most of the papers came out, it was versus buffered sailing. The papers were basically done in Belgium or somewhere outside of Montreal. They were done in rheumatology offices. And the six-week time frame, they were about even with buffered sailing. But the VSCO people had a little bit more pain post-injection for 24 hours. So our academy and the AMSSM wrote rebuttal letters. And so now you can do VSCO. Make sure that you, I don't think you necessarily have to put down they have Kelgan, Lawrence scores of 2 to 3. It should be something in there should say that they have at least moderate degenerative changes. Mild's not going to get it. If you could put down a KL 2 to 3 or 4, that's fine. But really make sure that you have good documentation of their radiographic findings. Intracept is one of the hot new things. It's been out for many years now. We finally started to approve it this past May. We had a lot of talk about it in-house. It seems like it works well for vertebrogenic low back pain. I can approve it for that. Got a couple of minutes? I'll be done in a second. You can't have any other findings. So if there's a big disc, we're not going to approve it. So it's got to be vertebrogenic back pain with the appropriate findings on MRI emotic changes from L1 to S1, basically. They've failed meds, PT. They haven't had a fusion. If they've had a laminectomy or a foraminectomy or foramina, I can't even pronounce it. If they've had surgeries that's at least six months prior, we can approve it. We can't approve repeats just yet. And I think there's like a 40% repeat rate at this point. Trigger point injections. I get a lot of these sent to me, and it's usually the same three or four providers. They give a decent history. If they have fibromyalgia, it makes it a lot harder. So we typically don't reimburse if they have fibromyalgia. They have to have exhausted every other treatment for fibromyalgia. But what I do see the most and why it gets flagged the most is because there are no exam findings. All I get is they have trigger points. So for those of you who are old like me and remember the Travell and Simons book that came out, and they had these great descriptions of trigger points. And I used to give that talk since I was a fellow. Document that they have like a latent twitch response, that they have a taut band, that the pain when you press on it radiates somewhere, and that's the pain they feel. You can use a local anesthetic or a dry needle. Dry needling itself that they do in therapy or in chiropractor's offices is a completely different thing. But just make sure, again, you have really good documentation and promise. See, I thought you'd make it under five minutes. So thank you. And we'll entertain questions. So if you come up to the microphone and talk, we do have some questions from the live stream. And the first couple pertain to disability. First question, what do you advise to have locum tendon physicians who might not be available for follow up discussion after paperwork submitted? From my standpoint, we really work on an almost real time basis. We get notes day after appointment. So there shouldn't be a lot of that. If you're a locum tendon, my advice would be document as well as you can. Because once you move on, we're not going to be able to contact you. Another question was about spinal cord injuries. What do you do about neurogenic bladder and bowel? And what I tell people is, how long does it take them to cath? Half an hour or 45 minutes extra? Say that in their restrictions. Need 30 minutes twice a day off work to allow for catheterization. Whatever you think is necessary, that's more than reasonable. We would approve it. One last question, and we'll go to the mics here. For patients who are off work due to poor endurance and psychiatric impairments, like PTSD, how do you mention that on a disability form? We actually have a separate behavioral health division that assesses separate from physical. I would say, unless you really feel comfortable in that arena, as a physiatrist, I would defer it to their psychiatric provider and not even get into it. But if you wanted to, put it in and put the reasons. Fair enough. Hello. Hi. I want to say thank you first. Specifically, I'm actually a medical director for another insurance company. And so I couldn't agree with all three of you more. When I'm looking at my reviews, I'm not looking to deny. I'm always trying to find that path to approval and make sure we're finding the medical necessity to get there. My team actually does, one of the things that's in our scope is actually acute inpatient rehabs and SNFs. And what I wanted to add to the great talks and everything you've provided for at least the acute rehab space is that one of the barriers, one of the principal barriers that I see repeatedly is the issue with the medical necessity of the physiatry involvement. It's that three days a week, face-to-face, what ongoing acute issues are going on that require the member to be there as opposed to a SNF. And unfortunately, in a lot of reviews, it's not very well detailed. They may mention not the chronic issues. They may have controlled hypertension, controlled diabetes. That's not what we're interested in looking at. Instead, I'm looking for things like somebody with a subdural with high blood pressures that need to be controlled. I'm looking for what the ongoing things are. So I just want to add that kind of two cents in terms of what, at least on our side, for the acute rehabs that I'm missing. And I often get it on the peer-to-peer, but we don't see it on the documentation, like you said. As a medical director for 30 years of an inpatient rehab unit, I couldn't agree with you more. I mean, that was the bane of my existence was trying to. On the medical side, that's where all the denials are coming from. Correct. And again, it comes down to documentation, because a lot of our colleagues talk about the rehab needs, but they don't mention the medical side of it. Or it's checkboxes. And everybody's so used to checkboxes. You can check off high blood pressure, but if you don't describe well enough what the issue is, we can't guess at it. And so like they said, it's got to be written and described out well enough for us to be able to get there. And like I said, it's often we get there on the peer-to-peers, but it would save us some time on both ends if we could see it on paper, too. Thank you. Good morning. Hi. I'm a physiatrist. I've worked in industrial medicine, workers' comp, and such, currently with wound care and hyperbaric medicine. So my perspective of this is twofold. One, with DME, I see patients being referred to me with equipment which I never would have thought were appropriate. The folks who are filling these things out have access to these guidelines, and I feel like they're maxing out the insurance for whatever they can get for it. Are there any checks and balances for that aspect? Because if it's about trying to get something approved, it seems to be fairly straightforward for someone else, and then a primary care just signs off on it. So when we see things that are really outrageous, they send them off to peer review. And if there's not enough documentation, then the peer reviewer will say that the documentation doesn't meet the need for this piece of equipment, or that they didn't try other things before that. But it is a very big cost to the system, and people think that you're just the deep pocket. But you are really trying to, and I'm not going to say the insurance company doesn't make money. Everybody's in business. You're in business. They're in business. But at the end of the day, I think the person is the patient, and we want to give them the appropriate treatment. So we try. Second question, this has to do with disability. So I'll inherit patients who were treated by ortho, their X-fix, and then we end up kind of taking over, taking care of the wounds. And then the forms come in for disability. I try not to be able to predict exactly how long a thing will go. Is it reasonable to say, OK, within the next couple of months, this is what I'm expecting a patient to be able to do? Because the end questions of, like, when am I expecting this to be resolved and such, I think it's unfair to the patient, for me. Yeah, we never ask when it's going to be resolved. We're really asking what they can do functionally now. Can they work now? Do they need restrictions now? But if you want to put on the form, anticipate this level for the next three months, yeah, that helps us. But it's really about the now, what they're doing. And whether it's any occupation, can they do anything? Or can't do their own? And then if there's orthopedic aspects, is it OK to say, I'm deferring the other mechanical aspects to ortho because they have their own timeline? So I didn't say on one of the examples. I really wanted to say the reason we had to ask for more information, they had two treating providers. One was a PCP, and one was a neurologist. The PCP said defer to neurology, and the neurologist said defer to the PCP. At some point, somebody's got to give something. Yeah, you can always defer if you don't feel comfortable in that. But I think we're physiatrists. We're musculoskeletal doctors. And I think based on our training, we should take the point on it. At least that's my feeling on it. But you've got to do what's comfortable for you. If it's more related to the surgical fusion in the back, yeah, maybe defer to the surgeon. But if it's more of the pain or the musculoskeletal, I think you've got to take it. Thank you. I think we should do another question. We'll take one question from here, and then we'll come back to you. So the next question was, what do we do if they tell us we are not allowed to do during period of period to speak to a physician? So they got denied Ferubinol for an adult CP patient. They would not let me speak to a physician. What is our next thing to do? Wow, we never do that. That's weird. My response would be, I think the next thing to do, there's an appeals process for every insurance. I think that's the next thing you do is you start the appeals process. Yeah, we never do that. I actually give all the physicians I speak to myself. Because I'm like, if you have a problem, call me. Because these are people. I guess there was another question somebody asked about DME for a standing wheelchair and how it might benefit somebody emotionally as opposed to their ability to function. Interestingly enough, about six months ago, I approved one. I think they're really on a case-by-case basis for these very expensive pieces of equipment. But we do have to understand there are people at the other end of this. And it was helping the caretaker as well. So there were a whole bunch of reasons. So if you have reasons to want these things, I know this was an online question, and I know it's expensive, you might be able to get it through. And don't be afraid to call someone. I'll tell you, as a primary wheelchair person for my company, I've approved one in three years. This person works for the CIA. She lived independently at home. She came out of, I think, Hopkins. And the neurologist called me from there. But typically, we don't. They were saying it's beneficial. I can't approve what's beneficial. I can approve what's medically necessary. There's a difference. Sir. OK. Excellent presentations. Some years back, I was doing IMEs. And I guess the question is, how independent are IMEs? So I was doing IMEs. Wasn't the main part of my job, but I was a couple a month. I was doing it for a while. And I had a patient who didn't speak English well, dyslexic, MVA, complete C5 quad. And my report was, this is going to be a hard getting them back to work kind of case. I received a phone call from the insurance company saying, you can't really say that. So I changed the wording slightly. And I never got any more referrals from them ever again. Said insurance company, a couple of years later, I read said insurance company had lost a class action lawsuit from disability insurance patients, saying that they were unfairly denied coverage. So I'm saying, is this a weird case, or is this something that goes on? I mean, I can't speak for everything that goes on in the industry. Certainly, I think it's a little an outlier and shouldn't happen. The whole concept of IME is a misnomer, because no one's ever independent. Somebody's paying you, so right off the bat. But you try to say as neutral as possible and just say the truth. We would never ask, or I would never. I can't speak for the company, but I'm pretty sure. We wouldn't ask you to change your report on your opinion. The example I gave where they didn't address the issue, that's a problem. There's times where, because we audit most of our IMEs, we get back. And we'll ask them to clarify, just like I had the example, I asked him to clarify when he said walking made him better. Well, explain it to me. That's all. But I would ask for clarification. But we didn't ask you to change things. That would be odd. OK, thank you. And we get favorable and unfavorable IMEs all the time. So really do what you do best and be a physician. I'm not doing IMEs. No, you know what I'm saying. But I'm saying to everybody in this room, if you're doing an IME, be the physician in the room. And don't worry about what somebody else is going to think of your IME. You're the one seeing the patient. You're the one who read the records. Do your job the way you were taught to. And don't let anybody else make you feel uncomfortable or pressured. And do it with no bias in either direction. Because I've gotten some IMEs back where I go, what is this guy talking about that can work unrestricted? I thought there was restrictions. But the IME wanted to please the insurance company. That's just as bad as the other side. So stay neutral. Thank you. So we got another online question, which I do not think I can answer. It said, for Florida workers' compensation, do you anticipate any new state legislation, regulations, rules to govern the issue of physician-dispensed meds? And to that, I would have to say talk to your state people. Because I don't know if they're going to change any of these rules or regs, if any of them are coming down the pike. I do know Florida physicians are allowed to dispense meds and have dispensaries in their office, as long as they have a dispensing license. But these rules and regs change all the time. And I don't sit on that committee. The next question from here, which is really an interesting one. I may have missed the point totally. How can we trust private insurance as has an aligned interest with our patients when these companies are insanely profitable? New York Life made nearly $17 billion last year. They go on, all the different companies. While you may not be trying to deny claims, making the process harder and more convoluted on overworked physicians definitely seems strategic to increase the number of denials. Sorry you feel that way. A comment was made about how difficult physician's office phone trees can be. Setting up peer-to-peer calls with large insurance carriers is 100 times worse. Asking physicians to document more in progress notes or additional forms is always an easy way to increase noncompliance, because it's so hard to follow through at the clinical practice level. So there really wasn't a question in that venting. But I hope what you got out of this hour and a half here is that we want to work with you. We don't want denials. My company specifically says, the baseball phrase, tie goes to the runner. They tell me, try to figure out how to approve this claim. I was shocked when I got there, because when I took this job, that was my biggest fear. Oh, they're going to want me to deny everything. And that was not the case. I often get a claims manager saying, hey, the doctor said they can go back to work, but they've had four back surgeries. Do you think that's real? The claims managers talk to our patients, our customers, your patients, and they form relationships. And they want to do right by them. So this person clearly needs a vacation, and I'm sorry, and you know. Hi, Andy. Yes. I just wanted to say, filling out those physical capability forms, that's unreimbursed care. I charge patients for that. Most of us do, or did. And I mean, they're not fun. No, they're not at all. And I just wanted to make that point, that it makes sense for those of us who are already overburdened to charge patients extra for filling out those forms. But at New York Life, have you ever considered paying physicians to fill out those forms? So we've had this discussion right and left. The problem is, even paying, we get bad results. And it just doesn't seem right to pay for bad results. And I understand, in the workers' comp, you can charge for that. In the disability arena, you're trying to help your patient. And you won't get those forms if it's already in your note. It's only when it's not there that we start asking more questions. Right. But it's 20 minutes of your time, a half hour of your time. So I mean, it's. I'm not sure it really takes that long to go through that. I mean, I could have a debate with you. I think it's pretty clear. But no, right now, they don't pay, because we've gotten, in the past when they have, we've gotten really. If the doctor writes a good note, they're probably going to fill out the form well. If they write a bad note, they're probably not going to fill out the note well, even if they're paid. That's kind of been our experience, unfortunately. Well, it looks like that might be it. Yeah, thank you, everyone. I hope it was helpful. Thank you for your time. Thank you.

insurance considerations

physiatrists

patient care

income protection

claim processing

disability insurance

own occupation

workers' compensation

medical documentation

diagnostic history

medical directors

transparency

collaborative role