Posted on Mon, Aug 30, 2010 @ 10:54 AM
Question:
I am a practicing therapist in the Industrial Rehab field in Pennsylvania. We have been unsuccessful up til now in getting long term disability companies to pay for FCEs. It seems that if a doctor requests it, then the carrier states commercial insurance is responsible for payment. Most commercial insurances do not cover FCEs either. I am wondering if this is a situation unique to PA and if anyone has any information on who to contact with these disability carriers to try to get them to start paying for FCEs.
Answer:
OK, here we go...
FCEs for disability are a difficult, but growing area of practice. If you follow our monthly medico-legal webinar series you will have noticed that about half of the court cases we review are ERISA cases and the other half are ADA-EEOC cases. Given the string of settlements recently published in these two areas I see a growing opportunity for evaluators who can cultivate relationships with disability carriers. (read my recent article in Advance for Occupational Therapy Practitioners for more details).
The first step in finding a payment source for a disability eval is to identify the covering party. There are several options for proceeding:
1.) Ask the client (the patient) for a copy of his/her application for disability. (They should have filed paperwork by now if they are applying for payment of benefits). Within that paperwork you will find who wrote their policy and who is managing the "administrative file".
- If the client has not filed for benefits, but is a professional person he/she probably has a copy of a personal long term disability policy (they should have it!). In this case the policy should have contact information.
- If the insured is not a professional-level person, the policy may be a group policy. Again, ask the client to obtain a copy of the policy. I personally would not do the leg work at this point; many, many times the person thinks they are covered, but are not. Or they think they should be, but don't really know if they are. Let them do the leg work to obtain the details you need.
2.) Once you have identified the payment source you will begin a long road to discovering who is responsible and why they are responsible. The policy will have details about the exclusion term of the policy, the "same job" or "like job" terms of the policy, etc. It is at this point that you MAY discover whether the client is even entitled to be considering a disability claim.
3.) Now, if you get this far, be sure you have agreement for you to perform and get paid for your services. The underwriter may already have in place a team of professionals to perform these services. If they do, suggest that you be added to their team.
Sound like a long road? It is and is probably not worth pursuing for one client. You really want to build relationships with attorneys, first, and carriers, second, so your initial investment of time returns dividends over time.
Think of this as a 5 or 10 year engagement.
If you want to discuss this further call me at 1-800-443-7690 and/or tune in to our monthly free webinar.
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Posted on Tue, Apr 13, 2010 @ 01:06 PM
Question:
Getting written referral questions is like pulling teeth. We are thinking about making a referral form that can be checked off. What do you think and do you have any other suggestions on getting those?
Answer:
Not getting clear referral questions sets you up to not be at the top of your game. Thinking Evaluators working important cases always develop a clear understanding of the purpose for evaluation as well as specific referral questions.
A step toward getting some kind of referral guidance is to use a form listing the questions you typically answer, like "Did the client provide full physical effort during testing?" or "Were the client's reports of pain and disability reliable?", etc. (For those who have completed the Functional Capacity Evaluation Certification Program, a sample form can be found in your course manual and on the website in the Resources section.)
Another idea is to use a triage format to guide the referral source through the thought process. Start with the types of FCEs you do: RTW SJSE (return-to-work, same job, same employer), RTW (return-to-work, not same job), residual capacity, Ability to Benefit, Short-Term Disability or Long-Term Disability. The triage is created by the system in which you work: when doing short- or long-term disability, does the system focus on "ability" or "restrictions"? The answer to this will guide the referral source in checking off the path the case will follow. If it is a RTW SJSE the referral source may want you to exclude any medical information from the published report.
In the long-term, educating your referral sources is the best solution. One tactic we found to work is to annually hold a luncheon for referral sources. Try to get case managers and support staff from physician's office to attend the lunch. The point of the lunch is a very short presentation on the subject of Functional Capacity Evaluation (FCE). You would typically start with a discussion of how to refer, the uses of FCE, etc. (These days a brief discussion outlining the 7 uses of FCE would be a good opening to the discussion of how to refer.)
The key to the lunch is the short presentation followed by input from your audience: let them talk! You will find that seasoned referrers will have a lot to say about your services; less seasoned participants will tend to listen to the more experienced referrers. This is an excellent opportunity to build relationships with the new crop of potential referrers.
If all of this seems challenging, join my "How to Write an FCE Report" online course.
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Posted on Wed, Mar 24, 2010 @ 11:17 AM
Question:
What do you believe is the future for cases involving Short-Term or Long-Term disability, compared to what we're used to in Workers' Comp?
Answer:
This is an excellent, forward looking question.
Here's my thinking on the future of Functional Capacity Evaluation:
Keep in mind that we are talking about the FCE market in the United States. My comments would be different if we were talking about British Columbia. (The markets in Ontario, Canada and the United Kingdom have problems similar to the U.S. market, but are at a different phase of market development.)
Recent inclusion of functional capacity evaluation reports as evidence in short- and long-term disability cases foreshadows positive change to the practice of FCE in the United States.
Here's the background:
For the most part FCE's performed for workers compensation are not reviewed in an informed environment.
In the U.S., with very few exceptions, there is no legal review process that acts as a crucible of quality. Since the workers compensation system is a no-fault, non-tort system, very rarely do two informed attorneys sit across a table or stand before a labor board and examine expert FCE witnesses. In most cases the arbitrator of quality is the fee payer. This lack of informed review allows a very low standard of practice for functional capacity evaluations.
The important change is the use of short- and long-term disability cases in courts that have the power, under the Federal Rules of Evidence and the Federal Rules of Civil Procedure, to examine the details of an FCE. Under these rules a written report must be submitted for cross examination. And, when submitted for cross examination the evaluator must be able to present and defend his/her findings. The evaluator cannot rely on "the computer told me the result" or "the formula for determination is secret". And, given the findings in Indergard v. Georgia-Pacific, a job-calibrated functional capacity evaluation protocol will replace the standardized test battery approach to FCE. My belief is that the necessity for public testimony by functional capacity evaluators will dramatically change the FCE landscape.
The downside in the current FCE arena is the growth of FCE referral brokers and the emergence of superficial FCE training programs.
My observation of referral brokers is that they tend to reinforce the status of FCE as a commodity. A broker's expertise is the ability to market and sell. This takes advantage of the new evaluator who has not established a practice based on answering referral questions. Coupled with the broker's lack of quality differentiation, the result is a fast moving "mill" of evaluations churned out with little focus on validity, practicality and utility (see the Practice Hierarchy for definitions).
Safety is the foundation of the Practice Hierarchy espoused by
the APTA, APA and NIOSH and is the central focus of Matheson FCEs.
The second part of the downside formula is the annual emergence of superficial FCE training and "certification" programs. Every year we have people come through the five-day Matheson Functional Capacity Evaluation Certification Program with the intention of rolling out a copy of our training. Every year we have people stand outside our classrooms counting the number of people attending the program. I can feel them calculating what they perceive to be a great revenue stream. I can also see them figuring out how to set up the training in low cost venues with little or no transportation costs for equipment and computers. And, just like spring coming each year, these folks offer two or three days FCE "certification" courses within a few months of having attended our courses.
The result of these superficial training courses is that it has diluted the long-term quality of service.
One can participate in this type of training and easily set up a practice taking referrals from brokers. But, just like unqualified people buying too much house from home loan brokerage mills, eventually the market collapses.
I think the FCE market is in that state now.
Request a free, 30-day, no-obligation trial of our Functional Capacity Evaluation Software!
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Posted on Mon, Mar 22, 2010 @ 01:54 PM
Question:
How do you balance between being objective with the clients and doing an extensive review of the case and medical file? I have had private investigation reports thrown in to files. Also do payers balk at paying for time spent in reviewing and preparing for FCE?
Answer:
My suggestion is one you have heard before: the referral questions and the purpose for referral establish the scope of the engagement. Are you being retained to administer a straight-forward FCE? Are you being retained as an expert witness for the purposes of file review?
Once scope is established, read the documents that are pertinent to your mission. In most cases sub rosa video tapes are not germane to your purposes.
The scope of your engagement should also set the parameters for the extent and cost of file review. File review and deposition/trial preparation generate a significant portion of a high level Thinking Evaluator's work.
If anyone has any comments or suggestions about this topic, please feel free to add your input in the comments section!
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