Archive for the ‘Neuropsychological Tests’ Category

As a consultant I’ve always held the opinion there is something inherently wrong with a disability insurer who sends a letter to an insured with inaccurate statements. In fact, some statements are so obviously inaccurate one has to wonder whether those who make them are qualified to review claims at all.

Mass Mutual recently sent an insured a letter stating, “…as a patient you are entitled to these [psychotherapy notes] records.” This statement is grossly inaccurate and I would have thought Mass Mutual would know better.

Very rarely will therapists and psychiatrists release their patient notes directly to mental health patients. It makes good sense not to do so since what is contained in the records could potentially be harmful to those who are reading them. In some cases, therapy notes have been noted to be the cause of patients attempting to hurt themselves and therefore, it is generally recognized that therapy notes should not be released to mental health patients.

In addition, therapy notes are regarded by mental health professionals as proprietary to them written for the purpose of “reminders” of what took place during therapy sessions. Therapy notes are NOT written for the purpose of verifying disability through mental health restrictions and limitations. Mental health providers now regard patient notes as private references for their eyes only.

Over the last several years those who provide mental health therapy have noted the misuse and misrepresentation of information by private disability insurers to the extent that they themselves have office policies not to release therapy notes to anyone. More often providing “actual psychotherapy notes” to companies like Prudential and Mass Mutual hurts insureds more than they help.

Here’s how:

Patient notes rarely document “affect” which is an observation of how the patient’s reactions are, (flat or normal), and therefore insurers use this omission to deny claims. Prudential, for example consistently states in denial letters that the therapist failed to comment on “affect” and denies claims just on that basis.

Most behavioral therapy does not require neuropsychological or other tests to diagnose clinical depression and many other anxiety states. Yet, insurers look for documentation of “objective testing” in the notes when most therapy does not require it, or there is a lack of psychological tests available to diagnose specific conditions. There is a non-acceptance of WHO DAS 2.0 (in lieu of the GAF Score) by insurers, and clearly isn’t considered “objective evidence.”

In other words, if the actual psychotherapy notes do not contain exactly what Prudential and Mass Mutual want to see, claims are denied. The expectation that all therapists document what is needed by insurers to evaluate claims is unreasonable and ultimately unfair.

In the past, Unum denied a depression claim because surveillance showed the insured having sex with his girlfriend in the woods. Patient notes were submitted to Unum but were not considered as compared to the surveillance. Therefore, according to Unum those with depression aren’t supposed to be having sex. What idiocy!

Recently, Mass Mutual threatened an insured with claim termination if he didn’t obtain his therapy notes and submit them. Mass Mutual’s claims manager told me personally, “Those records belong to him and he needs to obtain them and provide to us.”

The letter clearly said, “No additional payments will be made until we receive the daily treatment records from [your doctor]. What if this patient’s therapist refuses to release his patient notes? Should Mass Mutual penalize the insured because his therapist refuses to release notes? And, even if the psychotherapy notes were released, Mass Mutual (Prudential in particular) will allege the notes do not contain sufficient detail to continue to pay the claim.

Are you getting the idea that mental health insureds and patients are “clucked” regardless of what they, or their therapists do?

In any event, Prudential and Mass Mutual continue to insist on psychotherapy notes, which by the way, is an out-of-contract request. No where is anyone’s policy or Plan is there a duty or requirement to submit actual psychotherapy notes as “proof of claim.”

When I asked the Mass Mutual claims manager to fax me the page from someone’s policy requiring submission of actual psychotherapy notes, she gave me the run around and then said, “but our Authorization allows us to request them.” That’s true, Authorizations may request submission of notes, but that doesn’t mean the therapist is willing to release them.

Unfortunately, ERISA Plans often include the phrase, “…satisfactory to us…” which  permits “discretionary authority” to the insurer to decide what is and what is not “proof of claim.”

Mental health claims remain a constant source of controversy as insurers continue to deny claims for failure to submit actual psychotherapy notes they may not be entitled to.

Therapists should be able to submit mental health restrictions and limitations in summary form (filling out forms or submitting letters) rather than giving up patient notes not intended for the validation of private disability.







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Neuropsychological testingRecent conversations with reliable neuropsychologists suggests that it is more common these days not to provide raw data to insurance companies. According to my sources neuropsychologists don’t have good opinions of insurers who request raw data so that internal physicians can interpret test results in ways that favor the insurance industry.

Currently, it’s customary for insurers to request raw data (actual test results) from qualified evaluators so that insurance MDs can interpret the data differently. Although neuropsychological tests are generally regarded by the insurance industry as objective evidence, those in the industry know differently.

Neuropsyche tests consist of a battery of tests selected by the evaluator based on the patient’s history, diagnosis and probable outcome. Test scores are obtained from the tests themselves and are then compared to normative values consisting of statistical population scores for those in similar groups. Once scores are obtained, evaluators interpret the test results and render summary reports representing opinions of what the test scores mean. To say that neuropsychological evaluation represents “objective evidence” is a stretch.

The American Psychological Association forbids the transfer of raw data to those who are unqualified to interpret it. Therefore, even when the raw data is provided to insurers the “chain of evidence” must be maintained in order to protect the integrity of the tests. In addition, neuropsyche evaluation cannot be done more than once in a 12 month period. Typically, a baseline test is completed and if appropriate all future test results will be compared to baseline.

The transfer of raw data to insurance companies interferes with the integrity of the data. It is now known that insurers such as Unum and Prudential request the raw data so that it can be interpreted by internal physicians to support business decisions already made to deny claims. Neuropsychological tests are not objective whether they are performed by claimants’ evaluators or internal insurance physicians.

In my opinion and experience, neuropsychological testing is a garbage-in, garbage-out evaluation. Neuropsyche IMEs performed by insurance evaluators often fail to choose the correct battery of tests to determine disabling levels of cognition, brain fog, chemo brain, and many other dementia or self-reported type illnesses. Although there are collections of tests out there to evaluate fibromyalgia, most insurance evaluators do not test to prove disability, but to discredit it.

Insurance IMEs always include the MMPI-II or a newer version of it misused to evaluate malingering. Therefore, from the onset, insureds and claimants are “set up” by defense neuropsychological evaluations when the correct battery of tests is not administered.

Due to the insurance industry’s corrupt use of neuropsychological data, many evaluators are choosing not to release actual test data from their offices. “I will never, never let that happen”, one client reported her neuropsychologist saying, “I will never release actual test data to an insurance company. The data is misrepresented and results in further psychological damage to my patients.”

It would appear that the insurance industry may have fouled its own process by using neuropsyche raw data to further its own profitability objectives for so many years. What used to be thought of as “objective evidence” is really the result of differing opinions as to what raw data scores actually mean. In short, raw data evaluated by 5 qualified neuropsychologists could result in 10 opinions.

I’m happy to see neuropsychologists smarting up to insurance abuses of the specialty and thinking twice about giving raw data to insurers. My impression is that some evaluators are savvy to the industry’s abuse of the raw data and are anticipating changes on the way preventing the release to insurers.

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Prudential logoAlthough Prudential Financial can have its finer moments, the company is second only to Unum Group in bad faith and unfair claims practices. The company’s medical review process is actually worse than Unum’s in that it allows Registered Nurses to override medical decisions and documentation from MD specialists, and board certified physicians.

Treating MDs with board certifications are getting angry and frustrated at Prudential’s use of RNs for medical review. One neuropsychologist said recently, “How dare those unqualified RNs tell me I don’t know what I’m talking about.” But they do, and Prudential’s claims are denied as a result of allowing Registered Nurses to practice medicine without a license, or any other specialized qualification. Most of the RN reviews are outsourced to medical review facilities; in addition, Prudential also uses Unum’s old “claim killer” physicians who are still working in the Portland, ME area.

In my opinion, if attorneys stopped their “settlement chasing” for a moment and questioned these practices in court, perhaps Prudential would move in different directions. However, at least for the moment Prudential is profiting from using RNs for their medical reviews that often override recommendations given by board certified medical doctors.

Yesterday, a Prudential claimant contacted DCS, Inc. about an appeal that has been delayed over and over again because of Prudential’s insistence in obtaining the raw data from a neuropsychological evaluation obtained by the insured. Although opinions about neuropsyche testing differ, it remains clear that this type of testing is NOT “objective” since the raw data (the tests themselves) are scored against normative standards on which opinions are then rendered by a neuropsychologist. It’s no secret that any set of raw data given to 5 neuropsychologists may produce 10 different opinions.

The American Psychological and Neurological Associations require “raw data” to be sent only to those who are qualified to interpret it. This means that one neuropsychologist must request the raw data which is then sent to another neuropsycholgist. Raw data cannot be sent to a claims handler, an RN, and may never be placed in a disability claim file. Neuropsychological data may not be obtained with a signed Authorization either. The “integrity” of the test data should be protected at all times. I myself have found actual test data in Prudential claim files…….shame on you, Prudential!

Prudential doesn’t get it. It’s claims handlers send signed Authorizations to neuropsychologists demanding the release of raw data. The doctors quite appropriately refuse to send it. Delay, delay, delay…..Prudential just doesn’t get it. If they want the raw data, a neuropsychologist must write a letter asking that it be sent directly to him/her for review. Raw data should never be reviewed by RNs, nor should it be placed in disability claim files.

Why doesn’t Prudential, a major insurance company know this, especially when its VP of Claims is Cathy Liston, a former VP of Unum Life Insurance? Prudential Financial always has been a disorganized and chaotic mess. It operates on the cheap, and does not train its claims handlers to any great extent. The company engages in several unfair claims practices that should place it into “Conduct Market Review” on a regular basis.

Prudential’s “trick” if you will, is to pay STD within a week or two of maximum duration and then deny it before claimants actually meet the EP of the LTD policy. It’s not the STD Prudential doesn’t want to pay, but the more expensive LTD. One really bizarre characteristic of Prudential’s claims process is to send out multi-page letters regurgitating policy provisions over and over again. Prudential’s letters really do not contain very much new information, and if the claims handler is asked to explain the policy provisions, claimants find they really don’t know very much about it.

Prudential also refuses to pay for fibromyalgia, chronic fatigue and quite often depression claims. Our non-profit organization NCDI reported a Prudential RN for contributing medical reviews beyond her expertise on a depression claim and practicing medicine without a license. The Board of Nursing in Maine refused to do anything about it, no doubt due to the tremendous insurance lobby and political influence we have in Portland.

Prudential’s reviews are not known to be timely either. The company delays paying initial benefits as well as overturning legitimate appeals as long as it can. Combined with arrogant claims handlers, Prudential’s customer service is non-existent. In my experience, Prudential’s claims staff rarely pick up the phone to answer calls.

The issue of attempting to obtain neuropsychological data with authorizations is a serious one and should be reported to state insurance departments as well the American Psychological Associations and Medical licensing boards. Optimally, neuropsychologists should be the ones who report insurance companies who do not obey the rules, but it’s rarely done.

Although Prudential Financial doesn’t get a great deal of bad press, it really is a horrible company. In my line of work I have connections with attorneys who complain about the company all the time. This brings the top three worst disability insurers – Unum Group, Prudential and CIGNA to the forefront as those employers should stay away from in the group STD/LTD market.

In the meantime, Prudential claimants continue to get “plucked” at every opportunity and the company is just another in a long line of “bad eggs” in the group disability insurance market. Unfortunately, Prudential insureds are in for a really hard time.

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I know I’ve said this before, but every time I think I’ve heard it all about Unum’s unfair claims practices, something new comes to light that tops the last egregious protocol to deny more claims.

Unum has been requesting quite a few neuropsychological evaluations even from insureds who are physically disabled, not cognitively or mentally. Recently, a very prestigious Unum IME neuropsychologist blew the whistle when he told a client, “Unum is requiring me to administer so many tests I can’t possibly finish them in one day!” Oops! Busted!

Since when is an insurance company allowed to determine the battery of tests administered during an IME? Although neuropsyche tests are said to be “objective” they clearly are not when Unum’s paper reviewers who have vested monetary interests in denying claims can dictate the make-up of the battery of tests administered during their IMEs.

As you may recall, neuropsychologists are supposed to review the patient’s case history to determine which tests should be administered to determine or evaluate specific diagnoses. When neuropsychological tests are administered by treating physicians, the purpose is to construct a “battery of tests” which separately and/or in combination show tendencies toward certain cognitive or mental problems.

Unum and other insurers “stack the deck” against insureds by having input (Unum actually requiring certain tests in the battery make-up) into tests which do not evaluate insureds’ claimed disabilities. Although the MMPI-II was not designed to pinpoint malingering, it is consistently used by Unum as an identifier to malingering and somatoform disorders (imaginary or “all in your head.)

In order for neuropsychological tests to have the semblance of objectivity, a qualified neurologist or neuropsychologist selects the tests and evaluates the results against a set of normative values.

If insurers such as Unum are allowed to choose the make-up of the battery of tests to be administered, the test is unlikely to pinpoint any diagnosis or mental defect close to the claimed disability.

In fact, neuropsychological tests may be a “set-up” from the beginning. Without the right tests administered given a specific medical history, neuropsychological tests are useless and operate more of a “garbage-in, garbage-out” process. If insurers such as Unum are allowed to request certain tests in the “battery” then it seems only fair that treating neuropsychologists should have input into the battery of tests as well.

In addition, I have to wonder about professional neuropsychologists who cave in to Unum’s demands to dictate tests to be administered for money. Unfortunately, it appears IME physicians are willing to give up discretion for test determination thereby giving the insurance company exactly what it’s paying for – a report supprting claim denial.

There’s a great deal of money to be made by giving neuropsyche IMEs and, like Unum’s internal physicians who give up their ethics for money, IME physicians are apparently allowing Unum to dictate not only what tests are to be administered but how many.

Attorneys need to take notice of this new development of allowing companies such as Unum to dictate the make-up the battery of neuropsychological tests. Insureds should always demand to know who is actually choosing the tests to be given. Is it Unum or the IME neuropsychologist?

Attorneys and insureds should start asking the right questions: “Have you reviewed the insured’s medical file before determining the battery tests to be administered?” “Please disclose the battery of tests to be given to the insured prior to the actual IME.” “We would like to have the battery of tests reviewed by the patient’s own neuropsycholgist prior to the IME.”

What really bothers me is that communications to and from the IME Network or facility are not included in the claim file or Administrative Record. ERISA disclosure require Unum to disclose all information used in making the termination or denial decision yet IME communications, contracts, and other information provided to IME physicians are NOT disclosed.

Copies of sign-on or case agreements should be included in claims themselves as well as payments made for IME services. Not providing copies of all communications between Unum and IME facilities/IME physicians is an ERISA violation in my opinion. Attorneys need to smarten up and start requesting IME documentation even if they have to subpoena it from the IME facilities or network.

This new phenomena clearly shows that the word “independent” in the acronym IME does NOT stand for objective or fair. What does it say about Unum as a company that it now “stacks the deck” against insureds by choosing the battery of tests to be administered by an IME physician who is paid money?

Unum continues to “stack the deck” against insureds and claimants in many different ways. Choosing, or selecting any part of the battery of tests administered by an IME neuropsychologist should immediately invalidate the neuropsychological IME.

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