Feeds:
Posts
Comments

Archive for the ‘Physician Issues’ Category

There seems to be a great deal of confusion as to when the insurance company pays for medical information and when the insured or claimant foots the bill.

If the insurance company sends you, the claimant, regular and customary update forms to give to your treating physicians for completion, then you are required to pay the bill. In fact, most ERISA Plans contain specific language that claimants are responsible for providing “proof of claim” at their own expense.

HOWEVER, on those occasions when insurers send forms directly to physicians for completion, the insurance company pays the bill. In my opinion, physicians are cheating themselves from collecting fees for their time.

In reality, physicians should be charging insurers not only for their time, but for use of office machines (computers and photocopying), and office personnel in addition to the actual time spent in filling out the requested forms. Some physicians begin by charging $100 per request and then increasing the fee by $100 increments when multiple requests for the same information are received.

Treating physicians will often fax the insurance company an invoice for the required fee with a note stating that once the fee is received he/she will provide the information. Even physicians don’t trust insurance companies when it comes to payment.

So, the rule of practice is actually very simple – if insurance forms are sent to you for your normal update from your physicians, YOU pay the bill.

When forms, questionnaires, narratives or patient note requests are sent directly to treating physicians from insurers, the insurance company pays invoices sent to them by the treating physicians.

If your physician hasn’t been billing insurers for information requests sent to them directly they are cheating themselves out of fees for their time and use of office resources.

Please speak with your treating physicians and make them aware that any requests they receive directly from your insurance company are billable opportunities. I find that when physicians bill your insurers it keeps them from requesting (or losing) the same information over and over again.

Physician billing actually keeps insurers from harassing physicians for frequent information, and it keeps the insurance companies honest about obtaining only the information they need.

Read Full Post »

Unum’s Internal Physicians Practice Voodoo Insurance Medicine by Linda Nee

There’s an old saying, “If someone can’t do their job, they always teach.” Insurance companies like Unum typically hire physicians, who for whatever reason, can no longer perform clinically but want tush jobs paying big money.

It’s not as though Unum’s physician’s run around sacrificing heads of chickens, but make no mistake – insureds and claimants are harmed by the extraordinary lack of ethics it takes to document denials for the insurance industry.

Insurance medicine, including IME physicians is a multi-billion dollar a year industry. Once employed or retained by Unum or any other disability insurer the objective is to immediately review patient notes and medical records so that insurance companies can justify legitimate denials of claims that should in fact be paid.

Although insurance physicians hired directly by Unum lack actual recent clinical experience and practice they do lend their “board certified” certifications to the illusion their opinions and documentation are credible. It is also true Unum “buys” the credentials of its internal physician consultant’s to the tune of $125,000+ per year in salary with an option of receiving up to 30% in yearly incentive bonuses for supporting Unum’s agenda to deny claims.

 I am told by physicians today that nearly all practicing physicians are “board certified” making Unum’s emphasis on the credential an a gross exaggeration. Although physicians who stack the deck against insureds are no better with credentials then they are without, Unum always pays top dollar in yearly bonus for physicians who agree to support the company’s denial agenda.

Insurance medicine is an entirely different expertise from medical patient diagnosis and treatment since insurance physicians conduct only “paper reviews” and have no actual medical treatment history with insureds who submit claims. Clearly, those physicians practicing insurance medicine for salary and bonus have no patients other than the corporation itself.

Skilled in self-interest “interpretation” of medical records, Unum’s physicians seek to assist Unum in meeting unreasonable profitability goals. In fact, Unum couldn’t do it without its pay for play hires who deprive thousands of insureds and claimants from legitimate benefits each year.

In addition, the objective of practicing insurance medicine is to “assist disability insurers achieve annual targeted financial goals” rather than identifying and treating disease. A second objective is to provide, through written reports and documentation, the “illusion” of credibility about whether insureds can work or not.

From the thousands of medical reviews I’ve read over the last 25 years on both sides of the claim fence the following appear to be clear objectives of all insurance-paid physicians:

  • Paper review only for the purpose of discrediting any medical restrictions and limitations provided by any physician not paid for by Unum. (Treating physicians) In fact, one of the first things UnumProvident did was to announce that only internal medical reviews would be used to approve or deny benefits.
  • Document medical standards, which support Unum’s agenda to not pay claims rather than current medical diagnostic criteria recommended by the AMA.
  • Engage in doc-to-doc calls for the purpose of intimidation and persuasion to obtain a work release or buy-in from the treating physician agreeing to a return to work even when the patient would not be able to sustain work at any level.
  • “Snatch” key phrases from patient medical notes that support Unum’s position of denying claims at the expense of all else contained within the records.
  • Document and support Unum’s Quality Compliance Department’s directives as to language and content of written medical reports and documentation for the purpose of guaranteeing appeal upholds and state and federal regulatory scrutiny.
  • Support claim denials by rendering reports and documentation which make the non-payment of benefits “look good” as if the denial was the “absolute correct” decision.

Clearly, in my opinion Unum insurance physicians appear to take no pride in accurately diagnosing disease, but rather choose to do the bidding of the company paying their salary. Each physician has his/her price for leaving the standards of traditional medical practice behind from “do no harm” to “harm as many as you can.”

A good case in point recently, is a female physician client who was diagnosed with 1) herniated disks with spondylitic changes with encroachment, 2) spinal stenosis, 3) angular bulging disk, 4) reversed curvature suggesting muscle spasm, and thoracic spondylosis. In addition, the insured will require surgery on both of her knees in the future.

Also, this insured was offered a lump sum settlement by Unum in 2006 – an offer she turned down because the offer represented less than 53% of the net present value at the time.

As part of Unum’s current agenda to “go get all the claims in the EDU and deny them” this unfortunate insured was again targeted for “risk management”. Unum’s “Medical Consultant”, contacted the treating physician by phone and attempts were made to persuade the treating physician that this insured could return to full-time work without restrictions.

Several weeks after the doc-to-doc call, the insured received notice Unum scheduled an IME. Just how much medical evidence is needed in order for Unum to pay this claim? Clearly, Unum’s scheme is to investigate claims for the purpose of denial rather than approval.

Years ago Unum’s physician claimed a HIV insured with a T-cell count of 200 could return to work full-time. It’s unclear where that medical standard came from since upon investigation DCS, Inc. learned a T-cell count of 500 was considered to be functional for a HIV patient and that counts as low as 200 placed the patient at risk for severe bacterial infections. If this isn’t voodoo medicine I don’t know what is.

Unum’s docs often communicate surveillance information to treating physicians that falsely accuse of activity including trips to Toronto when the insured didn’t even have a passport. Unum’s physicians do not follow-up on information they are given and therefore support Unum’s agenda unintentionally, or as some would say, blindly.

Working for Unum as a medical physician consultant does not come without a price. My observations are that it is similar to working for the mafia – once in, you either support the cultish agenda to deny claims, or you’re out. All Unum employees learn very quickly that its “their way or the highway.”

Years ago DCS, Inc. was contacted by a former Unum Medical Director, terminated because he refused to change the wording of his reports to comply with what Quality Compliance wanted him to do. His descriptions of what Unum’s management did to him prior to termination are pretty scary including humiliating him in front of peers.

In the end, Unum’s internal physician consultants’ support agendas that have nothing to do with the practice of medicine, or the identification of reasonable restrictions preventing insureds from returning to work. As “reborn company hacks” they review medical records with a deliberate prejudice to comply with management’s profit targets even though their recommendations could cause harm or even death to insureds.

A good example of the potential harm documented by Unum physicians is the pattern of practice of denying addicted anesthesiologist claims by alleging these physicians could return to the surgical arena where drugs are readily available. It’s no wonder the rates for remission are lower in this specialty since anesthesiologists are forced back to work prematurely by Unum physicians.

Bottom line, insurance physicians practice “paper medicine” because they either are incapable of practicing on their own, or choose the cushy life behind a desk at the behest of insurance management. Unum’s physicians sell-out their medical licenses and credentials to the highest bidder, and quickly learn the “lingo” of disability insurance – their opinions becoming a “turkey shoot” to Unum insureds.

What attracts physicians to Unum are commonalities of self-interest. Unum wants to use their credentials to bolster the notion of credibility, while at the same time physicians use Unum to provide better than average salaries and benefits when actual medical practice isn’t an option. One of the cardiologists I worked with quickly learned his “denial role” when the Medical Director had him on the carpet for “approving too many claims.”

In the end, Unum’s physicians do not practice medicine in the traditional sense, but rather use their education and experience to further the agenda of the most egregious disability insurer in the world.

One has only to wonder what goes through the mind of a Unum physician when it’s clear their documentation isn’t medically sound and is destined to cause future harm to someone. Does sending an insured neonatologist with HIV back into the NICU after suffering three heart attacks and having 5 stents placed actually make sense? Would you want your newborn infant cared for by a physician who isn’t physically able to be there when you need him?

Insurance decisions to return chronically ill and addicted insureds back to work could have serious consequences for the general public who may not want seriously ill medical professionals treating them.

We can only hope as educators and consultants in the insurance industry that we can open the eyes of insureds and claimants to one of the most popular and profitable insurance medical scams in the United States.

Unum applies a multi-heirarchial medical review process that “encourages credibility by numbers.” First, there is a walk-in RN review followed by one or more doctor’s reviews, and finally a review with a “medical director.”

Since all of the physicians employed by Unum are “scared straight” no one disagrees with the decisions made by physicians who first reviewed the claim. What this process actually does is pinpoint exactly Unum’s strategy to give the illusion of credibility with more than one medical review in the record.

IME physicians earn in excess of what they would ordinarily make running their own medical practices, while internal insurance physicians crank out thousands of voodoo chicken claw medical reports intended to deny more and more legitimate claims.

The trend today, however, is for insurance physicians to work for various medical review facilities who then review information for the insurance industry. The thought is that companies such as Unum remain “an arms length” away from the medical review process and less susceptible to bad faith accusations and lawsuits. In one example I reviewed recently, an outsourced medical review was TWO arms lengths away from the actual company fiduciary.

I’m sure the thought behind “outsourcing” is to  add to the credibility of the review/denial process but it is the way it is, and the public doesn’t seem to have problems identifying unfair review when they see it or read it.

Perhaps we should start asking physicians what it takes to sell out their personal integrity and medical licenses to insurance companies who use them to better their profitability. What makes insurance physicians believe that it’s appropriate for the insurance industry to establish standards for what they document and sign their names to?

I wonder what their responses will be when they actually realize the jig is up and they are no longer respected by practicing physicians who take the oath of “do no harm” seriously. Insurance defense physicians are recognized as bottom feeders by peers which is why some IME physicians hide the fact they also work for insurers to conduct IMEs.

Unfortunately for insureds, the medical review process remains tainted with bias and prejudice, documented by insurance physicians who do more harm than good.

Read Full Post »

Insureds diagnosed with FMS or CFS may have more difficulty finding Rheumatologists who are willing to sign off on private disability. Although Rheumatologists continue to treat and receive payments from FMS patients, they are less likely to support FMS as a legitimate cause for permanent disability.

What I see emerging are Rheumatologists who throw their patients under the bus when it comes to signing disability forms giving patients less than sedentary capacity for work. From my perspective, about half of practicing Rheumatologists do not believe FMS or CFS is cause for disability with the remainder still willing to treat, but not certify as disabled.

I have no problem with physicians who are up front with patients about their assessments of FMS and work capacity. Some Rheumatologists rightfully discuss the fact that he or she believes a patient can “do something.” Of course, insurance companies are ecstatic when treating physicians complete forms noting, “patient is capable of sedentary work.”

ERISA Certificate holders are most hurt  by “iffy” Rheumatologists because of the “any occupation investigation” that takes place after 24 months. All insurers need to deny claims is a statement from treating physicians that patients have “sedentary capacity” since there are always “alternative sedentary gainful occupations” identified, (not always legitimately), to deny claims.

However, I do have a problem with Rheumatologists who accept fees from FMS patients receiving private disability but never inform them they won’t support total disability  or if they do, for very long.

A good example is Stephanie, who was treating with her Rheumatologist since 2003 when he retired. In the past, he supported her disability due to FMS, but unfortunately she had to find another doctor who would also support her disability.

Without informing her, the new Rheumatologist accepted a call from Unum’s doc and said, “I can’t believe this patient can’t do something.” Without any further investigation, Unum denied Stephanie’s claim. To begin, Stephanie should have discussed the possibility of doc-to-doc calls with her physician in advance, and secondly she should have been informed by her doctor he felt she could work.

It is more appropriate for FMS treating physicians to “work toward” building work capacity and engaging in “work hardening” programs and treatment plans rather than giving work capacity to an insurance doctor out of the blue. This Rheumatologist did not act in the best interests of his patient.

A situation like this should never occur. Those who are disabled due to FMS and CFS have a hard enough time supporting private disability claims without getting the double whammy of doc-to-doc calls and treating physicians who suddenly throw them under the train.

The private disability industry hasn’t changed just because FMS and CFS aren’t the nasty Internet priority anymore. Insurers are reluctant to pay FMS claims and aggressively risk manage them until they can be denied.

I urge FMS insureds and claimants to have conversations with their Rheumatologists to discuss several very important things:

  1. Whether or not you will allow your Rheumatologist to speak with any insurance company on the phone; and
  2. What your realistic work capacity is, and whether or not your physician is willing to support total disability. If so, there should be a treatment plan in place that accurately reflects the Rheumatologist’s assessment of future work capacity.

FMS and CFS are very difficult impairments to support long-term. Therefore, it is even more important to speak candidly with your treating physicians about your work capacity.

It’s not really a good thing to suddenly get a denial letter because your Rheumatologist spoke with an insurance doctor on the phone and threw you under the bus without you knowing about it in advance. Yet, this seems to happen quite a bit with Rheumatologists treating patients for FMS.

 

 

Read Full Post »

After roughly 25 years in the business I am absolutely convinced that one of the reasons why insurance companies harass treating physicians with vexatious requests for information is because what they get back is not what they need, or are looking for.

Most treating physicians are very close to their patients and remain supportive during every phase of patient disability. Despite the fact that they are now required to fill out forms from every possible source (SSDI, Worker’s Comp, Private Disability, Personal Injury Litigation etc.), they do the best they can while trying to do their real jobs of providing patient care. The physicians I have dealt with on behalf of my clients have been totally supportive, and it is obvious they care about the health and well-being of their patients.

However, while I am extremely grateful to the physicians who take the time to  support disability correctly, there are some physicians who continue to regard time spent in filling out forms as a waste of their time. All disability claims are paid or not paid based on the quality of medical information sent to the insurance company. And, while insurers are busy doing everything they can to find ways to deny claims, it is now more important than ever for physicians to report the totality of patient impairment, and do a really good job.

DCS, Inc. specializes in assisting treating physicians to report medical disability wisely. Although I can’t go into a great deal of my proprietary strategies in a public forum, here are a few items physicians should be documenting on a regular basis.

  • Diagnoses, both primary and secondary with ICD-10 codes.
  • Prognosis.
  • Statement as to whether patients are at MMI.
  • Details concerning the physician’s treatment plan.
  • Medical restrictions and limitations. (Activities patients may never do, versus activities they may do, but only to a limited extent.)
  • Physicians should always provide what I call a “disability statement.” If the patient is “totally and permanently disabled”, the physician should say so.
  • Physician statement regarding exercise, activity and that it is recommended as part of a viable treatment plan.

Statements from physicians such as, “No work”, or, “Patient is disabled”, is not sufficient to support private disability. The doctor needs to provide much more detail about why his/her patients are unable to work. Of late, I’m hearing physician comments such as, “What does it matter? Insurance companies don’t pay attention to me anyway.”

Although this observation may have some truth to it, insurers do pay attention to medical reports if only to try to find ways around them. Strong, well-documented medical reporting makes it more difficult for any insurer to challenge disability claims.

I also find that some patients are reluctant, or afraid to communicate what is needed to their treating physicians. I can understand this since some physicians fly by during consultations because they are so busy, particularly in the larger physician facilities. It’s hard to try to discuss disability forms when physicians give their patients 5 minutes of follow-up office time.

Physician reporting can be improved when patients also take the time to discuss why they feel they are unable to return to work. Treating physicians are NOT mind readers and shouldn’t be expected to conjure up medical restrictions and limitations relating to jobs or occupations when needed. DCS recommends that insureds and claimants show their treating physicians job descriptions and explain why they are unable to do certain things.

Bottom line, physicians who do not take the time to do a good job reporting impairment are repeatedly harassed by insurers to provide more and more information.

Medical reporting is a priority for private disability.

 

 

 

 

 

Read Full Post »

physicians heading southThere is significant evidence to suggest that a growing percentage of treating physicians are firing, or refusing to treat patients with private disability claims, and for good reason.

Nearly 30 to 40 percent of patients treated by physicians now consists of those who require completion of paperwork to obtain benefits whether it is social security, private insurance or workers’ compensation. “I’m in the business of patient care”, one physician confided to me, “not filling out paperwork insurers ignore anyway.”

While the majority of physicians nationwide continue to muddle through the paperwork, other doctors are “fed up” with private disability insurance and the harassing manner in which their office staffs are confronted with endless requests for patient records and forms. “I don’t make any money filling out these forms”, another psychiatrist said, ” and I refuse to do it, even though I do support my patient’s disability.” Physicians clearly find themselves conflicted when trying to balance efforts to support patients who cannot work, with costly office and staff disruptions and vexatious calls from insurers.

Patient treatment notes are not only sought after by insurers because they are viewed as absolute proof of “regular care”, but narratives of treatment can be more easily misrepresented and key phrases “snatched”  so that “illusions” of work capacity can be documented by internal reviewers. The dichotomy is that patient notes are not written by physicians to support disability claims, but are personal medical diary notes of consultation and treatment. Patient notes are never written by physicians to support disability claims, but instead reflect written records of past treatment visits.

Many physicians today do not keep patient notes in their offices but employ outside vendors to maintain and store exhaustive patient records. Obtaining copies of patient notes can be complicated and costly to send out; managing patient notes requests takes valuable staff time away from patient care. Bottom line, physicians are more and more reluctant to take on the responsibility of continuously providing patient notes and filling out endless forms and are asking patients to take their treatment elsewhere.

Some physicians are also “spooked” by the idea they could be asked to testify in court. Although this is also true of workers’ compensation, physicians may view disability insurance as an ogre of useless time spent in court. In addition, some physicians may treat and support disability even though they never truly “get off the fence” and say specifically patients are disabled. Testifying a FMS patient is totally disabled in court seems a bit risky to rheumatologists even though monthly disability forms are completed for the patient.

Physicians can control insurance harassment, but rarely seem to know they can. Physicians can require insurers to submit all requests for patient notes in writing to include a set fee such as $100+ for photocopying, and administrative time. Insurers can be charged anywhere from $100 to $250+ for completing forms faxed directly to their offices. In fact, DCS suggests that physicians bill by invoice any time they receive requests for medical records. Medical records should also not be released by physicians until payment is received.

Physicians can simply direct their staff to say, “We do not accept phone calls from insurance companies. Please submit requests in writing.” Patients themselves can request copies of their medical notes to submit as proof of claim. Still, physicians can stop insurer harassment of their office staff by informing insurers the office does not accept phone calls directly from insurance companies. This policy also puts a halt to doc-to-doc calls as well. Physicians always have the option of “nipping the problem in the bud” rather than becoming disgruntled by patients who need forms completed on a regular basis. Why they don’t do this more often is a mystery.

The recent trend of physicians to refuse patients receiving private disability is a growing problem for insureds who must submit frequent “proof of claim” to their insurers. It is not helpful to insureds and claimants to continue to treat with physicians who refuse to complete paperwork and often find themselves looking for treatment elsewhere. Neurologists are the most frequent medical providers to fire patients when harassed about paperwork. Osteopathic surgeons and pain management MDs are also infamous for refusing to complete disability paperwork beyond a certain point.

The growing trend of physicians to throw disability patients under the bus is increasing at an alarming rate. Without the written support of treating physicians disability claims are likely to be denied.

DCS recommends insureds and claimants speak frankly with their physicians about the need for disability paperwork and have an understanding as to how requests for patient notes and signed forms are to be handled. Anytime physicians balk, or express dissatisfaction with filling out paperwork, patients should say, ” Since I am receiving disability and must provide proof of claim I will need to find another physician who is more willing to fill out my paperwork. Can you refer me to someone?”  It won’t take docs to long to figure out they are losing patients, and income.

Patients often take advantage of their physicians by demanding forms be filled out in a hurry, or continuously calling offices to see “where we are in getting those patient notes together.” Claimants should always offer to pay an additional reasonable fee to have paperwork completed. Insureds and claimants should always be aware of the possibility their physicians aren’t quite as hep to filling out paperwork as you might think.

Having a reliable physician is essential to any successful disability claim and current trends are indicating physicians just aren’t putting up with it anymore. Unfortunately, insureds and claimants find themselves in positions of having to constantly search for doctors who aren’t refusing to accept them as patients because they have disability claims.

Without prompt receipt of patient notes and signed disability forms disability benefits will not be paid. Once again insureds and claimants are placed in Catch-22 positions because insurers continue to harass for paperwork.

If physicians keep pulling out of the process more and more insureds will find it difficult to get paid – yet another injustice in a long list of obstacles posed by a system only insurers can profit from.

Read Full Post »

DoctorI would like to take the opportunity today to give more information concerning Unum’s internal medical reviews particularly since the company continues its “patterns of practices” to ignore and exclude all information from treating physicians relying solely on its own internal reviewers. In fact, Unum’s hierarchy of medical review is so unfair and egregious one wonders how claims are paid at all.

Although I’ve written many articles and posts over the years I think it’s important to emphasize first and foremost that Unum’s internal medical reviewers are paid annual percentage bonuses to support the company’s agenda to deny legitimate claims. Either Unum’s physicians tote the line and grab their bonuses, or they are swiftly discredited with peers and terminated.

Medical management uses annual bonuses as leverage against its own staff to encourage competition and compliance in cooperating with the company’s business agenda. It is my understanding from a former Unum Director that internal physicians are warned by upper management not to discuss or reveal salaries or bonuses under penalty of immediate termination – pretty scary stuff.

It it important for insureds and claimants to actually think about this for a moment. Coming out the gate, there is no such thing as a fair, or objective medical review anywhere within Unum walls. It follows that every document signed by a Unum physician demonstrates the physician’s conflict of interest to render prejudicial medical reviews in an effort to bolster the company’s business agenda.

There is an old saying, “it is impossible to get someone to see the truth when their salary depends on ignoring it.” This is especially true of Unum’s internal physicians and other IME docs who sign their name to reports they know are inaccurate.

It has been suggested to me after posting my letter of complaint concerning RN reviews that RNs who render written opinions concerning medical information are actually “practicing medicine without a license.” In particular, RNs who document their opinions without knowledge, training and background in specific specialty areas, also misrepresent the content of patient notes and records because they are unskilled. Unum RNs provide documented opinions in areas in which they are not trained.

Secondly, Unum buys “board certification” credentials and then boasts about them in nearly every Unum communication referencing internal medical reviews. Most of Unum’s internal physicians are paid salaries in excess of $200,000/year. It’s clear that since Unum pays for the “board certification” credentials it expects to receive a more than favorable return on its investment.

In truth, most treating physicians are also “board certified” and Unum has no comeuppance on credentialing at all. (We recommend all insureds and claimants document board certified credentials of their treating physicians and include a current Curriculum Vitae in their claim file.) Insureds and claimants shouldn’t be intimidated by Unum’s mention of “board certified internal reviewers” since most physicians today are board certified if they’ve been practicing more than a few years.

Unum also makes a big deal about finding “board certified IME physicians” which in my opinion are false statements made in order to hire  its own IME-tried reviewers even if they are located long distances away form insureds’ residences.

Finally, Unum’s internal review process attempts to create the “illusion” of credibility so that any outside regulator or unknowing insurance official might be deceived into thinking Unum’s decision to deny claims are the right ones to  make. This is done by “hiding in plain sight” a hierarchy of medical review, which on the surface might appear credible, but is really stacking the deck against insureds.

Most Unum reviews consist of: an RN walk-in review, and OSP review (floor physician), a “board certified” specialty medical reviewer, and finally a review by a Medical Director. The RN sets the stage for the outcome of the review since no physician further up the chain of review ever disagrees with prior physicians. These patterns of business practices stack the deck against insureds and claimants and essentially denies them the right to fair and equitable reviews.

In the end, insureds and claimants can’t ever get a fair deal from Unum and employers need to know that. Those employers who genuinely seek to provide benefit coverage to protect employees should not depend on Unum’s internal review systems to supply fair and objective reviews to employees.

As a claims consultant my objection to Unum’s internal and IME medical reviews is that company physicians often document medical opinions which are medically unsound and could potentially cause harm if insureds and claimants took them seriously.

Sending opiate addicted neonatologists and anesthesiologists back to work, or alleging HIV patients with CD-4 counts of 250 can work are examples of Unum medical reviews with potential to cause death or harm. It’s insane that state regulators and Congress allow insurance companies to “cause harm” instead of preventing it.

Unum Group is a corporation and like all corporations will trample over the backs of any group of people in order to show windfall profits. I strongly suggest insureds and claimants speak candidly with their own treating physicians about Unum’s potential to cause harm and make sure medical conditions and symptoms are properly documented in the file.

In the meantime, claimants can report any Unum internal physician or nurse to the appropriate state licensing agency and ask for investigations of physicians who deliberately misrepresent patient notes and other medical information.

Read Full Post »

Patient RecordsAs calls continue to come in from insureds concerning Unum’s medical requests to treating physicians, I begin to wonder whether my posts are read and clearly understood.

In one instance recently reported to DCS, an insured diagnosed with colon cancer was denied by Unum based on old medical information signed-off in October and November by a member of the treating physician’s staff. (This is May 2013!)

Apparently, Unum faxed a release narrative to his doctor, who without even checking patient notes, authorized a return to work full-time. Unum often sends requests for medical records including a two-page release narrative hoping treating physicians will quickly sign-off in the middle of their busy day. In fact, Unum makes daily calls to physician offices if they don’t get the work release information back. If one treating physician refuses to sign, Unum will contact another, and another, until it gets what it’s looking for.

Of course, Unum doesn’t want to involve insureds in the process since they may influence physicians to continue to advocate for total disability. Therefore, treating physician requests are faxed directly to the physician without the knowledge of insureds.

Physicians just want to make the nuisance of filling out insurance paperwork go away, and in the middle of a busy day, will sign almost anything to make that happen. Insureds and claimants must understand that they need to maintain complete control over information communicated to any insurance company concerning their care.

In a recent previous post my recommendations included having open and frank conversations with all treating physicians to discuss how insurance requests and phone calls are to be handled. Most physicians I speak to assure me they do not accept phone calls, or take the time to fill out private insurance paperwork. Still, many physicians feel they are obligated to respond to Unum, an insurance company looking to deny benefits to their patients.

Let me be clear…..insureds and claimants have control over their medical records. “Medical records” include all lab reports, consultations, mental health therapy notes, clinical consultations, fertility consultations, updates, pharmacy records, and any other medical information whether verbal, written, or collected in any data base. Medical records belong to the patient, and patients have a right to decide whether information can be released, to whom, and when.

Let me explain it this way….several years back an insured contacted me with an incredible story. Apparently, she received a call from a stranger in Portland, ME explaining that she was walking in front of Unum’s HOI when she saw paperwork rolling down the street. She chased some of it and discovered it was medical records belonging to the insured and wanted to know if she wanted them back. After several months of dishonesty from Unum, it was discovered one of its claims handlers took the paper file of the insured home, but dropped it in the street and failed to pick it all up.

This consultant has received copies of Federal Tax Returns from Unum belonging to someone other than my client. Federal tax returns contain address and social security number information. Unum had a fit when I refused to return the information to it, but instead returned it to the insured. The misconception that patient records are somehow “safe” with an insurance company is entirely unfounded.

Further, insureds and claimants have the absolute right to discuss the release or restriction of medical records with those who maintain them, such as treating physicians. Once medical records are released, they lose any HIPPA protection afforded them. Insureds and their treating physicians can mutually decide in advance how to handle information requests from insurers.

Patients are well within their rights to request they be notified of any insurance request for information and have an opportunity to review the response before anything is sent out directly from the physician’s office. If a mistake is made, the insured patient then has an opportunity to discuss their physician’s response directly with him/her. Insureds need to maintain complete control over their own patient records including potential phone calls and requests for “updates” containing questions concerning return to work.

The unfortunate fact is that once a physician responds to an insurance company in a certain way it can never be taken back, a fact any insurance company will use to make their case for denial. Physicians can’t one day provide written releases to return to work, and then the next day say patients are totally disabled. To do so discredits the physician, and nothing he/she says beyond that will be credible. Physicians know their responses will be inconsistent and therefore often refuse to “correct” errors made, even when patients are harmed by losing their benefits.

In addition, I find insureds are often far too trusting of their treating physicians. There are occasions when physicians communicate one thing to insureds, and quite another to a Unum doc contacting him/her by phone. Let’s not underestimate Unum’s clever way of intimidating treating physicians into agreeing with Unum’s agenda to send everyone back to work. Unum’s docs know what works and in most cases their methods work every time.

Approximately half of rheumatologists who treat fibromyalgia do not believe the “syndrome” of symptoms is a credible impairment for disability. Still, physicians will be very sympathetic while the FMS patient is in the office, but it can be a different story when a Unum doc is on the phone. Insureds need to have direct conversations with all treating physicians concerning, not only their physical or mental disability, but how insurance requests for updates and information are to be handled. Insureds have the right to review all medical requests for information as well as any paperwork filled out by the physician before it is sent to Unum.  

I am at a loss that so many insureds still “sit back” and give absolute control over patient records to insurers who are looking to deny their claims, which isn’t really very smart. While it is true Unum has a right to review medical records as part of the claims process, it is also true that patient insureds have absolute control as to who will provide the “proof of claim”, including the right to correct any inaccurate information prior to it reaching the insurance company.

In fact, no information should be sent directly from any treating physician’s office unless the insured has been notified of the request and given an opportunity to review the response, or have additional consultations with the treating physician prior to its release. Insureds and claimants who do not maintain control of this process are likely to get burned.

It is my hope that readers of this blog consider carefully what patient information could be provided to any insurance company and the potential of it being inaccurate, or at best, not consistent with your understanding of what your doctor will report if contacted. Do you really want to risk losing your claim because your physician communicated inaccurate information about you to your insurance company?

As a reminder to DCS, Inc.’s clients, I have an electronic brochure available to you which is often requested by treating physicians. This information is proprietary to DCS, Inc. clients, but if you are a client and have not requested this brochure, please send me a private email.

Other readers should make an appointment with their treating physicians and have the all-important discussion/agreement concerning how records requests and phone calls from insurance docs should be handled. Your claim could depend on it.

Read Full Post »

Older Posts »

%d bloggers like this: