Posts Tagged ‘RNS practicing medicine without a license’

Nursing PoliceAs a follow-up to the post of July 6th concerning nurses, it looks as though the Maine nursing police are serious about looking into our complaint that RNs who render opinions concerning medical records are actually “practicing medicine without a license.”

You may recall a Prudential RN, without any education, training or experience, supplied documentation concerning a mental and nervous claim that actually misrepresented the content of the insured’s medical records. As a result the client and I filed a complaint with the Maine Board of Nursing protesting the psychological harm done to the claimant resulting from her review. Registered nurses are NOT physicians and regardless of their paper review experience do not have the medical expertise to officially document medical conclusions or unskilled opinions.

Today’s response from the Board of Nursing indicated an investigation will take place and a copy of the complaint sent to the Maine Assistant Attorney General. Historically, RNs have been employed by the insurance industry to provide documentation as to whether medical restrictions and limitations obtained from medical records support disability.

Although insurers continually defend that medical reviewers do not make claims decisions, the allegations are mere smokescreens since internal medical reviews are relied upon by those who do render claims decisions. Insurance reviewers are generally careful to word their documentation in a way that does not suggest they are actually making claims decisions. It’s all buzz and cover-up since medical reviews are the primary source of disability claim denials.

In reality insurance physicians and RNs should be held accountable for the interpretations made from patient notes which favor the business agenda of insurers to deny legitimate claims.

Insurance companies are culpable as well for allowing RNs to render medical opinions by taking the “cheap” way out. How can an RN’s medical opinion over ride that of a qualified psychologist or psychiatrist? Apparently for Prudential, obtaining pieces of paper written by just about anyone is enough justification to deny claims. It isn’t right.

And, DCS, Inc. is glad to see that at least one Maine state agency is willing to investigate and is planning to take our complaint seriously. Generally, the Maine Department of Insurance and Attorney General support Unum, Prudential and other insurance facilities housed in this state by giving them a free ride at the expense of insurance consumers.

Our thanks go out to the Maine Board of Nursing for its willingness to investigate the complaint against Prudential’s RN medical reviews.

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NursingLast month DCS, Inc. reported an RN employed by Prudential as causing harm to an insured without proper credentials. It has since been suggested to me that Registered Nurses who render medical opinions drawn from patient notes and records are actually practicing medicine without a license.

Although the idea of practicing medicine without a license hasn’t been raised, it is at the moment customary and normal insurance practice for RNs to read medical records including patient notes, x-rays, MRIs, nerve conduction and sleep studies, cardiology notes etc. and document opinions as to what the information means and whether insureds’ restrictions and limitations are reasonable. Insurance companies rely on the documented RN reviews to make claim decisions which can be harmful to insureds when nurses aren’t specialized or experienced in any one area of medical specialty.

What is it exactly that qualifies a Prudential RN, with no ¬†specialty training in psychiatry, to document the treating therapist was “vague” when describing the insureds “affect?” Without appropriate specialty training in psychiatry, RNs should not be allowed as a matter of license to review ¬†psychological therapy notes and comment as though they were experts with training, education and experience or familiarity with the DSM-IV.

My experience with Unum RNs probably soured my opinion of insurance RNs in general. Treated as the top of the food chain by Unum management, RNs threw their weight around quite a bit. As a Lead Specialist in the Cardiac/Psyche Unit, I observed RNs were performance managed to review as many claims as they could, adversely documenting most of them. At the time, the “floor medical review” or “medical walk-ins” were pressured to “keep up the numbers” and send insureds and claimants back to work.

One rather small Unum red-haired RN reviewed a claim for a gentleman status post heart transplant with an Ejection Fraction of 15%. Her documentation write-up suggested the insured could return to work as a truck driver. As an experienced and Army trained medical person, I realized the review was not reasonable since someone with an EF of 15% is probably having difficulty breathing with any type of physical exertion. Several months later this same RN came into my cubicle, crying and cowering on the floor fearful she was about to get fired. I wonder why.

Still, one has to question why Unum’s RN supported Unum’s business agenda when her file review was medically unsound and could have caused physical harm to the insured. It’s all the same story though with insurance – play the numbers regardless of the consequences.

Although Registered Nurses are required to be licensed by the various states, there is little to no oversight from state agencies controlling malpractice of insurance medical personnel. Like internal physicians, RNs park their ethics at the door and support the corporate profit agenda to keep their jobs. While we can accept paper-reviewing physicians as qualified to render peer medical reviews, we should not automatically accept the documented opinions of RNs employed to review patient medical records without specialties in the area of review.

Most RNs who work for insurance companies are not BSNs meaning they have no college 4-year degree in Nursing. In addition, many Registered Nurses have little to no specialty training in any one area. What is really egregious is that some insurers employ LCSW or degree social workers to review medical records as well.

In my opinion, insurance lawyers should start asking state legislators whether it is appropriate for RNs to render medical opinions (peer reviews) outside of any specialty, if indeed they have one. There are some insurers who deny claims based on RN reviews and never have the claim information reviewed by a physician at all. (Prudential)

Where does the state license authority come from that allows RNs to represent their opinions as coming from medical expertise? Again, in my opinion, RNs do NOT have any state license authority to review patient medical information and render medical opinions. They are, in effect, practicing medicine without a license. Documenting insurance claims inappropriately is malpractice just as if a hospital RN caused harm to any patient.

From the insurance company’s perspective RNs are cheaper than “board certified” physicians to employ, and are probably more willing to document claims according to the company’s business agenda. Nevertheless, Registered Nurses, regardless of how experienced they are in the insurance and claims areas, are not qualified physicians and have no business documenting medical records, or reading MRIs without appropriate education, training and experience in the specialty area.

The future of RNs in the insurance industry could be challenged when insureds, claimants, consultants or attorneys raise the issue with state licensing agencies and legislatures. Do we really want RNs making medical decisions which could cost insureds millions in future disability benefits? Some disability claims have in excess of $3-$4 million dollars in financial reserve at stake. Decided by a Registered Nurse? Really?

Although the issue of insurance RNs practicing medicine is not raised very often (if ever), it is an important one, and Registered Nurses should not be allowed to hold out their licenses as credentials sufficient to review and document medical records on which thousands of dollars are at stake. Insurance RNs are practicing medicine without a license and should not be allowed to render medical opinions whether it concerns a cancer patient on a hospital floor, or an insured with a private disability claim.

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