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Posts Tagged ‘Unqualified RNs reviewing disability claims’

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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