Some Thoughts on the Cost-Effective Management of Psychiatric Disability Claims
The essence of any successful case management strategy for mental and nervous disability claims is a cost-effective approach which can efficiently verify and honor legitimate claims while simultaneously identifying those which require further investigation and corroboration.
Since IMEs can be costly, the first common sense step is typically to determine whether or not an IME is warranted at all. Some companies employ in-house psychiatric consultants to review mental and nervous claims and make such decisions; others perfer to use independent professionals, particularly in contentious and litigious cases. Either way, pre-screening and reviewing cases is the much preferred and more cost-effective method. However, for claims which may need to be verified through the IME process, opinions may vary as to what constitutes being cost-effective.
Penny Wise and Pound Foolish?
Once the decision is made to arrange a mental and nervous IME, the focus shifts to determining who should perform the IME, what if any testing needs to be performed, and what questions need to be submitted to the examiner. In terms of cost-effectiveness, a critical question arises as to what the adjuster should be prepared to pay for the IME. As fees vary greatly according to region and the level of professional experience of the examiner, we have found that it makes more sense to first determine which kind of mental health professional (psychiatrist psychologist, or neuropsychologist) is needed, and what level of scrutiny and amount of testing will be required to adequately determine functional status.
As much as it may be important to pay a reasonable and competetive rate, companies can severly undermine a case by letting this process be totally dependent on securing the lowest possible fee.
IMEs and Malingering
Malingering is a frequent concern in mental and nervous claims given the inherently subjective nature of patient self-reporting as to their functional abilities and limitations. It is also important to understand that malingering should not to be confused with those who are faking or fabricating a mental illness. The difficult question which needs to be answered by the IME examiner is often not whether or not there are psychiatric difficulties, but rather do those difficulties rise to a level that renders the individual unable to function in a work environment? It should also be noted than malingering itself can take the form of Axis II pathology, and is not necessarily conscious or voluntary. A malingered presentation can also coincide with a serious and bonafide psychiatric illness. Thus a diagnosis of malingering does not necessarily mean that the individual is work capable.
"Conscious" malingerers are typically individuals who have had or continue to have psychiatric difficulties, but for purposes of secondary gain exaggerate them or fail to report improvement from formerly disabling levels. It is both our professional and case management opinion that all mental and nervous IMEs should incorporate and include motivational and effort testing (both psychological and neuropsychological when indicated) to help corroborate the veracity and severity and scope of reported symptoms.
A Professional IME Process
FHIPA offers insurers a top-to-bottom, professionally managed IME process with a proven track record for fairly and objectively verifying both legitimate claims and for identifying cases of symptom exaggeration and deliberate voluntary malingering. While the previous section focused mainly on disability claims, malingering can also be an issue in workers compensation claims, liability, and fitness for duty cases.
Our five step IME process may be summarized as follows:
Step One: Assessing the Records At no additional cost we will professionally review any mental and nervous case file sent to us to determine the specialty requirements for the IME examiner and the nature and scope of testing needed. A professional is also always available to consult with and discuss your case's special needs and requirements.
Step Two: Locating the Examiner We will locate the appropriate IME examiner from among our 2,500 member nationwide network of pre-screened mental health professionals, schedule the exam, and handle all records and payment arrangements through our central office in Sunnyside, New York. All our providers are rigorously pre-screened before IMEs are assigned. Each must be in clinical practice in their specialty and must provide proof of licensing and adequate malpractice insurance, have prior IME experience, furnish copies of Cvs and sample IME reports, and sign a statement that they are not currently charged with a misdemeanor or felony, and have not at any time been subject to\or notified of any pending disciplinary actions or ethics code violations.
Step Three: Formulating the IME Referral Questions When requested, we will prepare a professionally crafted individualized IME referral questions letter based on a careful review of the case file and with the input and approval of the referral source. We also translate any insurance or job-related issues and policy language into clinically formulated (and legally and ethically supportable) questions the examiner can directly and fully address. Professionally crafted IME questions letters help guarantee high quality reports which fully address the referral issues. The failure to submit a professionally crafted referral questions letter is perhaps the most serious deficiency in the IME process. On average, companies and vendors which use generic form letters, or have inexperienced non-professional staff members prepare the referral questions, get inferior reports which often contain unsolicited opinions and fail to adequately address referral issues.
Step Four: Review the IME Report A draft copy of each IME report is reviewed by a professional peer before it is signed and submitted to the insurer. IME reports must conform to Forest Hills IPA standards and guidelines, refrain from issuing clinical opinions outside of specialty areas, and also address any specific IME questions and issues submitted for consideration by the referral source.
Step Five: Convenient Billing and Provider Payments FHIPA's central office in Sunnyside, New York conveniently handles all records mailings, customer billing, and provider payments. All fees are payable to and collected by The Forest Hills IPA Inc., which in turn makes all payments to providers. There are no additional fees or charges beyond the agreed upon IME fee. Fees are confirmed to clients in writing by fax the day an appointment is scheduled. In cases where an exact fee cannot be quoted at scheduling time (not sure of testing requirements, size of file, etc.) we will quote a minimum and maximum fee range or an hourly rate.
About The Forest Hills IPA Inc.
The Forest Hills IPA Inc. is an individual practice association which operates a nationwide network of licensed mental health professionals and consultants. Established in 1987, our ranks include psychiatrists, neuropsychiatrists, psychologists, and neuropsychologists.
More than an IME Company
As detailed in the above five point IME process description, we are much more than an IME company. Our professional expertise in the mental health arena uniquely qualifies us to assist insurers in arranging quality evaluations. Our knowledge and familiarity with a wide variety of psychological and neuropsychological test batteries is particularly useful to our clients. We are also familiar with testing strategies employed to assess malingering tendencies, and with difficult to document conditions such as CFS, somatiform disorders, and fictitious disorders. What's more, all incoming referrals are handled by a licensed psychologist, so clients always have ready access to professional advice and assistance -- a valuable service you can't get from a regular IME company.
We accept referrals in the mental and nervous arena for disability, no-fault, workers compensation, liability, and fitness for duty cases. We also offer forensic level peer reviews in the same areas.
For a complete description of available services, click here.
Evaluation Criteria
Basic components in our psychiatric, psychological, and neuropsychological IMEs and subsequent written reports include: a minimum one hour face-to-face interview; a listing or summary of medical records reviewed; a brief physical description of the examinee and his/her presentation on the day of their examination; diagnoses where applicable in all five DSM-IV axes categories; the subjective complaints and symptoms reported by the examinee; an assessment of how and at what (pre-morbid) levels the examinee was functioning at before becoming disabled (disability cases); if testing is administered, a complete list of tests administered along with details on objective and subjective findings; a statement of findings regarding the presence and extent of a psychiatric disability (language formulation may vary depending on the policy and questions asked by the consultant and/or insurer) or if no fault, a statement of causal relationship; if applicable, a prognosis regarding recovery prospects; if applicable, an assessment of current treatment efficacy and appropriateness and present and/or future need for treatment and required frequency.
Nationwide Services for Insurers
Peer Reviews & Consulting
Includes full documentation of all records reviewed and detailed professional reporting on diagnostic validity, treatment efficacy and appropriateness, apparent degree of disability, severity of reported symptoms, back-to-work prognosis, and recovery potential.
Depending on the reported diagnosis, reviews are conducted by a licensed psychiatrist, psychologist, or neuropsychologist. FHIPA consultants are also available to discuss review findings and follow-up case management recommendations.
Available for disability, no-fault, workers compensation (including New York), liability, and fitness for duty cases.
Psychiatric, Psychological & Neuropsychological IMEs
Includes record review and a full listing of all records reviewed, extended interview time when authorized, administration of psychological and/or neuropsychological testing when requested and indicated, detailed responses to all referral issues and questions, and peer review of a draft report before submission.
Available for disability, no-fault, workers compensation (including New York), liability, and fitness for duty cases.
Mental and Nervous IMEs that include Motivational and Effort Testing
Available in mental and nervous cases, and typically performed by either a clinical psychologist or neuropsychologist. We will advise clients regarding the type of testing required and its estimated scope. Includes record review and a full listing of all records reviewed, extended interview time when authorized, administration of psychological and/or neuropsychological testing when requested and indicated, detailed responses to all referral issues and questions, and peer review of a draft report before submission.
Available for disability, no-fault, workers compensation (including New York), liability, and fitness for duty cases.
Hard to Find Doctors IMEs
While our main specialty still resides with mental and nervous cases, FHIPA now offers selected customers IME scheduling services for other clinical and medical specialties. Please call (718) 786-1328 for more details on eligibility for this service.
Available for disability, no-fault, workers compensation (including New York), liability, and fitness for duty cases.
A Partial List of Clients
Cigna Group Insurance, Marathon Ashland Petroleum, Assurant, Fort Dearborn Life Insurance, Lincoln Financial Group
Insurer Services Page
Complete List of Services
Peer Reviews & Consulting 