You're very disappointed with the
results of your psychiatric disability file review.

Psychiatric versus Medical Reviews
A recent popular trend has been to substitute file reviews for IMEs. Such strategies are sometimes appropriate in physical injury cases, where it is often possible to solicit conclusive opinions on disability issues based solely on a review of medical records. This is especially true when key elements involve interpretation of x-rays, lab tests, and other objective data which can be reviewed and evaluated without seeing the patient.

However, when applied to psychiatric disability issues, such strategies raise serious legal and ethical questions. One rather chilling example of this is the nationally publicized case last winter in which one of our largest managed care groups was sued by dozens of members for using "paper reviews" to determine the need for psychiatric hospitalizations.

Insurers who determine eligibility in psychiatric disability cases without having performed an IME could face similar legal challenges. With the number of pending laws suits in this nation at an all time high, disability insurers need to know what questions they can, and cannot, expect to have addressed in a psychiatric file review.

Have your cases reviewed by a licensed
consultant familiar with the clinical and legal
limitations of a paper file review.

It's just that simple! And it's common sense when you consider that psychiatric illnesses are behaviorally expressed conditions whose symptoms and manifestations can only be assessed via personal contact with the patient.

Mr. Smith goes to Monaco
This is not to say that reviewing professionals cannot speak to disability issues or furnish critical analysis and commentary. For example, it’s entirely permissible for a consultant to opine: "If true, reports that Mr. Smith recently went to Monaco on an extended vacation raise serious questions as to the validity of Dr. Tallman's current diagnosis of disabling agoraphobia." (We're referring here to a common form of agoraphobia which entails an excessive or disabling fear of leaving one's home, traveling long distances, wide open spaces, etc.)

The following language, however, can get your company into deep trouble: "Based on reports that Mr. Smith traveled to Monaco, I would conclude that Dr. Tallman's diagnosis of disabling agoraphobia is invalid." The key problem words here, of course, are "conclude" and "invalid." Their use clearly implies that a clinical determination of disability is being made based on second or third party "here-say" information.

While this simple example seems rather obvious, I encouter case files every day in which consultants use careless language or issue conclusive opinions on diagnostic and disability issues based soley on paper reviews. Some of these consultants are not even licensed mental health professionals. Such language is a recipe for case management disaster, and fertile grounds for cross examination if the case ever goes to litigation.

For more information on "the dos and don'ts" of file reviews, please contact us at (888) 779-2524. Or visit our web site and download a copy of our special on-line guide for disability specialists: The ABCs of Managing Psychiatric Disability Cases.

Sincerely,

Leonard Grossman Ph.D.,
President, The Forest Hills IPA Inc.
Diplomate, The American Board of Forensic Examiners

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