Psychiatric Consultant's Role Continues to Grow at Life Insurance Company

Psychiatric TimesPsychiatric Times Vol 14 No 9
Volume 14
Issue 9

I find expertise is best defined by the attending psychiatrist. I usually ask them whose opinion they respect in the community, whether that person is acceptable to them to do the evaluation and if their conclusions about disability would be acceptable. If the attendings have no one in mind, I have developed a network of excellent forensic psychiatrists around the country from which I can draw. In this case, I make a suggestion, and ask the attending if the particular provider is acceptable.

Disability claims are handled at insurance companies by claims department analysts who usually have minimal medical background. Physicians and nurses-former clinicians-serve as consultants. Analysts become skilled at handling certain types of claims, understanding the nature of the disorder, its treatment and the usual time for return to work following treatment. This is fairly straightforward in the musculoskeletal and cardiac areas.

Psychiatric claims, on the other hand, were beginning to generate concern for insurance companies. Their numbers were climbing, the duration of these claims had lengthened, and staff physicians were finding their knowledge inadequate to deal with large numbers of routine, as well as complicated, neuropsychiatric claims. Therefore, they began to think of employing a psychiatrist to serve as a consultant to the claims department and to the full-time (nonpsychiatrist) physicians.

In March 1993, in response to the request of a friend who was one of their officers, I began talking with the claims department. We had several meetings to talk about how psychiatric input could be utilized. First, direct consultation with the disability analysts could be done on a regular basis, and perhaps eventually we might want to have the consulting psychiatrist call attending psychiatrists to discuss the cases, treatment and expected return to work. At the time, we were uncertain how this would be received. Additionally, we felt that a psychiatric consultant could begin to formulate policy and procedure that would address clinical features, treatment issues, prognosis and expected return to work. It was clear that new claim forms would have to be developed for the attending psychiatrist and the insured, as well as the disability analyst.

I agreed to a three-month trial period as a part-time consultant, contributing eight hours per month to the project. We agreed on a nominal hourly rate consistent with community standard.

My first task was to become familiar with the records, organized very much the way a hospital chart is organized, the chart's thickness depending upon the length of time the insured has been "on claim" (receiving disability payments) and the amount of input that has been obtained from providers. Included are all medical reports and process notes by the analyst, as well as information regarding the contract language, copies of income tax returns, and other significant data such as court records and newspaper clippings. The company has a policy of having field representatives visit the insureds when they are on claim, usually at their home or office, and usually with the permission of the insured's attending physician. Reports of these calls are also included in the record.

My first two weeks were spent poring over various charts to get a feel for the organization and content of the reports and how they interrelated. During this time I also had regular meetings with the company's medical director, a board-certified internist, who took me on "rounds" reminiscent of hospital rounds during which we visited with individual analysts at their desks when they wanted to see us to discuss various claims.

The medical director had been the medical officer responsible for reviewing psychiatric claims, and he seemed delighted to have me working toward taking on this responsibility. I was also assigned a registered nurse who was handling many of the psychiatric claims, and although her clinical experience was in the cardiac care unit at a local hospital, she had remarkably good knowledge of and sensitivity to psychiatric claims.

After about six weeks, my medical mentor decided that I was familiar enough with the insurance claims and records that I could make rounds myself and, working closely with my nurse mentor, try to help the analysts resolve their questions. The time went quickly, and I found the challenge to be refreshingly different from the clinical work that filled the rest of my weekly schedule. The analysts were all bright and articulate; they seemed grateful that I was on staff and that the company had seen the need for more expertise in handling their claims. At the end of the three-month trial period, I was eager to continue, and the company was eager to have me do so. The company has a large education/communication audiovisual department with state-of-the-art technology. I began preparing some lectures on common psychiatric disorders for presentation.

It also became evident that eight hours per month were not sufficient to accommodate the department's needs. We negotiated to 12 hours, which has steadily grown, so that currently I am there 16 hours per week.

I developed a psychiatric claim management plan, necessitating the creating of a new information-gathering form for the analyst, physician and insured. I began to see a need for phone discussions with the attending psychiatrists, and began calling selected providers after scheduling 30-minute appointments.

Having been interrupted in my clinical practice repeatedly by managed care companies wanting information, and usually resenting the interruptions, I told the company that paying psychiatrists for their telephone time was the only viable way to accomplish our goal. I further told the company that paying the doctors at their usual rate for a half hour of their time seemed most appropriate as well.

The contacts with the attendings proved to be remarkably easy. I was warmly received for the most part, though initially there was some apprehension from most of them. I made it routine to introduce myself as a psychiatrist in private practice serving as a consultant to the insurance company. I explained that my task was to help determine the nature of the disability, as well as treatment plan and anticipated return to work. I also gave them billing instructions for their phone time, suggesting that they bill for a full half hour at their usual rate, rather than a rate predetermined by the insurance company. This proved to be a rapport-builder.

Discussions were never adversarial, and most of the time some partnering was accomplished, since the clinician's goal is usually the same as that of the insurance company, i.e., return to work for their patient. I now make about 10 such calls per week and have some nice relationships with a number of psychiatrists throughout the 50 states.

Another area that needed my attention was independent psychiatric evaluation. In this situation, the insurance company hires a local psychiatrist, usually with forensic training, who understands the relationship between impairment and disability. I saw the need to revise the approach for utilization of independent psychiatric examinations. These examinations were usually requested when the analyst was "stuck." The more teleconferences I had with attending psychiatrists, the more I found that often they felt themselves in an awkward position-between the insurance company and their patient-being asked to sign off on conditions that were either not those of disability or were not entirely clear to them. Many attendings seemed very interested in having an objective independent psychiatric evaluation done by a local expert.

I find expertise is best defined by the attending psychiatrist. I usually ask them whose opinion they respect in the community, whether that person is acceptable to them to do the evaluation and if their conclusions about disability would be acceptable. If the attendings have no one in mind, I have developed a network of excellent forensic psychiatrists around the country from which I can draw. In this case, I make a suggestion, and ask the attending if the particular provider is acceptable.

After I had been psychiatric consultant to the entire claims division for two years, it became clear to the company's vice president of policy benefits that even more benefit was possible with specialization. Rather than randomly assigning new psychiatric claims to the analysts, a defined "psych team" was developed to handle all psychiatric claims. All team members are clinically experienced analysts with master's degrees.

While we are still early in the "experience curve," claims seem to be handled more efficiently, customers remain satisfied and morale is high.

I continue to find this opportunity challenging and gratifying, and one in which I continue to learn about our psychiatric profession. I am pleased at the generally excellent level of psychiatric treatment going on around the country, and the quality and expertise of the providers of that care. Continuing to work as a part-time consultant fits my needs nicely, and the company seems satisfied in this regard, as their budget is much more consistent with a consultant than another full-time on-site physician.

Psychiatric Times asked Dr. Logan some questions about his experiences working as an insurance company's psychiatric consultant-Ed.

PT: Have there been cases that involved litigation and if so, what was this like for you?

Logan: I have been deposed on two cases in which clients hired attorneys to contest their denial of benefits. Neither case went to trial. Most of the questions in the deposition centered around my "connections" with the insurance company and how this might have influenced my opinions. Questions related to my opinions were not problematic since I serve as a consultant and interpreter of other clinical opinions and data support, and how well these opinions reflect on limitations in the insured's ability to perform occupational duties. Questions relating to treatment were answered based on accepted standards of practice for various disorders, as well as on the natural history of those disorders.

Have there been cases in which the claimant's attending physician was clearly delivering substandard care and if so, how was that handled?

The issue of standard of care comes up occasionally. Most often it is my suggestion to the attending nonpsychiatric provider that they consider a psychiatric medication consultation and follow-up as seems appropriate. On only one case was it clear to me that the board-certified psychiatrist's knowledge of and treatment for alcoholism was substandard, enabling his patient to continue using alcohol abusively while remaining on claim for the limitations resulting from the abusive drinking. In a nonjudgmental and professional manner, I confronted him with this, only to be told that my way wasn't his way, thank you. There was nothing further I could do, which I found to be professionally frustrating but out of my control.

What about cases in which the attending physician believes that the claimant should not go back to a particular job, even though he/she may be able to do so.

These cases arise occasionally when the attending psychiatrist believes that a return to work is likely to bring about a relapse to an illness in remission but offers no actual limitations. While it is understandable that the attending psychiatrist wishes to protect while advocating for his patient, anticipated limitations are not necessarily disabling.

Is there ever a feeling of pressure to find a claimant not disabled? Should the psychiatrist restrict himself or herself to the issue of psychiatric incapacity, as opposed to the more legal or actuarial term disability?

I have never felt pressured to find the insured not disabled. My job is not to determine disability but rather to gather clinical information from records, from attending psychiatrists and independent examiners and then present it to the disability analysts in a fashion enabling them to understand what, if any, limitations exist.

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