Disability determination has to be made with great caution both to ensure that healthcare services are being used appropriately and to control healthcare costs. Processes such as medical peer review, utilization review and such other review procedures help evaluate whether genuine disability applicants receive the medical services they require, whether these are provided by an appropriate healthcare provider in an appropriate setting, and also whether these are administered through proven methods. In other words, review processes are a way of making sure that superior quality of care is administered as cost-efficiently as possible, in keeping with current evidence-based guidelines.
Let us consider the different types of medical reviews and assessments that are significant in the disability claims determination process.
- Clinical review by a registered nurse: The insurer may request a nurse clinical review to evaluate a disability claimant’s condition. The nurse would perform a medical chart review to find evidence substantiating the claimant’s functionality, limitations/restrictions. The reviewing nurse may contact attending physicians to obtain any additional clinical information they require or to clarify any doubts they may have. If the nurse feels that the medical opinion expressed in the chart is not supported by evidence-based medicine, a peer review may be requested.
- Medical peer review: These reviews may be done with or without peer-to-peer contact. Just as a nurse clinical review, this type of review is also based on medical records. It is performed by a physician who has credentials equivalent to that of the treating physician. Sometimes, a peer to peer review may be needed, and this must be authorized by the insurance company. Such conversation between the peer physician and the attending physician could prove useful. Once the review process is over, the peer review physician would provide a medical opinion regarding the extent of the claimant’s restrictions and limitations. Sometimes, he/she may find that no restrictions/limitations exist, and provide the clinical reasoning on which such a conclusion is based. The insurance carrier would base its decision on this clinical reasoning, when deciding whether to accept or deny the claim.
- Fitness for duty (FFD) review/examination: These reviews are employment related and are usually ordered by the employer. It is a medical evaluation done to make sure that an employee can safely carry out a specific job or task under the working conditions. Such evaluations are usually done after an injury or illness. Apart from physical FFD evaluations, psychological FFD reviews may be required if the employee is noted to have mental health disorders or stress reactions that could lead to or contribute to behavioral health problems, substandard performance and other factors that could put the health and safety of himself/herself and other workers at risk. In such cases, a psychological FFD would help determine if these workers are psychologically capable of performing their job. If they cannot, suitable recommendations may be made in this regard. Though FFD reviews fall within the province of the employer, a managed care partner working with a health plan can also suggest that one is needed in the disability determination process.
- Independent medical evaluation (IME): This involves an objective medical examination by a third party that is usually requested by insurance companies, HR managers, lawyers, benefits providers or employers. It is usually performed when a person is injured and requires third-party documentation to confirm the extent of his/her injury. The independent medical examiner will evaluate the claimant’s ability to function and respond physically and/or mentally to various tasks. Recommendations or restrictions on the claimant’s ability to perform daily activities may be made. The IME report may be used to confirm or deny benefits, insurance coverage or settlements to the claimant. The report may also outline steps for safe return to work procedures that employers can follow. The IME is similar to a peer review, and the main difference is that an in-person medical examination takes place apart from the medical record review.
- Functional capacity evaluation (FCE): This is a set of tests performed to determine a claimant’s physical capabilities. It reviews the claimant’s health and capacity to function against the demands of potential jobs and work environments. The review may evaluate the claimant’s ability to meet a particular level of physical activity or an ability to carry out certain tasks such as lifting and carrying heavy objects. The FCE ma also evaluate the claimant’s ability to tolerate certain activities such as sitting or standing for specific periods of time. Also, pain levels when performing certain tasks may be monitored.
A medical peer review company assisting insurance lawyers understand the importance of the above-mentioned reviews. These reviews that are comprehensive and accurate, help minimize the risk of injury or worsening of the impairment, and thereby save significant costs for both employer and insurer.