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Underwriting and Claims

The Missing Link

Physical Therapists and Functionality

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As disability claims specialists, we are all familiar with the drill. We call the doctor’s office and then are asked to fax a request to get medical documentation on a claimant. We wait for several days, sometimes even weeks, before calling again to follow up on the request. Once the documents finally arrive, we find ourselves reviewing brief office visit notes with little commentary on functionality and that rarely include any reference to ability to return to work. And, because the treating physician’s opinion is paramount in many aspects of the disability claim decision, we must often try to find creative ways to obtain the information we need.

In a world where “busy-ness” rules, are there places where we could bridge this gap? We know claims staff have many files to juggle, and physicians and their offices struggle to keep up with incoming calls and requests for patient information. Other than from physicians, who see their patients infrequently, is there a way to obtain accurate information on an individual’s level of function and help him or her return to a productive lifestyle safely and without delay? We think so, and here’s another tool in the toolbox you may not have considered: the physical therapist:

“Physical therapists (PTs) are health care professionals who diagnose and treat individuals of all ages, from newborns to the very oldest, who have medical problems or other health-related conditions that limit their abilities to move and perform functional activities in their daily lives.

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“PTs examine each individual and develop a plan using treatment techniques to promote the ability to move, reduce pain, restore function, and prevent disability. In addition, PTs work with individuals to prevent the loss of mobility before it occurs by developing fitness- and wellness-oriented programs for healthier and more active lifestyles.”1

Group disability insurers are focused on finding innovative ways to help claimants to promptly return to work, and, in order to do so, there is an increased emphasis on understanding functional capacity. Because playing the waiting game for records that seldom address true capabilities wastes time and money, there is inherent value in going directly to the source – the physical therapist, the provider who works most closely with the claimant on his or her day-to-day recovery and improvement in functionality. PTs see the individual frequently, often two to three times per week, and consequently have the best insight into the person’s physical abilities, potential job options and even into his or her motivation to return to health and productivity. Perhaps most important, for physicians who are seeking assistance in accurately identifying their patient’s capabilities, PTs can be the conduit to that information, apprising them of the claimant’s functional capacities so that they can make decisions on appropriate return-to-work (RTW) restrictions or limitations.

You may be familiar with physical therapists through having requested a functional capacity evaluation (FCE) to determine a claimant’s ability to perform a specific occupation. Here’s a good definition: “An FCE is a comprehensive, objective test of a person’s ability to perform work-related tasks. FCE’s differ from traditional Physical Therapy evaluations because the emphasis is on functional task performance. ... The limitation is then documented in terms of the functional limitation vs. the specific anatomical structures, range of motion, or strength deficits that cause the limitation. Likewise, diagnosis is a relatively unimportant factor in the evaluation.”2

What you may not know is that physical therapists not only treat musculoskeletal conditions (back and neck pain, general orthopedic conditions affecting shoulders, knees and hips), but they also are highly skilled in understanding the functional capacity of individuals with a variety of disorders, including many diagnoses you see on a regular basis in disability claims: myofascial pain, vestibular (dizziness, vertigo, balance) disorders, concussions, headaches, temporomandibular joint disorders, lymphedema, and various upper extremity and hand conditions such as carpal tunnel syndrome.

Another important reason to reach out to physical therapists is that they will actually talk to you. They’ll answer questions about function. They’ll offer to contact the treating physician. They can provide the policyholder with job modification suggestions. They can advocate for return to work within realistic limitations and restrictions and conduct work conditioning and work hardening programs to prepare a claimant for RTW/own occupation. A brief, summary example of a positive outcome follows:

Physician with extensive spinal osteoarthritis and history of chronic pain. Contact with her employer found they could consider making accommodations to allow a return to work. However, the employer also requested documentation of specific restrictions and limitations, given the critical nature of the patient care she provides. The claimant was interested in increasing her functional capacity, and was referred by her treating physician to physical therapy. The claim examiner contacted the therapist and learned the claimant was making excellent progress, hoping to avoid future surgery, and wanted to RTW when she felt it was “safe.” The therapist estimated approximately 30 days more participation in therapeutic exercise and treatments. He also offered to speak with the employer regarding possible ergonomic modifications, as well as provide specific information on the claimant’s functional capacities, which were gradually improving as she learned proper body mechanics and became stronger and more confident. End result: The treating physician released the claimant to a gradual return to work based on the recommendations of the physical therapist.

A forward-thinking approach is the key to the management of both simple and complex claims. Why not consider adding a question to your initial interview with the claimant: “Are you treating with a physical therapist?” In addition, it is a good idea to always incorporate this contact with any other medical providers on the claim, provide this information to any consulting nurses or physicians on your team, and, of course, communicate the PT’s recommendations to the treating physician. When all parties work together, you maximize your time and efforts – and everyone wins.

Rather than taking a “wait and see” approach and struggling on the hamster wheel of office visit note requests, contact the provider who is in the best position to comment on the claimant’s functionality – the physical therapist. Chances are you will obtain the information you are seeking in a more efficient manner, which will lead to decreased claim durations and positive outcomes for the insurer and claimant.

References

1 www.apta.org
2 Saunders, Robin, MS, PT and Piela, Catherine. “Functional Capacity Evaluation, The Saunders Method.” On the Risk, 1998.
 

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  • Attending Physician Statement
  • APS
  • asymmetric
  • anti-selection
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