Well, I’m gonna tell you right up front that this was not actually submitted by a physician in the course, this was sent to me by one of the followers of the companies, actually. So, from a little critical of the report, it was not submitted by a physician at the course. So, we’re gonna go over this in detail because I think this is a good example of what not to do. So, the question the physician was asked, the physician was asked by an insurer to render an opinion as to whether the patient’s chronic pain was disabling. Okay. The question is quite simple. Was the chronic pain disabling? So, let’s see how this reviewer answered. “It is indeed a difficult opinion to give in this case.” Okay. That is what I call a parenthetical remark, which adds nothing to the review. As a matter of fact, when I went to high school when we wrote reports and book reports, if we had parenthetical remarks, the teacher would circle them and give you an F, and just send it back. So, if you were editing this report, which should have been done, you can take your pen and your book, if you like, and cross out that parenthetical remark. “It is indeed a difficult opinion to give in this case as it may be many chronic pain cases.” That adds nothing to the solution.
“There’s a great deal of subjective input from the claimants.” Yes. All input from the claimants are subjective in pain cases. That adds nothing to this at all. Now, “it is difficulty to make objective determinations.” Now, I don’t know where this person went to school, but where I went to school when they taught English, a sentence did not read it is difficulty. Okay? That obviously indicates that the person did not even proofread this, and really makes no grammatical sense. In any event, it’s difficult to make objective determinations with the subjective pain issues. That’s what this person was asked to do. If it wasn’t difficult, they wouldn’t have sent it to him, they would have done it themselves. That’s what he’s being paid hundreds of dollars an hour to do. But the reviewer goes on and makes another classic mistake. “I would go on to give the claimant in this case, the benefit of the doubt.” Okay.
Now, you do not have to be a rocket scientist to figure out that as a physician reviewer, you are not in a position to give the benefit of doubt to anyone. You’re supposed to be reporting on the records there. So, giving the benefit of the doubt would be violative of your duties, it would be unfair to both sides, and obviously, it cannot be done in any kind of report. So, that really is a non-starter. And then he goes on to explain this, that because he’s presumably permanently disabled. Now, again, I do not know what presumably permanently disabled means. Obviously, this doesn’t help. Either he is permanently disabled or isn’t permanently disabled. Presumably permanently disabled means nothing. And again, it’s just mass confusion and results in this report being thrown in the trash, eventually. The reason I say this is another parenthetical remark which adds nothing to the report, which should be stricken out if you’re editing. Is a complaint claiming complaints of fairly significant pain? Yes, it’s not a big surprise that a person who is suffering from chronic pain complains of pain. That is not a big surprise.
Yes, he’s suffering from pain, which has minimally improved since his surgery. “As brought up by Dr. Shadle, they may have been some discrepancies even in the claimant’s medical records.” They’ve been changes to medical records. Okay. Now, we see what the whole problem is. This is a conspiracy. This is like the magic bullet on the JFK assassination. There’s some big conspiracy in this case where the person tried for benefits. And if somebody is changing the records, we don’t know who changed the records, we don’t know how they changed the records, and in fact, there’s very little to do or anything to do with this report. But we’ve got to a conspiracy in here. There’s changes to the records, which I’m not sure that changed the revisions. So, even if there was a conspiracy, it didn’t change anything anyway. This makes one suspect. Again, not exactly a very affirmative statement about the claimant when he reports severe pain. So, is he saying that the person changed the records, his doctor changed the records, a third party changed the records? No clue.
“Despite that,” another parenthetical remark which adds nothing to the report, “I have to consider repeated visits and valuation of this claimant by the physician who ultimately documented that he had significant pain.” Yes, he’s had chronic pain. “He requires ongoing medication which may alter his ability to think clearly and make adequate decisions.” Okay. We need to know if it does alter his ability, not whether it may alter his ability. Because if it does alter his ability, then he’s disabled. If it doesn’t alter his ability, then maybe he’s not disabled. And that’s what this reviewer was hired to do, to determine whether or not this chronic pain was disabling. And as you can see by reviewing this one short paragraph, the physician reviewer here failed to do so. But then he sums it all up in a saving grace on his last sentense. And here he says, “This is a difficult situation to say the least.”
Yes, doctor, we know it’s a difficult situation. That’s why we hired you to determine this answer. That’s why we’re paying you $300 an hour. Okay. So, what happens here now when the insurance company gets this report? Well, it becomes part of the record. They obviously can’t use this report in any way, shape, manner, or form because it’s of no use, and they’ll have to go out and get another doctor to do the same job. Obviously, this doctor will not be getting any additional work from this company, or any other company that finds out about this report. So, the bottom line is that this report, on this relatively simple issue, is a complete failure, unfortunately.
Excerpted from SEAK’s stream on-demand course,How to Start, Build, and Run a Successful Disability and File Review Practice