Claiming Disability

[CBSstalker]

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I would like your opinion on a case. A few years ago my attending had a good rapport with a patient (will refer to him as X) who was on psychiatric disability. X was an educated professional who claimed that he couldn't work. My attending felt that he could, and a few times they had talked about this.

Once in awhile X would explain to my attending why he couldn't work. One day X asked her to fill out a disability compliance to treatment form. This was nothing new. She has filled these out for him before. So, she filled out the form in front of X and decided to not send it out without even telling the patient. She did this because she felt that the patient was ready to go back to work and knew that she wasn't going to get anywhere by telling him that. She felt that X would just argue with her as he had done so before. Not knowing what to do, she decided to not send the form out. So, what do you think of her decision of not submitting the disability form that she wrote up? What else could she have done besides talking to the patient as she had before?

Thank You.

 

[hamstergang]

What else could she have done besides talking to the patient as she had before?

Why should there be anything else besides talking to the patient about it and being honest? I'd you don't think disability is appropriate then say so. Or if it's your policy to not do such paperwork for patients you're treating (I know some do this, as there's some conflict between treating a person to make them better and giving them disability which encourages them to remain ill) then say that. Why make it more complicated?

 

[CBSstalker]

Why should there be anything else besides talking to the patient about it and being honest? I'd you don't think disability is appropriate then say so. Or if it's your policy to not do such paperwork for patients you're treating (I know some do this, as there's some conflict between treating a person to make them better and giving them disability which encourages them to remain ill) then say that. Why make it more complicated?

He was not my patient. My attending had this discussion with him before.

If a patient is very sick, how are they going to live without help? Disability doesn't enable patients to continue being sick. That is ridiculous. Many patients do want to get better and work. Many do. Some of these patients are very career oriented.

 

[heyjack70]

He was not my patient. My attending had this discussion with him before.

If a patient is very sick, how are they going to live without help? Disability doesn't enable patients to continue being sick. That is ridiculous. Many patients do want to get better and work. Many do. Some of these patients are very career oriented.

In my experience working in community mental health clinics, the majority of patients on disability do not want to work at all. The few that do want to work are very careful to watch their income closely to avoid losing their disability benefits. I think patients want to get better, but they also want to keep getting a monthly check. I think this make financial sense for most patients. They are comparing $800/month tax free from disability for doing nothing with $800/month from a part time job at 30 hours a week. I think this clearly enables patients to avoid returning to work. Why would I work if I can get the same money while sitting at home watching TV?

The equation changes if a person is able to work as a computer programmer making $80K/year. They would much prefer to get back to work.

 

[wolfvgang22]

It's generally best to avoid lying to a patient, and avoid lying to organizations/government entities asking if the patient is disabled.
If the patient believes their doctor is going to fill out and send a form, and then doesn't, the patient will probably eventually find out that the recipient never got the forms. Then the patient will no longer trust the doctor, anyway.
Lying on legal forms, is, well, illegal, and can get the doctor in trouble.
A doctor should do his or her best to be empathetic with the patient, while being honest about the patient's condition. Many times people don't like honesty, and seek secondary gains from illness. Not every patient will love you for being honest and ethical. Neither will every employer.

 

[erg923]

Disability doesn't enable patients to continue being sick.

Unless someone is floridly psychotic, I am hard pressed to believe individuals with psychiatric illness are unable to do some kind of work for any extended period of time. That strikes me a ridiculous.

Long-term (psychiatric) disability also seems markedly at odds with the recovery model of mental health treatment/services that most of us operate under.

 

[CBSstalker]

I wasn't referring to long term disability. Some do end up working even if it is only part-time. This seems to be the case where private providers in my area report. I am not generalizing. I am only talking about my neck of the woods and providers that I know personally.

 

[Armadillos]

I think its a real tragedy how the disability system in America has become a band aid for poor social safety net programs overall. It has additionally put the medical profession in a bad spot of being a financial gatekeeper.

If I had my way I would provide better programs for the impoverished and I would make the standards to get disability much, much higher so fewer people qualify, but once they qualify I would allow them to continue getting their benefits even if they managed to make a miraculous recovery and start working again.

As it is now, getting disability basically assures someone stays sick the rest of their life which is incredibly sad

 

[hamstergang]

He was not my patient. My attending had this discussion with him before.

If a patient is very sick, how are they going to live without help? Disability doesn't enable patients to continue being sick. That is ridiculous. Many patients do want to get better and work. Many do. Some of these patients are very career oriented.

This seems to miss the point of my post. I know you were not the attending physician since I read your post, but I used 'you' to explain generically what I think one should do. And I'm not arguing whether treatment and disability are at odds with each other, only stating that some do feel this way.

My point is just to tell the truth to the patient (and the government). It's actually rather simple.

 

[CBSstalker]

I think its a real tragedy how the disability system in America has become a band aid for poor social safety net programs overall. It has additionally put the medical profession in a bad spot of being a financial gatekeeper.

If I had my way I would provide better programs for the impoverished and I would make the standards to get disability much, much higher so fewer people qualify, but once they qualify I would allow them to continue getting their benefits even if they managed to make a miraculous recovery and start working again.

As it is now, getting disability basically assures someone stays sick the rest of their life which is incredibly sad

First I think there needs to be clarification on the different types of disability. I used to work as a physician assistant and have filled out disability forms. Now as a behavioral health social worker, I help patients file for disability. It is just part of my job, although i do think some patients are just lazy. Anyway I am familiar with the entire process of applying for the 2 types of disability programs.

At least in my state, disability from the state welfare system is not meant to be long term. Any patient that is still disabled after a year of receiving state benefits must apply for Social Security benefits. If they don't, they will be automatically kicked off of the welfare system and will end up with nothing. Now it is F*** hard to get Social Security benefits. It is not easy like the state.

I have seen people malinger on state disability, but not on Social Security. It is very hard too. But, as always a few can slip through the cracks. But, this is very rare.

TL;DR: There are 2 types of disability programs: there is one from the state, which is meant for a short term disability. It's not hard to get. After one year of receiving state benefits, one must apply to the federal govt. for Social security benefits. Social Security is for long-term disability. It is F***** hard to get. I have had patients/clients and a relative try to get Soc Sec benefits and could not. So, I suspect there could be many people malingering/not really needing benefits whom are on state welfare and hardly any on social security because Soc Sec has a long and hard screening process.

 

[keifernny2]

The physician has no legal obligation to complete the paperwork, however telling the patient that you did and not sending it is unethical.

Many of the disability forms that my patients bring to me actually do not originate with SSA or state disability and are simply forms that their disability-mill lawyers have generated to try to get the patient greater disability benefits. Some of these forms are very long (I've seen some that were 10 pages), and I know some psychiatrists that will actually require the lawyer to pay for the completion of them (rather than billing the patient or medicaid) since the purpose of these does not actually have to do with patient care or treatment.

 

[CBSstalker]

Back to my original question: I think the attending should have just wrote the report in a way that suggests the patient wasn't disabled. Then, she should have sent it in, and the patient would not even have received a disability evaluation. If her patient just argues with her than that is all that could probably be done. Just thought of this. I have never dealt with a case of malingering (neither as a PA or Social Worker).

Also, I have clients on social security whom work and volunteer.

 

[CBSstalker]

It's generally best to avoid lying to a patient, and avoid lying to organizations/government entities asking if the patient is disabled.
If the patient believes their doctor is going to fill out and send a form, and then doesn't, the patient will probably eventually find out that the recipient never got the forms. Then the patient will no longer trust the doctor, anyway.
Lying on legal forms, is, well, illegal, and can get the doctor in trouble.
A doctor should do his or her best to be empathetic with the patient, while being honest about the patient's condition. Many times people don't like honesty, and seek secondary gains from illness. Not every patient will love you for being honest and ethical. Neither will every employer.

I think the attending could have just written the form in a way that doesn't suggest that the patient was too disabled to work. The attending had many conversations with the patient about working, but the patient always had some reason of not being able to. Patient has a long history of getting fired.

I think this would kill 2 birds with one stone: the doctor fills out the report honestly and the patient doesn't get an evaluation.

 

[hamstergang]

Back to my original question: I think the attending should have just wrote the report in a way that suggests the patient wasn't disabled. Then, she should have sent it in, and the patient would not even have received a disability evaluation.

Telling the patient you'll fill out disability paperwork and then indicating they aren't disabled seems wrong to me. Better would be to make clear to the patient that you don't feel they meet the requirements, and so if you were to complete the paperwork that's what you would indicate. Then you give the patient a choice: either you can not fill it out, or you can fill it out and say they aren't disabled.

Again, the theme here is being open and honest with this as I don't see a reason to do otherwise.

 

[CBSstalker]

Telling the patient you'll fill out disability paperwork and then indicating they aren't disabled seems wrong to me. Better would be to make clear to the patient that you don't feel they meet the requirements, and so if you were to complete the paperwork that's what you would indicate. Then you give the patient a choice: either you can not fill it out, or you can fill it out and say they aren't disabled.

Again, the theme here is being open and honest with this as I don't see a reason to do otherwise.

I do see what you are saying. If the attending were to have done what I suggested here, the patient would figure out that she was being dishonest with him: suddenly he is no longer asked to come for an evaluation. Then, all rapport is destroyed.

It seems like a provider has to be careful when approaching a patient. It can be a very sensitive situation. I am glad that I never had to do this as a PA.

 

[clausewitz2]

While it is true that everyone gets rejected to a first approximation on the first pass at SSA disability, appeals are frequently successful. The fact that I am currently in a state where in some counties literally 20% of the working age population is on SSA disability should suggest strongly that it is maybe not as difficult to linger on the federal disability rolls as you think it is, OP.

 

[CBSstalker]

While it is true that everyone gets rejected to a first approximation on the first pass at SSA disability, appeals are frequently successful. The fact that I am currently in a state where in some counties literally 20% of the working age population is on SSA disability should suggest strongly that it is maybe not as difficult to linger on the federal disability roles as you think it is, OP.

In my area of the woods, it is much less than that for SS patients. I am only talking about mental health patients. First, not everyone even gets evaluated. Second, the evaluation given by a federal neuropsychologist is very thorough. It is a 3 hour evaluation that consists of an interview and neuropsychological testing. Patients may exaggerate their symptoms during the interview, but their scores on the neuropsychological tests often indicate that they are high functioning.

 

[CBSstalker]

Correction in my posts: I referred to the physician in my post as my attending. Technically, she was my SP (supervising physician) when I worked for her as a PA.

 

[birchswing]

Something doesn't add up.

If it was just a compliance to treatment form, the doctor throwing it away is just sabotaging the patient's ability to continue receiving disability benefits. The doctor's not even making a case that the patient doesn't have a disability—presumably that was already established. They're at that point just obstructing a bureaucratic process necessary to continue receiving benefits. If a form is just asking whether or not a person is complying with treatment, shouldn't the doctor just say up front whether they'll fill it out or not? It doesn't even have anything to do with whether the person is disabled or not. I have to get these done for my college since I left on medical leave and came back under what they call a medical clearance process. My psychiatrist has started charging me $25 a pop for her to check a box and sign her name (and she'll only fill them out during sessions). I guess she could refuse to do it altogether. But if she were to say she did it and didn't, I think she would be in breach of some sort of law or code at least. Even if you're not charging, I think you would assume that agreement to fill it out implies the cost of doing so has been paid for as part of customary treatment. It's not like you're handing it to a stranger and hoping they'll do it out of goodwill.

 

[erg923]

I have seen people malinger on state disability, but not on Social Security. It is very hard too. But, as always a few can slip through the cracks. But, this is very rare.

Your personal experiences are not an empirical study of the topic, so I am not sure how you can reach such a conclusion.

CBSstalker, I'm not sure I "get" this post? This is a not a complicated or even a debatable issue.
You dont' blatantly lie to patients. You don't obfuscate your clinical opinions in writing to authorities, to patients, or government organizations/programs. What debate are we having here?

Its sounds to me that like your attending either did not have the clinical skills, or perhaps just lacked the patience to deal with this difficult clinical-legal matter in the context of treatment. If he/she didn't want to play the disability tug-o-war game...then he/she shouldn't play it. That is a clinical training/competence issue. Nothing more.

 

[Armadillos]

First I think there needs to be clarification on the different types of disability. I used to work as a physician assistant and have filled out disability forms. Now as a behavioral health social worker, I help patients file for disability. It is just part of my job, although i do think some patients are just lazy. Anyway I am familiar with the entire process of applying for the 2 types of disability programs.

At least in my state, disability from the state welfare system is not meant to be long term. Any patient that is still disabled after a year of receiving state benefits must apply for Social Security benefits. If they don't, they will be automatically kicked off of the welfare system and will end up with nothing. Now it is F*** hard to get Social Security benefits. It is not easy like the state.

I have seen people malinger on state disability, but not on Social Security. It is very hard too. But, as always a few can slip through the cracks. But, this is very rare.

TL;DR: There are 2 types of disability programs: there is one from the state, which is meant for a short term disability. It's not hard to get. After one year of receiving state benefits, one must apply to the federal govt. for Social security benefits. Social Security is for long-term disability. It is F***** hard to get. I have had patients/clients and a relative try to get Soc Sec benefits and could not. So, I suspect there could be many people malingering/not really needing benefits whom are on state welfare and hardly any on social security because Soc Sec has a long and hard screening process.

I'm not talking about people malingering to stay on some sort of disability benefit. I'm talking about genuinely sick people who are less likely to recover because there is less financial incentive to continue to rehab themselves. It's not their fault, it's a messed up system.

 

[CBSstalker]

Something doesn't add up.

If it was just a compliance to treatment form, the doctor throwing it away is just sabotaging the patient's ability to continue receiving disability benefits. The doctor's not even making a case that the patient doesn't have a disability—presumably that was already established. They're at that point just obstructing a bureaucratic process necessary to continue receiving benefits. If a form is just asking whether or not a person is complying with treatment, shouldn't the doctor just say up front whether they'll fill it out or not? It doesn't even have anything to do with whether the person is disabled or not. I have to get these done for my college since I left on medical leave and came back under what they call a medical clearance process. My psychiatrist has started charging me $25 a pop for her to check a box and sign her name (and she'll only fill them out during sessions). I guess she could refuse to do it altogether. But if she were to say she did it and didn't, I think she would be in breach of some sort of law or code at least. Even if you're not charging, I think you would assume that agreement to fill it out implies the cost of doing so has been paid for as part of customary treatment. It's not like you're handing it to a stranger and hoping they'll do it out of goodwill.

In my state, the compliance to treatment form (to receive state welfare benefits) not only consists of listing the dates that the patient came for treatment. It also includes a description of the current diagnoses, current symptoms, and recommended treatment. They ask for all of this info on the form. After a provider fills it out, a group of state evaluating doctors reads the form and decides whether or not the patient is disabled enough to come for an evaluation with one of their state appointed doctors. It is done this way because patients improve over time. Even just a little. And that little improvement can be enough for a person to be able to work. What you are talking about is completely different.

 

[CBSstalker]

Your personal experiences are not an empirical study of the topic, so I am not sure how you can reach such a conclusion.

CBSstalker, I'm not sure I "get" this post? This is a not a complicated or even a debatable issue.
You dont' blatantly lie to patients. You don't obfuscate your clinical opinions in writing to authorities, to patients, or government organizations/programs. What debate are we having here?

Its sounds to me that like your attending either did not have the clinical skills, or perhaps just lacked the patience to deal with this difficult clinical-legal matter in the context of treatment. If he/she didn't want to play the disability tug-o-war game...then he/she shouldn't play it. That is a clinical training/competence issue. Nothing more.

I am not arguing anything. I will change my wording and say that it is easier to obtain state disability benefits because the screening process is not as rigorous as it is for SSA. With SSA patients go for neuropsychological testings and an interview and the patient must list every provider they have ever seen for the documented disability. Again, I am not arguing anything. I agree honesty is best.

 

[birchswing]

In my state, the compliance to treatment form (to receive state welfare benefits) not only consists of listing the dates that the patient came for treatment. It also includes a description of the current diagnoses, current symptoms, and recommended treatment. They ask for all of this info on the form. After a provider fills it out, a group of state evaluating doctors reads the form and decides whether or not the patient is disabled enough to come for an evaluation with one of their state appointed doctors. It is done this way because patients improve over time. Even just a little. And that little improvement can be enough for a person to be able to work. What you are talking about is completely different.

Gotcha.

 

[Psychobabbling]

Telling the patient you'll fill out disability paperwork and then indicating they aren't disabled seems wrong to me. Better would be to make clear to the patient that you don't feel they meet the requirements, and so if you were to complete the paperwork that's what you would indicate. Then you give the patient a choice: either you can not fill it out, or you can fill it out and say they aren't disabled.

Again, the theme here is being open and honest with this as I don't see a reason to do otherwise.

Man, I sure as hell can't wait to finish residency. I have a few things I'd like to re-learn lol

Real world: I feel you're symptoms are currently at a level that would allow you to work. I can not responsibly fill this out

Residency: Tell the patient you will fill out the form. Fill out the form in a way that just gives your honest assessment. Leave it up to the disability office to decide. You won't look like the bad guy.

 

[CBSstalker]

The state disability form doesn't have to be that detailed. The PITA part is where I had to go searching for all of the dates that the patient came to see me. There was no secretary to do this for us. Other than that I have filled some of these reports out in no less than approximately 15 minutes. Some providers write A LOT more.

 

[CBSstalker]

Man, I sure as hell can't wait to finish residency. I have a few things I'd like to re-learn lol

Real world: I feel you're symptoms are currently at a level that would allow you to work. I can not responsibly fill this out

Residency: Tell the patient you will fill out the form. Fill out the form in a way that just gives your honest assessment. Leave it up to the disability office to decide. You won't look like the bad guy.

You still could fill it out. It really is just filling out the dates that the patient came to see you along with the current diagnosis/diagnoses and current treatment recommendations. If the diagnoses doesn't fit the criteria for disability than the patient just doesn't get evaluated.

 

[splik]

Man, I sure as hell can't wait to finish residency. I have a few things I'd like to re-learn lol

Real world: I feel you're symptoms are currently at a level that would allow you to work. I can not responsibly fill this out

Residency: Tell the patient you will fill out the form. Fill out the form in a way that just gives your honest assessment. Leave it up to the disability office to decide. You won't look like the bad guy.

my own position is that disability evaluation is not part of the doctor-patient relationship. if someone wants me to assess the patient's disability status, then i will send them the documentation in the charts, but if they want anything else then they will have to pay me $230 which is what the going rate for a psychiatric disability eval is in my state. there is a massive conflict of interest with the treating physician making this assessment on the patient's request. unfortunately the courts don't agree with me.

 

[CBSstalker]

my own position is that disability evaluation is not part of the doctor-patient relationship. if someone wants me to assess the patient's disability status, then i will send them the documentation in the charts, but if they want anything else then they will have to pay me $230 which is what the going rate for a psychiatric disability eval is in my state. there is a massive conflict of interest with the treating physician making this assessment on the patient's request.

Why would there be? The patient is not requesting it. The patient is applying for disability, and the government is requesting that the provider fill out the form. Who else is going to determine whether or not the patient is disabled.

 

[Shikima]

An independent physician via an indepentdent evaluation or 2?

 

[erg923]

Why would there be? The patient is not requesting it. The patient is applying for disability, and the government is requesting that the provider fill out the form. Who else is going to determine whether or not the patient is disabled.

The attending/treating physician NEVER determines this. The insurance company or whatever agency in question (SSA, VBA) ultimately does.

 

[CBSstalker]

The attending/treating physician NEVER determines this. The insurance company or whatever agency in question (SSA, VBA) ultimately does.

I know that. That is what I have been saying in all of my posts: with the state the provider is the first person to fill the form out with the aforementioned information. Then a group of doctors contracted with the state determines whether or not the individual gets evaluated by one of their state doctors.

SSA determination is more involved. The process begins where the patient fills out an application and must list every provider ever seen for the disability. Then SSA will contact the patient and interview them over the phone. Several month later, the patient receives letter or phone call stating whether or not they will be evaluated by one of the doctors contracted with SSA. If the patient gets an evaluation, they spend 3 hours answering questions and submitting to a neurosychological examination.

 

[splik]

Why would there be? The patient is not requesting it. The patient is applying for disability, and the government is requesting that the provider fill out the form. Who else is going to determine whether or not the patient is disabled.

The patient is requesting it if another agency is not paying for it. I'm finding it hard to believe you are a social worker. It is a conflict of interest assessing disability for my patients. For most patients it is in their interests to get more money and on the one hand it helps, on the other hand they will never get better if they get on disability. Also it harms the doctor-patient relationship if I don't assess them as disabled if they are requesting it and paying me. If someone else wants this, then they have to pay for it. It is not my job to assess patients' disability status in a therapeutic encounter. In fact there are few things more countertherapeutic. Unfortunately the courts have ruled that the greatest weight should be given to the treating physician's opinion in disability evaluation. The VA is infinitely more sensible in having a compensation and pensions person do the evaluation and the treating physician has no part in it.

 

[Ceke2002]

Here in Australia it's the treating Physician who is required to fill out the application paper work; the patient themselves then needs to take that paper work, along with a stack of other info on assets and available finances, to their local welfare (Centrelink) office and hand it in for assessment, then wait 4-6 weeks and hopefully get referred onto an independent assessor (if they haven't already been knocked back based on the paper work alone) who will then sit down and interview them, before making a final call as to whether or not disability payments will be approved. If you're application gets rejected at any stage you have the right of independent appeal, then the right of a tribunal appeal, then the right of court appeal.

My Psychiatrist agreed to fill out a disability evaluation form for me when we first started working together, not necessarily because either of us felt I was unwell enough not to be able to work at all, but being on disability would have allowed me access to a lot of training and return to work type programs. Unfortunately it ends up being a catch 22 situation a lot of the time - a person is stable enough to work, but can't get a job due to previous long term unemployment owing to inadequately treated MH issues/substance abuse/etc, they need to be on disability in order to access programs that will assist in returning them to work, but they're also stable enough to be able to work and don't necessarily meet disability requirements, but they're also long term unemployed and have little to no chance of getting a job without assistance, but unless they're on disability they won't have access to that assistance, but they're now stable enough to at least work part time so don't necessarily meet the requirements of disability, but they're also long term unemployed and can only access 'return to work' assistance programs if they're on disability...and round and round it goes.

I never did end up getting disability, I gave up after the fourth round of trying -- round 1: they lost my paper work; round 2: they rejected my application because one diagnosis written wasn't officially listed in the DSM (despite the fact that disability assessment for MH issues in South Australia is actually based off the ICD and has nothing to do with the DSM), round 3: resubmitted application, they then complained it wasn't detailed enough; round 4: my Psychiatrist re-does the medical assessment form with WAY more detail in it (like ridiculous, petty, stupid amounts of detail), I resubmit the application, Centrelink then proceeds to lose my application, again...and at that point, I just gave up.



Edited to add: The point I never actually got to being I think there's a difference between 'still in training, filling out forms by the book' and 'working in the real world, got some experience behind you, can make a judgement call when necessary'.

 

[CBSstalker]

The patient is requesting it if another agency is not paying for it. I'm finding it hard to believe you are a social worker. It is a conflict of interest assessing disability for my patients. For most patients it is in their interests to get more money and on the one hand it helps, on the other hand they will never get better if they get on disability. Also it harms the doctor-patient relationship if I don't assess them as disabled if they are requesting it and paying me. If someone else wants this, then they have to pay for it. It is not my job to assess patients' disability status in a therapeutic encounter. In fact there are few things more countertherapeutic. Unfortunately the courts have ruled that the greatest weight should be given to the treating physician's opinion in disability evaluation. The VA is infinitely more sensible in having a compensation and pensions person do the evaluation and the treating physician has no part in it.

You are not assessing the patient's disability status. The doctor fills out the form and sends it in. Then a group of contracted doctors with the state read the form that you filled out. The state contracted doctors determine whether or not the patient should even be evaluated. You are just filling out the dates of treatment, current diagnoses, and treatment recommendations. Your buck ends there.

As a PA I have filled these state forms out. As a social worker, I lead patients and family members through the process. Sometimes a patient is so disabled that he/she needs the help of a family member to apply for benefits. Among many other things, I followup on how my clients are doing with their doctors, and how their treatment is going.