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Medical Documentation: a Disability Case Management Perspective

Copyright © Alan Cantor 2018. All rights reserved.

This article was originally published on LinkedIn in February 2018.

On disability case management

During my career I have held a wide range of positions: curriculum designer, adult educator, assistive technologist, employment accommodation specialist, job developer for people with disabilities, return-to-work specialist, accessibility consultant, accessibility project manager, macro programmer, researcher and writer.

Most recently, I served as a full-time disability case manager for a large organization. In this role, I was responsible for administering employees' short term sick leaves, long term disability leaves, and workplace accommodations.

Nothing shines a brighter light on the intricacies, contradictions and messiness of people's lives than their health problems. I found the work interesting, challenging, and rewarding. Each case was unique. The ability to see a case through to completion required a thorough understanding of sick leave and accommodation policies, good communication, plus tact, perseverance, and creativity.

Over the years I gave a lot of thought to how to best to manage cases, both straightforward ones and “messy” ones. In this article, I reflect on the challenges disability case managers face when they receive inadequate medical information to justify a medical leave or a request for accommodations.

The medical report

In the disability case management world, the medical report is the linchpin document. Medical reports are usually completed by employees' physicians, psychologists, physiotherapists, and other health care providers. When reviewing a report, a case manager assesses the legitimacy of a sick leave, or the need for a workplace accommodation, based on the persuasiveness of information contained in the report.

In my experience, about one medical report in ten is incomplete, questionable or contradictory. The high proportion means that ferreting out information is a vital skill for disability case managers.

Better medical information, step-by-step

When a case manager receives inadequate medical documentation, the first thing I suggest doing is telephone the employee. Point out the gaps in the report, and ask that they follow up with their healthcare provider to request an amended report.

Most individuals were motivated to comply, and open to discussing their health issues. For those who were not comfortable talking about their medical condition, I tried to be supportive while setting clear expectations. I understood that people may not want to disclose details about conditions that are stigmatizing (e.g., an addiction) or embarrassing (e.g., colitis). I explained they were not obliged to reveal details to me at that moment, but their healthcare provider needed to include more information next time.

During these conversations, I sometimes learned that employees assumed their personal medical information would be communicated to Human Resources (HR) or their supervisors. In these cases, I turned the conversation to the subject of confidentiality. I assured them that their personal medical information would remain private. I encouraged unionized employees to contact their representative for guidance. I also discussed the limits of confidentiality. For example, where an immediate danger of harm to self or others is imminent, safety trumps confidentiality.

Usually, the outcome of our conversation was that the employee returned to their healthcare provider, and submitted an amended report that contained enough detail for a decision.

But what if the report was still lacking? With the employee's consent, I would seek clarification from the healthcare provider. Normally, I would write a letter that included a list of questions. To make responding less daunting for the healthcare provider, I kept these letters short and to the point.

When a healthcare provider did not respond within a reasonable time, I would follow up, sometimes more than once. The time and effort were usually worthwhile, as the healthcare provider presumably knows the employee and has access to medical histories, laboratory results, and consultation reports.

If your organization has an occupational health physician, another way to fill gaps in the medical documentation is to ask the occupational health physician to make a “doctor-to-doctor” call. I noted many times that physicians responded more quickly, and gave more detailed answers, when approached by other physicians.

If there is still insufficient information to make a decision, consider arranging for an Independent Medical Examination (IME). An IME is an assessment conducted by a healthcare provider who has no previous involvement, and will have no future involvement, in a person's care. Ideally, an Examiner brings fresh perspectives and clarity to the situation.

Reasons a disability case manager might consider pursuing an IME include:

  • The disabling condition is hard to diagnose.
  • There are conflicting opinions from different healthcare providers about the individual's ability to work, or on their restrictions and limitations.
  • It is unclear whether the person's condition is improving, or whether they have has reached maximum recovery.
  • There are indications that an undiagnosed mental health issue is confounding a physical condition.
  • For someone with a treatment-resistant condition, there are concerns that the employee should be referred to a specialist, e.g., a psychiatrist or endocrinologist; or another type of healthcare practitioner, e.g., a psychologist or physiotherapist.
  • There are questions about the appropriateness of treatments, e.g., an employee who relies primarily on complementary medicine and whose recovery is taking longer than usual.
  • The pattern of absences is suspicious, e.g., a physician repeatedly clears an individual to return to work immediately following the expiration of paid sick leaves.

Employees responded differently to the prospect of an IME. Those who were frustrated by their lack of progress usually welcomed an IME. A few viewed the IME as another hoop they were forced to jump through. Union representatives were generally supportive. A very small number employees refused to attend IMEs. A recent article by Maria Kotsopoulos provides an excellent overview on legal perspectives on employer requests for IMEs.

In most cases IMEs are unnecessary. An IME is indicated only when an employer or insurer is “stuck” — a decision cannot be rendered based on existing medical data. IMEs take considerable time to organize, and they are expensive — an IME can cost thousands of dollars.

Nevertheless an IME may be a wise investment. An Examiner who has no past involvement, and who will have no future involvement, is uniquely positioned to bring clarity to an unclear situation. Although an IME is not a panacea, a good Examiner can help pinpoint disabling conditions, suggest different treatment options, and sift through conflicting data to highlight the most salient facts.

Summary

I think anyone who has worked as a disability case manager would agree that obtaining sufficiently detailed medical documentation can be challenging. In this article, I have outlined a range of strategies for gathering reliable information: having conversations with employees, reaching out to health care providers, and as a last resort, arranging for IMEs.

I hope these perspectives are helpful reminders to disability case managers, and useful background information to others who have an interest in the well-being of people at work.