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The Bane of the Medical Reviewer

By Scott B. Elkind, Esq.

Both the Social Security Administration (SSA) and private disability insurers utilize medical reviewers as part of the claims review process.

SSA utilizes in-house reviewers working with the Department of Disability Determination Services (DDS). DDS offices are operated in all 50 states and provide disability reviews for both SSA and state workers compensation programs. It is all too common for DDS reviewers to complete the forms with the same check-offs time and time again, nearly always concluding that a claimant is able to perform work. These reviewers do not address particular reports in any way, but only render unsupported functional conclusions. These reviewers do not set forth a list of the medical reports they reviewed. SSA only pays medical providers $15 for all of a claimant’s medical records, whereas state statutes provide for a much larger charge. For this reason, many medical providers do not comply with SSA and their medical reporting is deficient when undertaking reviews.

On certain occasions, this firm has successfully compelled SSA to produce medical reviewers to appear at hearings. Each time this has occurred, the medical reviewer has been shown to be completely unqualified and/or biased in his or her assessment of a claimant.

Private disability insurers utilize both in-house and outside medical reviewers for undertaking claims review. In-house reviewers are non-practicing physicians and nurses who are salaried workers. These workers livelihood depends not only on their denying disability claims, but also how quick their turnaround is in submitting these reviews. This firm has discovered evidence that one insurer pays its in-house physicians bonuses in the form of company stock for their services. This fact underscores the biased nature of the medical review process in the disability insurance industry.

The outside vendors who provide medical reviews to the insurers are under contract to the disability insurers and receive large amounts of compensation for providing the numerous medical reviews needed. These reviews tend to find nondisability based on naked conclusions of the medical reviewer who fails to analyze the medical reports, but only summarizes their contents in a biased, selective fashion.

This counsel has obtained reporting from medical journals and the media which reveals that the medical review business is considered a good sources of additional income for medical practitioners. Unfortunately, these articles reveal a pattern of biased reporting in favor of the source of funding for these medical reviews which are utilized to deny disability claimants their benefits. Many of these physicians have no specialized training in or out of medicine to prepare them for this. Many others have chosen to retire from clinical practice and undertake this work to supplement their retirement income. This process results in a significant conflict of interest.

There is another important common element in all of the medical reviewing undertaken: no examination of the claimant is undertaken. The conclusions rendered in these medical reviews make it abundantly clear that these reviewers have little appreciation for the findings of treating physicians who have seen claimant’s over an extended course of care. Further, these reviews demonstrate a very high tolerance for the pain, fatigue, and impairment suffered by claimants. Since it only inures to their benefit to provide disability claim denials, the clear evidence provided by claimants is purposefully ignored.

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