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How to handle patient abuse of workers’ compensation or disability claims

Most likely you’ve already learned to manage the administrative issues and challenges related to workers’ compensation and disability claims.

Far more difficult to manage, however, are issues related to patients who are trying to abuse the system — particularly patients who expect you to cooperate, or even participate, in their schemes to bilk the system.

As one medical office manager, who asked to remain anonymous, told us, “It’s not the carriers; it’s the patients. They want to stay out of work and that’s why they are coming in.”

Abusing the system

Unfortunately, this patient mindset is not uncommon.

The Long Island Rail Road, a commuter rail system serving Long Island, NY, has repeatedly made headlines in connection with widespread abuse of disability benefits; hundreds of workers received payments for exaggerated or phony disability claims. The investigation, which has spanned several years, resulted in charges against physicians and consultants, along with several convictions, as well as revocation of benefits to “disabled” workers.

Obviously, there’s a difference between scheduling an appointment with a patient and contributing to insurance fraud, just as there is a difference between documenting patient complaints and an intentionally false diagnosis.

But it still creates a quandary. How do you handle patients who aren’t interested in medical treatment but instead want documentation to stay out of work?

Initial appointment

When a patient seeking workers’ comp or disability benefits first visits the office and you become privy to symptoms or lack of, you may be compelled to pass judgment. Although it may not be easy, try to refrain from doing so.

Instead, focus on the tasks associated with your position.

Make sure the patient fills out all new patient forms. Once this paperwork has been completed, you can then create a detailed patient file. This file will be referenced by the patient’s medical practitioner, who will in turn review the patient’s symptoms and evaluate his or her health.

Medical documentation

After the initial examination, you will receive the medical practitioner’s evaluation. It may show, or at the very least suggest, that the patient’s symptoms are questionable. At this point, you again may be inclined to react.

Nevertheless, remember the scope of your position.

Your responsibility is to maintain the patient’s records, file any paperwork associated with the claim, and provide the patient with any requested documentation.

In addition, it may be necessary to schedule a follow-up appointment, which is yet another reason to remain courteous and professional.

Ongoing patient contact

Indeed, a patient collecting workers’ comp or disability benefits, legitimate or otherwise, is typically required to periodically see his or her medical practitioner.

This means that you will likely have ongoing contact with the patient. Therefore, unless you can separate your personal opinion from your professional responsibility, you are setting yourself up for ongoing stress, which could result in poor job performance.

Your position requires that you remain courteous and professional when interacting with patients.

Flawed system

Yes, at times the system may appear to reward disreputable behavior. Keep in mind, however, that the system also provides assistance to those truly in need.

It’s also worth remembering that patients who attempt to cheat the system do sometimes get caught, as the LIRR case illustrates.

Meanwhile, by leaving medical diagnoses to the experts and leaving your attitude at the door, you will be doing yourself and the practice a service.

Setting an example

Finally, as tempting as it may be to vent to your staff, don’t. No good will come of these kinds of conversations.

Speaking negatively about patients will only create animosity toward them, which has the potential to affect how patients are treated when visiting the office.

Again, it’s about job performance – which, in this instance, for you, also involves leadership. Since you’re in a position of leadership, it’s your responsibility to set standards. Set them high, and adhere to them.

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