OK, here we go...

FCEs for disability are a difficult but growing area of practice. If you follow our monthly medico-legal webinar series you will have noticed that about half of the court cases we review are ERISA cases and the other half are ADA-EEOC cases. Given the string of settlements recently published in these two areas I see a growing opportunity for evaluators who can cultivate relationships with disability carriers. (read my recent article in Advance for Occupational Therapy Practitioners for more details).

The first step in finding a payment source for a disability eval is to identify the covering party. There are several options for proceeding:

Ask the client (the patient) for a copy of their application for disability. (They should have filed paperwork by now if they are applying for payment of benefits). Within that paperwork you will find who wrote their policy and who is managing the "administrative file".

If the client has not filed for benefits but is a professional person he/she probably has a copy of a personal long term disability policy (they should have it!). In this case the policy should have contact information.

If the insured is not a professional-level person, the policy may be a group policy. Again, ask the client to obtain a copy of the policy. I personally would not do the leg work at this point: many, many times the person thinks they are covered but are not. Or they think they should be but don't really know that they are. Let them do the leg work to obtain the details you need.

Once you have identified the payment source you will begin a long road to discovering who is responsible and why they are responsible. The policy will have details about the exclusion term of the policy, the "same job" or "like job" terms of the policy, etc. It is at this point that you MAY discover whether the client is even entitled to be considering a disability claim.

Now, if you get this far, be sure you have agreement for you to perform and get paid for your services. The underwriter may already have in place a team of professional to perform these services. If they do, suggest that you be added to their team.

Sound like a long road? It is and is probably not pursuing for one client. You really want to build relationships with attorneys, first, and carriers, second, so your initial investment of time returns dividends over time. Think of this as a 5 or 10 year engagement.

Again, if you want to discuss this further call me and/or tune in to our monthly free webinar.

Jennifer,

We have the same problem here in Indiana.  There are a few disability insurers that pay for FCE's, but not many.  In fact, I can hardly remember the last time I did one-probably last year some time.  It seems really odd that they will pay benefits month after month to a claimant, but won't pay for a one time test to assert what type of work somone can return to!  The sad reality is, I believe, that the insurer just passes on the cost to the policy holders, and sticks their head in the sand regarding improvements/status.  Another factor is that if the physician providing the care disregards your/my FCE results, and continues to keep the claimant off work, the insurance company  has gained very little in paying us to do the evaluation.  So, here we all are, stuck in this cycle-sometimes.  I can say that I do get disability FCE referrals from self insured companies-like coal mines in my area (but I think you are speaking to "commercial" insurers).  Once you do a good job for them (comprehensive and fair), they will probably send you more.  If a claimant approaches you for the FCE (and offers to pay for it in whole or in part), I highly recommend you speak with the client on the phone and state clearly your responsibilities, read; "effort"), and make sure they understand what they are paying for.  Not too long ago I did this very thing, and although she was willing to write a check, once I stated my role, she stated that this does not sound like the test she needed.  Hope this helps!