Understanding the differences, knowing how to spot each, and having strategies to deal with them can make a significant impact on reducing workers' comp costs, says a medical expert.
"What's really important for these cases is to identify the type of patient that you are dealing with early so that they can be treated appropriately ... the earlier you identify the true malingerers the more quickly you can weed them out," said Dr. Charles A. Gatto, an orthopedic spine surgeon at The Tri-County Spine Center in Morristown, N.J. "In order to do it, you must understand a few things about pain, about the expression of pain, about a few psychiatric conditions ... you need to know these things to be able to see what is going on."
In his session, Symptom Magnification and Malingering in the Workers' Comp Spine Patient, Dr. Gatto will explain:
- How to identify the red flags of symptom magnification and malingering.
- When and why to order a functional capacity independent medical exam or other second opinion.
- Best practices to get malingerers out of the workers' comp system quickly, and whether it can really be done.
- The specific documentation you need to keep these claims from becoming long term and costly.
Clinical issues for lay people. "Injured workers who are total malingerers are easy to spot -- to the trained observer," Dr. Gatto said. Attorneys, judges, insurers, and many others in the workers' comp system may lack the clinical knowledge to fully appreciate these cases end up keeping these claimants in the system for indefinite periods.
"Case managers have training but a lot of people don't, and there are very obvious things that go on in the physical examination that point to malingering," he said. "I try to explain them to non-clinical people."
In addition to explaining the whats and whys of malingering, Dr. Gatto goes over the importance of the physical exam, especially the patient's history. "If you're not looking from the history, you are not going to pick it up," Gatto said. "Most doctors don't. They are not workers' comp savvy."
Document, document, document!
Vitally important to the process is documentation. Without proper documentation, it is difficult to prove malingering.
"History and pain are completely subjective," Gatto said. "The way you get objectivity into history and symptoms is by documentation and follow up."
Gatto explained a scenario in which an injured worker who has been coming to him for three months suddenly complains of shoulder pain. The conversation might go like this:
Physician: "I haven't heard about shoulder pain until today."
Claimant: "I told you about that all along!"
Physician: "No, you didn't. We talked about various other things during the last five appointments. I dictated my notes right in front of you. I asked you to help me if I forgot something. There is no way you told me about shoulder pain."
The process works if the physician has documentation on everything, from the mechanism of injury, to follow-up visits and physical exams. He said little bits of information can become a mountain of evidence.
"Everybody's pain feels different," he said. "It's all about asking the right questions and documenting the heck out of it. The better you document the history and symptoms, the more objectivity you get down the road."
During the session, Gatto will show short videos to demonstrate his points. He says that while the videos are not meant to be humorous, they often are because the examples of malingering can be so blatant.
Where injured workers who are malingerers are intentionally lying, there are some injured workers who magnify their symptoms subconsciously. To identify and help these claimants, it's important to understand some different psychological syndromes.
"Cultural things, expressions of pain, many subconscious things that go on, conversion disorders, historical neurosis -- the dissociative type of issues," Gatto said. "For those patients you want to push them in the right direction. Treat their underlying psychological tendencies. If you understand them, you can treat them."
By understanding some of the clinical aspects of injured workers, it becomes easier to identify those that are wasting money and those that truly need treatment. That, Gatto said, is the goal.
"We want nothing more than to help the truly injured," he said. "We just want to weed out the people who are ruining it for them."
By Nancy Grover
The 22nd annual National Workers' Compensation and Disability ConferenceŽ
& Expo takes place Nov. 20-22 at the Mandalay Bay Resort and Casino in Las Vegas. The conference is produced by LRP Publications. For more information, visit www.wcconference.com.
Read more at the WorkersComp Forum homepage.
August 30, 2013
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