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Too sick to practice?

Medical records help insurers process claims

When Dr. Robert Bethea was 39 years old he began what would become an 18-year quest to determine the cause of a sporadic, yet ongoing affliction.

Bouts of pain in his left hand and arm progressed to chest discomfort that dug beneath his sternum and sometimes stole his concentration when treating patients. His search for a diagnosis led him to cardiologists, orthopedists and gastroenterologists and through a myriad of tests.

The discomfort would come and go—difficult treatment cases or stress seemed to provoke the pain, he says. Most of the time he looked and felt healthy, even jogging three miles each day.

It wasn't until he started working much less frequently ("My practice became hit or miss; I was starting and stopping and sending patients away") that he began considering his alternatives. He called his insurer, Great-West Life & Annuity Insurance Co. in October 2001. He had decided he might be better off selling his practice and working for the potential owner. It had been 18 years since his search for a diagnosis began. He still didn't have one.

"There are many conditions that disable dentists for which the symptoms cannot be objectively verified or quantified," says Gina Goodreau, senior manager of ADA Insurance Plans. "That doesn't diminish the veracity of the patient's explanation about the condition."

Ms. Goodreau, who manages claims review and underwriting for Great-West, says it's not so unusual for symptoms to lead a patient, or even the patient's doctors, down a path that either doesn't lead to a firm diagnoses or leads down the wrong track.

"What patients think might be wrong with them might not support the diagnosis advanced in support of disability," Ms. Goodreau says. "However, a record of medical care and treatment helps the insurer in processing the claim."

Disability claims based on what are sometimes called "self-reported" symptoms—symptoms that can't be objectively verified or quantified by a physician—can be problematic for both policyholders and insurance companies.

A patient with self-reported symptoms may tell his or her physician that work is impossible because of pain, fatigue, lack of dexterity or strength, yet diagnostic tests can't confirm the symptoms or the degree to which the problem exists. "That doesn't mean self-reported symptoms aren't often part of a legitimate disability claim, but it does highlight the importance of documentation," she says.

"Self-reported symptoms severe and frequent enough to interfere with work usually drive an individual to the doctor," said Ms. Goodreau. "The doctor will typically perform a physical exam, order tests and follow the patient over time, all of which lends credibility to self-reported symptoms at claim time."

It was six years ago, while dragging some tree limbs up a hill, that Dr. Bethea's symptoms evoked his own diagnosis. He told his wife, "I've got heart trouble. I know I do." He agreed to a heart catheter test. The test showed blockage in five major arteries, with 85 percent blockage in the left main coronary artery. "They call that one the widow maker," he said. He had heart surgery the following day.

Prior to 2001, Dr. Bethea had never considered filing for disability. He couldn't practice at full steam, or in all situations, but he wasn't ready to quit. Looking back, he can't think of anything he would've done differently if he had the chance to do it all over again.

"For my situation the doctors felt they were doing everything they should be doing, but one more test would've helped get to the root of the problem," said Dr. Bethea.

Dr. Bethea believes that health-conscious dentists may have a tendency to misjudge the source of their symptoms. "Somebody with my lifestyle, who jogged every day, would never expect to have certain conditions, such as heart disease," he explained.

Many conditions one might think could fall under self-reported don't anymore. Diagnostic criteria exist for ailments that have been notoriously difficult to objectively verify in the past, such as chronic fatigue syndrome and fibromyalgia.

The most common self-reported claim that can't consistently be verified or quantified by an attending physician—and also the leading cause of disability claims for dentists—is musculoskeletal pain and weakness.

Verifying and quantifying pain is difficult for insurers. ADA Income Plan Data from 2001-2007 shows that musculoskeletal disorders of the spine, shoulder and wrist make up a full 37 percent of disability claims.

As Ms. Goodreau points out, "If you put an MRI (magnetic resonance imaging) machine on the street and tested people walking by, you'd inevitably find degenerative changes and even bulging discs among people who have significant pain and in others who have very little or no pain at all."

A lot of factors come into play when insurers consider self-reported symptoms—the treating physician's evaluation, opinion, and treatment plan; progression and velocity of the symptoms; the age of the patient; prior and possibly related conditions.

Occasionally a dentist will work with symptoms for years then suddenly can't do it anymore. The pain that was well-documented, but the dentist could work with, is suddenly disabling.

"Insurers feels much more comfortable if it's pain that's been shown to be progressing," says Ms. Goodreau. "If it's a progressive condition, we expect to see that in the medical records. We should be able to see the condition worsening through the weeks, months or even years of evaluation and treatment."

She says some dentists are reluctant to report pain because they're afraid it will affect future coverage—"a personal decision they have to weigh," she noted.

(Ms. Goodreau says in almost all situations limited coverage is still available—even with a known musculoskeletal condition—with an elimination rider that excludes benefits for the pre-existing condition while providing protection against all other disabling conditions.)

Dr. Donald Rothenberg, a Massachusetts general practitioner, endured migraine headaches on and off for years, but it wasn't until about a year and a half ago that they started coming every day.

"They give me vertigo and affect my vision," Dr. Rothenberg told ADA News. "The pain has been so bad at times that I've had to go to the emergency room."

Despite the frequency and intensity of his symptoms, MRIs and CT (computed tomography) scans haven't revealed a cause.

Dr. Rothenberg filed for disability in October 2007. His primary care doctor and neurologist sent documentation of his visits and tests to his insurer, Great-West. Among the records Dr. Rothenberg sent were his appointment book and his monthly bank statement for the practice, tax returns and income reports, so Great-West could determine what he was earning in 2007 vs. what he was earning a few years prior. Dr. Rothenberg is collecting his benefits and says he understands why Great-West needed the documentation they asked for.

The ADA has member resources on disability insurance and ergonomics. They include:

  • For dental students: www.ada.org/prof/ed/careers/infopaks/ergonomics.asp
  • On ergonomics: www.ada.org/prof/prac/wellness/ergonomics.asp
  • For disability www.ada.org/prof/prac/wellness/disability.asp
  • The Council on Access, Prevention and Interprofessional Relations offers the Alternative Dental Careers packet for dentists considering careers outside of private practice. Contact Sherry Nash-Braun, toll-free, Ext. 2879.
  • The Relief Fund www.ada.org/ada/adaf/grants/relief.asp
  • The ADA Dentist Health and Wellness Program www.ada.org/prof/prac/wellness/program.asp#about.
Advice from Dr. Rothenberg

Dentists should continually upgrade their insurance as they get older, which is something I didn't do. When I took out my insurance I was in my late 30s or early 40s and everything was less expensive. I took out what I thought would be enough to cover my mortgage. It might have been enough for that time but I should've reassessed every three to five years."