Download Harvesting the Claim Management Benefits of Emerging

Harvesting the claim management
benefits of emerging
neuropsychological assessment
practices
David Fisher, Ph.D., ABPP, LP
PsyBar, LLC
952-285-9000
www.psybar.com
(C) PsyBar LLC 2008. All rights reserved.
Part 1: Overall Concepts
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LLC2008.
2008. AllAllrights
rightsreserved.
reserved.
Basic IME preparation:
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Make certain you have all the information you need
before deciding to conduct an IME including:
Complete medical records
Records of telephone interviews with the claimant,
the employer, and the treating doctor(s)
Relevant collateral contact information
Performance reviews
Attendance records and other work-related
information are helpful.
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Information to gather prior to
neuropsychological evaluation
– All prior neuropsychological evaluations
(Rarely from other countries other than
Canada and England)
– “Raw test data” and “raw test protocols”
mailed directly from the past psychologist
to the IME psychologist
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Information to gather prior to
neuropsychological evaluation
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Relevant medical information such as
neuroimaging studies, physicals…
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Past psychiatric/psychological
treatment records (standards in other
countries vary)
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Basic IME preparation:
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Write down all significant consistencies
and inconsistencies in all
documentation and telephonic
correspondence.
This might clarify issues, and will help
you write questions for the
neuropsychologist.
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Selecting the appropriate
doctor:
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MD psychiatrists often particularly
adept in evaluating claimants with
largely biologically based mental
disorders. These disorders include
schizophrenia, bipolar illness, certain
depressive and anxiety disorders and
the impact of medications.
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Selecting the appropriate
doctor:
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Neuropsychologists: Evaluate clinical
psychological problems, and cognitive
deficits.
Generally 5 year doctoral degree, plus
2 years of training in neuropsychology,
and then work supervision.
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Objective testing:
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Over a hundred years of research on
objective psychological testing has
demonstrated that it can measure
skills and behavior more accurately
than can the most skilled clinicians.
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Objective testing:
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As objective psychological assessment
has progressed, national psychiatric
and psychological assessment
standards have increasingly
acknowledged the importance of
including objective psychological
testing when assessing human
behavior.
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Objective testing:
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The courts have also increasingly
stressed the importance of objective
assessment. Satisfying the courts’
demands is especially important to
insurers and employers, when asked
to demonstrate that the assessment
was performed according to nationally
recognized standards.
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Objective Testing: Used along
with clinical judgment
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Helps you defend your claim
determinations (insurers) and
managerial decisions (employers).
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The
Great
Divide
He has either, a primary auditory verbal
memory deficit originating in the
hippocampal or mesio-hipppocampal area,
or difficulty with processing efficiency!
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But, what
can he DO?
How to ask questions:
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Clear, concise questions will help you
obtain the information you need to
confidently support your claims
decisions.
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How to ask questions:
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Before you write questions, clarify
your goal. (e.g. do you need to
determine causation, diagnosis,
percent disability, truthfulness etc? )
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How to ask questions:
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Avoid leading questions.
Unintentionally, Independent Examiners
might be influenced by leading questions
and consequently offer biased responses.
Even when Independent Examiners
impartially answer leading questions, those
responses are vulnerable to challenges
during litigation.
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How to ask questions:
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Development of a standard set of
referral questions.
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Minor variations in referral questions
can result in major differences in
Independent Examiners’ responses.
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Before you write your first question,
understand doctors’ vs. insurers’
perspectives:
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“I don’t necessarily
need to justify my
conclusions with
several kinds of
evidence.”
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“As an insurer, I can
be more confident
in making decisions
if there are several
types of convergent
evidence
supporting my
claims decisions.”
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Examples of referral
questions:
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From a psychiatric/psychological perspective only, please
respond individually to sections “a” through “e” below by
describing this claimant’s current abilities and limitations in
his/her ability to perform daily tasks. (Questions © PsyBar 2005 - 2008)
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Abilities and limitations in performing tasks secondary to
psychological symptoms and abilities, as:
a) reported by the examinee.
b) observed before, during and after the examination.
c) indicated by objective test data.
d) documented in the medical record.
e) documented by other means, such as with your collateral
interview(s). © PsyBar, LLC 2005 - 2008
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Referral question
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Please explain how your sources of
evidence above are consistent or
inconsistent with each other. For
example, is the examinee self-report
consistent with your observations
and with test data?
(Questions © PsyBar 2005 - 2008)
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Referral question
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Is the diagnosis you have offered, if
any, causally related to the xx/xx/xx
injury or accident? If not, please
explain the cause of this
psychological/psychiatric
diagnosis.
© PsyBar, LLC 2005 - 2008
(C) PsyBar LLC 2008. All rights reserved.
Referral question
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Is the treatment this claimant has
received related to the xx/xx/xx injury or
accident?
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What are your recommendations for
treatment for psychological problems
only?
© PsyBar, LLC 2005 - 2008
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Referral question
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Please describe mental health treatment if any,
that is currently needed as a result of the
xx.xx.xx injury or accident. Please be specific
and include the expected frequency, duration,
and exact type of treatment that this claimant
requires. Please tell the qualifications of the
type of mental health professional that should
provide this treatment. © PsyBar, LLC 2005 – 2008
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Part 2:
Neuropsychological IMES:
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Neuropsychology:
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Includes the assessment of
cognitive abilities with a
combination of objective /
actuarial procedures as well as
largely subjective observations.
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Neuropsychological assessment
used when:
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There is a trauma, injury or disease causing:
– Obvious cognitive difficulties
– Physical functioning (e.g. fatigue,
perceptual problems)
– Emotional functioning
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Neuropsychological assessment
used even if:
-neurological or other evaluations are not
helpful (MRI,CT etc. show structure, not
function).
-there is no gross impairment in cognitive
functioning that would be obvious to a
physician.
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A Good Evaluation will include:
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Extensive interview with the patient
(2 - 31/2 hours) with an additional 4 to
10 hours of testing.
Collateral interviews with spouse,
employer, and / or others
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A Good Neuropsychological
evaluation will contain a range of tests
measuring:
Intellectual abilities
 Memory Functioning
 Motor speed and coordination
 Naming skills & verbal fluency
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A Good Neuropsychological
evaluation will also contain tests
measuring:
Attentional abilities
 Executive
 Processing speed
 Personality traits & mood
 Truthfulness, motivation and
effort/malingering
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In a normal individual with no
brain damage:
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the measurement of different
cognitive abilities should result in
test scores that are roughly
equivalent to each other.
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Neuropsychological Test Scores of Average
Individual, with No Neuropsychological
Problems
(average = 100)
120
100
80
60
40
20
0
Memory
IQ
Category
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IQ usually remains stable after injury,
while other tests might not.
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“Full Scale” IQ scores tend to be
largely unaffected by most brain
injuries.
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Scores on other psychological test
scores frequently decline.
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Typical Neuropsychological Test Scores of One
Person, Before and After Brain Injury
120
(average = 100)
100
80
60
40
IQ
Memory
20
0
Before Brain Injury
After Brain Injury
Category
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Injuries to the front part of the
brain can cause problems with:
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the ability to understand abstract
concepts
concentration
the ability to form memories
(personality changes also associated
with damage to this area).
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Typical Neuropsychological Test Scores for
Patient with Frontal Brain Injury
100
80
60
40
20
Normal
Frontal Brain Injury
gh
n
Category
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tt
st
ra
c
Ab
C
on
ce
n
tra
ho
u
tio
or
y
M
em
t
0
IQ
(average = 100)
120
Severe brain injuries
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Can result in problems with:
memory
concentration
angry outbursts
understanding new ideas
paying attention
perceptual skills
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Typical Neuropsychological Test Scores of
Patients with Moderate to Severe Brain Injury
100
80
60
40
Normal
20
Brain Injury
gh
ho
u
A
C
bs
on
c
tra
c
tt
en
t
M
em
ra
tio
or
y
n
t
0
IQ
(Average = 100)
120
Category
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Psychological vs. organic
problem
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Inconsistency from one evaluation to
the next and problems worsen during
times of emotional stress
Inconsistency from one conceptually
similar test to the next
Pattern of deficits does not match
those usually seen in an organic
disorder
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Part 3: Validity
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Clinical Judgment/
“intuitional” perspective
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“I’ve evaluated thousands of patients
over 30 years and I know a faker when
I see one. Why do I need
psychological tests?”
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Clinical Judgment/
“intuitional” perspective
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Myth: With an interview, a
psychologist or psychiatrist, using
many years of clinical knowledge,
can consistently identify those
individuals who are deceptive.
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Clinical Judgment/
“intuitional” perspective
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Fact: There is little, if any, credible
evidence that experienced mental
health professionals are able,
across a variety of situations, to
reliably identify deception using
clinical judgment alone.
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Objective testing:
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Virtually always desirable for the
psychologist or psychiatrist to rely in
part on objective psychological test
results to assess deception.
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Test of Memory
Malingering
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15 minutes long and requires claimant
to remember simple drawings
Claimants who are not putting forth full
effort receives scores lower than those
obtained by patients with genuine
neuropsychological problems
Correct classification rate is
approximately 80%
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Validity Indicator Profile
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Sophisticated computer-scored test
Cannot be used with individuals who
are severely cognitive impaired
Both verbal and visual portions
Approximately 77% correct
classification rate
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Word Memory Test
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Computerized 5-minute verbal and
nonverbal are computerized memory test.
Contains hidden measures, which serve to
check the validity of the patient's test
scores.
Close to 100% accurate in classifying some
simulators versus good effort volunteers
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Portland Digit Recognition
Test (1991)
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Two-choice design, to select a previously
administered string of 5 digits.
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Some people score below chance levels.
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Only identifies those whose deception is
prominent.
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MMPI-II
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Revised throughout the 1980s
Examines validity of reports of psychological
disturbance (not specifically designed to
evaluate truthfulness regarding
neuropsychological dysfunction
Evaluates areas such as depression,
anxiety, attitude towards work and
psychotherapy, tendency to report physical
problems when under emotional stress, and
self-confidence.
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When does it make sense to
use more than one test to
evaluate deception?
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When you need to rule out deception
of both psychological problems (e.g.
depression) and cognitive difficulties
(e.g. memory problems).
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(e.g. MMPI-2 and TOMM)
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Determining deception by
comparisons to prior
scores:
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Person with brain injury:
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Scores show rapid recovery in first 4
months after injury.
Recovery very slow after 1.5 years.
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Identifying deception with
comparisons to prior scores:
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Suspicious patterns with brain injury:
Scores drop during times when recovery
should be taking place
Scores don’t match the pattern of low scores
that is predicted by the type of brain injury
(e.g. people with injury to memory centers
show deficits in many areas other than
memory)
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Identifying deception (incl.
defensiveness) by comparing
test scores collected at different
points in time
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MMPI-2 test scores during the
Independent Medical Evaluation are
much different than those obtained by
treating doctors.
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Determining deception with unlikely
patterns of scores across different
types of tests
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Severely depressed people often have
problems with more “effortful” memory
tasks.
While MMPI-2 scores suggest severe
levels of depression, tests of “effortful”
memory are strong.
(Compelling but very difficult to support this approach
though with research)
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How to request Specific
Psychological Tests
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Very diplomatically
Don’t tell the psychologist what to do
Focus more on defining the problem to be
answered and working with the psychologist
about the best tests to use
Very complex process, taking into
consideration test validity/reliability,
examinee age, sex, capabilities, etc.
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Foreign language neuropsychological
evaluations:
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Professional interpreter
Tests with appropriate normative data
Doctor familiar with culture
Release/consent forms translated
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Locations of PsyBar’s 1200 MD/Ph.D
experts
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David Fisher Ph.D., LP, ABPP
President, PsyBar LLC
5151 Edina Industrial Boulevard, #675
Minneapolis, MN 55439
952-285-9000
(C) PsyBar LLC 2008. All rights reserved.