CEO and Founders:David Gyepes & Rick Albert

Chief Administrator:Stuart Pearson

Ask the Experts Panel:

2017 Fall SACRS Conference.

National Disability Evaluations (NDE) provides Medical Advisory/Consultative services, Records Collection, IMEs and Record Review (MA) reports. Our network includes experienced physicians and specialists across a wide range of medical specialties.

The principals of Atrium Services Inc and First Medical Experts joined forces to form NDE.

CEO and Founders:David Gyepes, J.D., Ph.D., QME Richard Albert, MBA

Chief Administrator:Stuart Pearson

• Our physicians include:

Physicians

Orthopedics Psychiatry Internal MedicineNeurology Rheumatology CardiologyOncology Addiction Medicine Pain ManagementPhysical Medicine Neurophysiology Brain InjuryNeuropsychology Gastroenterology HepatologyToxicology Urology OtolaryngologyDentistry Pulmonology Allergists

– We endeavor to become a part of our client’s offices. These are relational building processes. Each client is unique. Over a period of time, protocols and systems develop and improve.

– Monthly status meetings foster protocol and report improvements.

– Communication frequency.

Administrative Approach

Medical Advisory/IME -

1. CERA will notify us regarding new cases via email.

2. CERA will upload pertinent documentation to NDE’s secured, HIPAA-compliant FTP account.

3. Our administrative staff will download the documents from the server, review re: choice of physician and specialty prior to Physician reviewing.

4. Once the Physician has had time to review the catalogue, the Physician and a designated representative or representatives of CERA will conduct a 20-30 minute conference call to preview the Physician’s opinions and to discuss the salient points of the Member’s case.

5. Approximately fourteen days following the conference call, Client will receive the Physician’s Medical Advisory report via our HIPAA-compliant server. The report will include the Physician’s findings as well as a fully annotated record review.

6. The Physician may suggest an Independent Medical Evaluation be performed if he or she cannot clearly give professional approval of the disability claim.

Procedures When a Disability Application is Submitted for Review

1) Workers’ Compensation: A. Three years prior to claimed injury to presentB. AMEs, PQMEs, PTPs PR-2s and P&S/MMI reports (Record reviews invaluable)

2) PCPA. 5 years prior to claimed injury to presentB. Different types of cases (Ortho v. Psych)

3) Hospital/Surgical records (Nursing notes)

Records

• Costs / Benefits

• Pros and Cons

• Tips1. Encourage members to submit records directly to you. 2. Instruct members that all medical files must be delivered to their CERA

rep and NOT the doctor

Records

• Recent QMEs or AMEs with detailed medical histories

• Obvious impairment situations with recent medical examinations

MA

• Records Missing/ Insufficient Records

• No relevant medical examination within last two years

IME

When to choose a MA vs. IME

MA followed by IME: CAUTION!!!!!

• Workers’ Comp. v. Disability

• Different Questions/Systems

• Physicians’ Idiosyncracies

• Evidence Based Opinions

• Report Structure

Training (Helping physicians/Helping CERAs)

1. Doctors’ confusion over workers’ compensation concepts muddies the disability waters.

2. Disability v. Incapacity

3. AOE/COE v. Service Connection

4. Permanent Total Disability v. Permanent Incapacity

Workers’ Compensation v. Disability

1. CERAs have different questions sets

2. CalSTRS and CalPERS approaches/questions

Different Systems/Questions

1. Following instructions

2. Intransigence v. Flexibility

3. M.D(iety)

4. Experience v. Specialty

Physicians’ Idiosyncracies

PLEASE NOTE: YOUR OPINIONS MUST BE LIMITED TO THE FOUR CORNERS OF THE EVIDENCE PRESENTED TO YOU. DO NOT MAKE ASSUMPTIONS OR BASE OPINIONS ON FACTORS OUTSIDE OF THE EVIDENCE REVIEWED.

Substantive Approach

Experience as lawyers and experts informs an evidence based approach (No Conclusory Opinions)

Evidentiary Chair Analogy: • 1. Records• 2. Objective findings (Testing and imaging)• 3. Self-Report/Subjective findings• 4. Examples 1)Psych (Validity Scales) 2) Ortho (Waddell’s Signs)

Substantive Approach

Lead with questions and recommendation.

1. Easier for Board Members- Board members quickly get to the crux of the matter without becoming unnecessarily confused or lost in details.

2. Physicians generate better evidence supported answers-Reduces likelihood of conclusory physician responses.

Report Structure

• Encourages doctors to submit evidence based answers. Improves clarity and brevity.

• Increases likelihood of quick report turnaround times

• Easier for your Board Members

Model Answers

Do you believe the applicant is physically or mentally incapacitated from substantially performing the usual duties of her job with or without accommodation?

Yes, to a reasonable medical probability, with or without accommodation, the member is physically/mentally incapacitated from substantially performing her usual job duties as a _____________ as defined in the submitted Job Analysis for _______County.” Specifically, the member cannot: (list usual job duties the member is unable to perform): (list usual job duties member can perform, but would cause severe pain making effective performance difficult or impossible); (list duties member can perform for a period of time but would cause further injury.)

Sample Model Answers

Do you believe the applicant is physically or mentally incapacitated from substantially performing the usual duties of her job with or without accommodation?

1. No, to a reasonable medical probability, the member is not incapacitated from substantially performing the usual duties of his/her job without accommodation. Currently, the member can perform the following usual duties (list usual duties).

2. No, to a reasonable medical probability, the member is not incapacitated from substantially performing the usual duties of his/her job with accommodation. Currently, the member can perform the following usual duties (list usual duties) with the following accommodations (List accommodations).

Sample Model Answers

Is the incapacity permanent?

Yes, to a reasonable medical probability, the member’s incapacity is permanent. Standard medical treatments (please list) have not resulted in material improvement enabling the member to perform his/her usual duties. There is no accommodation allowing the member to perform his/her duties in an alternative manner within his/her medical restrictions.

Sample Model Answers

Is the incapacity permanent?

1. No, to a reasonable medical probability, the member’s incapacity is NOT permanent. To a reasonable medical probability, it is probable that further medical treatment (specify treatment) will likely materially improve the member’s condition enabling him/her to perform his/her usual duties.

2. No, to a reasonable medical probability, the member unreasonably refuses low-risk, conventional treatment(s) (Please list) likely to materially improve their medical condition enabling him/her to perform his/her duties

Sample Model Answers

Is the incapacity permanent? (cont.)

3. No, to a reasonable medical probability, the member has an untreated, co-existing medical condition (please identify) that interferes with accurate evaluation, treatment and improvement of the claimed incapacitating condition.

4. No, to a reasonable medical probability, the permanency is speculative, indefinite or unable to be ascertained because (please list/explain).

5. To a reasonable medical probability, reasonable accommodation (please list/explain) would allow the member to perform usual duties within his/her medical limitations.

Sample Model Answers

Is the incapacity service-related?

1. Yes, to a reasonable medical probability, the incapacity is service-related. As documented in (cite records/ references), there is substantial evidence of a demonstrated real and measurable link between the applicant’s employment and his/her incapacity.”

2. Yes, to a reasonable medical probability, the member’s job materially aggravated or accelerated the underlying pathology of his/her pre-existing condition (please explain) causing the member to be disabled at an earlier time than if she/he had not worked for _____ County.

Sample Model Answers

Is the incapacity service-related?

1. No , to a reasonable medical probability, the incapacity is NOT service-related. As documented in (cite records/ references), there is insufficient evidence of a demonstrated real and measurable link between the applicant’s employment and her incapacity.

2. No, to a reasonable medical probability the member’s employment caused a temporary aggravation of symptoms (please list). The member’s job did not materially aggravate or accelerate the underlying pathology of his/her pre-existing condition

Sample Model Answers

Questions and Answers

David Gyepes, J.D., Ph.D., QME– dgyepes@ndeval.com

Rick Albert, MBA– ralbert@ndeval.com

Stuart Pearson– (844) 287-8180– spearson@ndeval.com

Contact Information

Thank you for your time!