While the claims support role for physicians employed by a disability insurer does not involve direct patient care, the skills developed in clinical practice are used in the consulting role. Physicians in both roles require a good foundation in clinical medicine, the ability to use evidence-based criteria for decision making and sharp, focused analytical skills. The physician in practice brings those skills to bear in diagnosing an illness and designing a course of treatment. The physician working with an insurer brings those skills to bear to assist claims staff by providing an accurate assessment of functional capacity. It is important to understand that the physician involved in the evaluation of disability claims does not make a determination of either disability or the eligibility for compensation.
A physician working with a disability insurer may be involved in:
- Initial liability and ongoing case management reviews of medical information to determine medical context, such as functional capacity and the presence of pre-existing conditions.
- Review of medical information in the appeals process.
- Review of medical information in life and accident policies to provide medical context for application of exclusion and indemnity clauses.
- Assistance in underwriting
- Management of the medical evaluation process and the physicians that participate in it.
Because of the type of claims managed, disability insurers may be most interested in physicians with expertise in general medical conditions and orthopedics: internists, family practitioners, physiatrists, orthopedists. Subspecialists are also employed by disability insurers, but in fewer numbers and more frequently as part time employees or consultants.
For underwriting, a broad general background in medicine is required, most often internal medicine. Forensic pathologists may be involved in assessing life and accidental death files.
In order to be successful and personally fulfilled working full time for an insurer, physicians must be able to adjust to the new reality of not being as involved in direct patient care (though some employed physicians maintain some level of practice), must be able to understand and accept the role of the physician as interpreting and reasoning from the medical record rather than diagnosing and treating, must be comfortable working as a member of—rather than leader of—a team, must be tech-savvy, and should have good partnership, time, and change-management skills. As in medical practice, physicians working in a claims environment will face a wide range of situations from the simple to the complex. As the needs of claims management change, physicians working with disability insurers may find themselves assuming roles different from the roles for which they were hired so a flexible approach to work and a continuing interest in professional development are assets.
Physicians who do not want the constraints of employed practice and are willing to forgo the rewards of self-employment for the greater flexibility of being an independent contractor can often work as consultants either in the medical aspects of the claims process or providing independent medical examinations.
Barbara Golder, MD, JD graduated from the University of Florida College of Medicine and Stetson College of Law. As a pathologist, she has worked as a medical examiner, hospital pathologist, and director of free-standing clinical laboratories. Her law practice involved medical malpractice defense, employment law, health care risk management, and license defense. She served as Treasurer for the Florida Medical Association and has served on the governing boards of several health related companies, including FLAMEDCO and Bexar Credentialing. A widely published author, she has written on a variety of health law subjects in such publications as AMNews, MLObserver and Medical Economics. She currently serves as Director of Medical Quality Assurance for Unum and resides in Chattanooga, TN.
Disclaimer: The views expressed here are those of the author and do not necessarily reflect the views of her employer or any particular insurer. This viewpoint does not purport to describe or recommend any current, past, or planned claims or other practices of her employer or any particular insurer.