Video: Non-Clinical Career Opportunities for Physicians in Disability Insurance

Edited Transcript from SEAK’s 2025 Virtual Non-Clinical Careers for Physicians Program

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Moderator: [I am] very pleased right now to have a presentation on opportunities for physicians in the Disability Insurance field, which is an excellent field. I’m very much looking forward to this talk, and we really have a thought leader with us today, Dr. David Berube. Dr. Berube has absolutely vast experience in disability insurance and disability reviews. He’s a former chief medical officer of both Lincoln Financial and Liberty Mutual, and he was a national medical director at Aetna, and now he runs his own shop, which is Group Health MD.  Dr. Berube is also a clinical professor at both Yale and UConn.

He completed his occupational and environmental medicine fellowship at Yale, earned his MD. at the University of Vermont and his BA at Wesleyan so big. 

Dr. David Berube: Well, thank you, Jim, thank you for inviting me, and also thank you to the SEAK organization and thank you also for the audience. It’s a great opportunity to meet with you today and to hopefully give you some clinical pearls. Congratulations on considering some additional opportunities in the medical field. And hopefully with today’s presentation, you get some insight on what’s going on in the disability insurance arena.

As Jim said I recently started my own consulting company. One of the things I learned is, you always want to try to get a tagline to describe kind of the purpose of your mission – and getting employees lives back on track is the one that I think keeps me interested and excited about what I do. 

So what are we going to cover today? So there’s basically things, you know, I want to go over after a brief primer on disability medicine and insurance medicine. We’re going to go over a review of the full-time, part-time, and contract opportunities. We’ll talk about some of the day-to-day activities that you would be involved in with these positions. Disability insurance is a payroll replacement requirement that an individual has to have a medical condition that would preclude them from performing a specific job or occupational function.

And that’s key. An example might simply be paid sick leave right? So someone has a brief illness, maybe for a day or so. And they typically may call in sick. In some organizations they may need a doctor’s note, and those types of benefits are probably amongst the most common that are used on a frequency basis.

Then you have short-term disability where someone may have an illness for perhaps up to months that requires them to not use a leg, not use an arm, and so on. The most common type of situation [for] short-term disability is going to be pregnancy, which we’ll talk about in a little bit that and the other types of conditions. And then you may have a long-term disability situation, where someone has an illness or injury for longer than months.  These types of insurance coverages do not cover the medical treatment. 

Moving to the long-term disability. Typically, it may be a condition for months or longer. What happens when you transition from short term to long-term disability? The requirements change as far as what you’re unable to do. The short-term disability period will cover you if you’re not able to perform activities in your job description. So the specific job tasks in long-term disability, they look at the occupational tasks. The best way I describe that might be with the job of cashier in the national economy. There are lots of different types of cashier requirements and some organizations like a small store, say a gas station where someone’s just behind the counter. Someone may be required to lift no more than, say [a few] pounds. But if you work in a hardware store you might be required to lift [more] pounds in the national economy assessment for long-term disability. 

And so in that setting, someone who works in a hardware store, for example, may be entitled to a benefit if they can’t lift their pounds, but someone in another setting, where the requirement might be fewer pounds may not be entitled to their benefit because they can perform those tasks and typically the benefits will go to retirement age. 

I mentioned that pregnancy is the most common short-term disability claim, based upon the frequency and the number of days where individuals are out of work with restrictions. Pregnancy is one of the few conditions where the medical necessity for restrictions and the duration is based upon policy.

Most companies will have a benefit that authorizes weeks for vaginal delivery and weeks for Cesarean delivery. Musculoskeletal conditions are going to be generally the most frequent [for short-term disability] after pregnancy. 

We do see some changes in the incidence of these various conditions, depending upon the type of industry and also the events that are going on a world level during the pandemic, for example, infections which you see is typically going to be number from a frequency perspective in respiratory conditions actually move to the top. And that’s something that you’ll see depending upon regional issues, and also, as indicated, the types of industries that people are working in.

So one of the things that the disability assessments for peer reviews requires is to assist the individuals who are processing the benefits, understand what’s going on with the medical records. They typically are going to be individuals who are college educated, but they may not have a lot of medical training. Some do, but typically they may not. So what they’re going to do is ask you to explain to them what’s going on clinically, and the most important question is, what are the restrictions? Are they reasonably supported? If so why, what is the rationale? What’s the start date for those restrictions? And at which time should they be reassessed? So, for example, as I indicated, maybe a sprained ankle. If someone has a severe ankle sprain and they’re restricted from activities such as standing and walking, climbing ladders, all those things that may be reasonable to restrict someone. 

As I indicated, the restrictions are going to be the most critical thing that you can describe for them in a peer review. And what I want to do is just go over some of the important factors that need to be addressed. When you review medical records for evidence of what restrictions may be reasonably supported.

So first and foremost, restrictions are not based upon a diagnosis alone.

[For example], if the diagnosis is hypertension, the diagnosis of hypertension does not give you any idea if the hypertension is well treated, well managed, or if it’s out of control and accordingly one would need to have an understanding of what the standard of care would be for evaluating a condition and looking for reasonable examination findings, reasonable follow-up treatment parameters to determine what is reasonable for assessing and determining what the restrictions should be.

If it turns out in the blood pressure hypertension example, that the diagnosis of hypertension and that treatment has occurred, and the parameters are now normal, and there are no other associated clinical issues that are going on of concern, in that setting, a recommendation of no work would not necessarily be clinically supported. 

The other thing to think about is that a self-report that an individual may have of, they are unable to perform a task based upon an individual’s feeling, and it may, you know, be a situation where they have pain, or they may have a fear of, say, standing on a sprained ankle, etcetera. That alone is not sufficient. The records would need typically a clinical assessment by an appropriately qualified treating provider. I think the self-report of an individual is very important, but the basis for a restriction is the medical necessity for a restriction, typically because there may be harm or further injury if that task would be performed, and an individual who has that condition themselves is not going to be qualified to evaluate themselves and write their own restrictions. For example, one of the key things that physicians who get into this field of work often ask me is well who makes the benefit decisions and the answer to that is not physicians. As a peer review physician, you have no relationship and typically no direct understanding with those policies and all those benefit determinations. So it’s important to avoid language which may be suggestive that you are making a benefit determination. So, for example, it’s not reasonable for you to make statements such as the claimant is disabled and entitled to benefits from Carrier XY or Z. Your role is to provide a medical rationale to explain the answers to the questions that are posed to you, which may include what are the reasonably supported restrictions from start date A and start date B, etc., and then the insurance carrier staff will review that and then determine if with those restrictions their essential job requirements may not be able to be fulfilled and then determine, based on that what their entitlements are. An example may be a situation where an individual believes they have a job requirement to say, lift [X] pounds and they have a job restriction of maybe lifting, only say [Y] pounds. And it turns out, all they really have to lift is [Y] pounds, and the employer says that yep, they can do the job at [Y] pounds, and they’re not then going to be entitled to a benefit just as a high-level example.

But there’s lots of scenarios, and so on, and the wording in your reports is the key thing – I want to caution docs to stay in your lane. Stay clinical. You are not the treating provider, but you certainly can review the records provided and give a clinical rationale of what is in the information that you reviewed.

There are a variety of position roles that exist [for physicians in disability insurance], and you know, the most prevalent one is going to be as a treating clinician, treating clinicians engage on a regular basis with a variety of insurance carriers. We all know this and are frequently asked to fill out forms. They’re typically called tending physician statement forms which have information that the carrier needs. What is the diagnosis? What are the restrictions? What’s the start date of those restrictions? What’s the end? Those restrictions? When’s the next follow up? So that’s something that you may already have significant experience with in your practice.

The additional roles to consider, though, may be having a role as a [physician]employee for an insurance carrier. I’ve had some of those roles, and in those roles which I’ll describe a little bit they may vary from being simply an educator, reviewing medical information, speaking to treating providers, etc., etc. You may also, instead of being an employee, be an independent contractor. Many carriers have opportunities where they don’t want a full-time employee, but maybe someone for only a certain number of hours a week and then also, insurance companies may contract with vendors, companies that would provide them access to hundreds of physicians of various specialties, for example, to help them meet their needs. So those are roles that you may want to get involved in and actually provide some services to insurance companies so that they can meet their benefit. 

So let’s talk a little bit about the chief medical officer role [and medical directors in disability insurance].

What do the chief medical officers and medical directors do? Well, they obviously support all of the various functions in the organization ranging from, you know, claim reviews and assisting claim managers to supporting sales, and you may say, well, I don’t want to be a salesperson, but you know, in my experience in doing this I’ve had wonderful opportunities where I was able to engage with medical directors of some of the largest companies in the US and globally and work with them on ensuring that their workforce was receiving appropriate health insurance, pharmacy, insurance, disability, life insurance, and other types of benefit plans. There may be a need to support those customers by looking at some of their data, working with the company that you’re a medical director or chief medical officer for, and ensuring that the products that are offered are supporting those customers to ensure that their employees you know, are well and healthy, and getting the care that they need. So when I have the word sales and marketing, working with actuarial staff, it’s looking at the whole picture and ensuring that the various individuals have a good understanding of what is needed. In those roles you may interact with treating physicians. I’ve given grand rounds.

And you also, I think, can get involved in supporting good health and good well-being. You know, folks returning to work can improve their health.  Just being out of work, receiving benefits has also been demonstrated in the medical literature to result in lower financial status and [be] associated with that lower health status. So we want to make sure that in the role of a medical director we’re promoting good health with all the products that the organizations who may be supporting offer for their members.

Now, as a peer reviewed physician, you may perform actually a variety of roles, for example, such as the ones I described for a medical director/chief Medical Officer.

The activity [of working as a physician for a disability insurer] is not necessarily only going to be focused on claim reviews. It’s possible that you may be assigned to assist with projects looking at data and other things so generally the description, the scope of work, that you may be contracting for as a peer reviewed physician, it can be pretty broad. The most common one, though, is going to be reviewing medical records that are provided as evidence and explaining to the benefits folks, or whoever you’re supporting what is going on and what the information those records mean and support. The challenge you’re going to have is to write things in a report in a fashion that is going to be easily understood, clearly understood, because your report is organized in a format which the reader is going to understand. If there are multiple pages, they can go through those pages and understand the various sections and due to labeling in your report and how you answer questions. It’s easily organized and you have to be very efficient and timely, as you can imagine the reviewing records can take quite a bit of time, can be very costly to pay for many, many hours of work. So you want to make sure that you are very efficient, and that you have set up a process with your workflow that is going to be seen as efficient. 

One of the goals is to be independent and to do a full and fair review.  You really want to do this in a way in which you’re not going to lean towards favoring one party or the other.  That’s critically, critically important. It’s true that perhaps you’re paid by an insurance carrier or you’re paid by a defendant, attorney, etc., depending upon who the payer is, but that said they do not have any benefit if you’re biased, what’s going to happen if you’re biased thinking that oh, an insurance carry wants me to help them deny claims. It can be vastly more costly if your report is inaccurate/biased and has inappropriate information because that’s going to be discovered, and then a second opinion is going to be obtained, and then there might be a conflict of the opinions, and then they may have to get a  tiebreaker opinion, and that goes on and on. If you provide a sound well-reasoned rationale that’s unbiased from the start, the correct decisions will be made by the parties reviewing your reports, and they will be much more satisfied with the work you’re providing. And then that’s a way in which you can get more work.

If you provide biased work, they will realize that it’s more costly to get additional reviews by others, and you develop a track record which is just not going to bring success to you in this line of work [as a physician performing disability reviews]. You want to also make sure that you have a good understanding of the clinical literature and evidence-based medicine you want to have. You know sound principles that you can explain. And you also may want to consider non-medical information. In some instances, they may provide you video surveillance video where there’s, you know someone with a sprained ankle who’s supposedly unable to walk, who’s not walking, and then you have to have an understanding of how to assess that information, and whether or not some clinical aspects of that can be interpreted, etc.

There’s also a role for an independent medical examiner.  The key differences between doing simply peer reviews versus independent medical exams are that an independent medical examiner gets to meet and speak to that individual, that claimant, but a peer reviewer does not. Medical examiners are often asked to opine on the abilities – what is an individual capable of.

Another thing with independent medical examiners. They’re often asked in a workers’ comp setting to opine on the impairment ratings.  You can do workers comp reviews as a peer reviewer, and may be asked to opine on impairment ratings, but the frequency of that is much less, and also both IME docs and peer reviewers may opine on the medical necessity for treatment. 

So why do I find [working as a physician in disability insurance] stimulating and rewarding? A broad range of medical knowledge is required, and one has the ability to review treatment and clinical issues across all states in all regions. And it’s very interesting to see records, for example, from one region where they may have just implemented new technologies that are not available in the region that that you are practicing in, for example, and able to see, you know what’s going on. If you are reviewing for a boards exam, and so on, you have the opportunity to review medical records on conditions that maybe are rare. But now, in this role you’re seeing them maybe once a month you know, and so on. So you do see more a large variety of clinical issues in doing this work as well. You have an opportunity to teach which I’m pretty passionate about, and also to manage a clinical program and assist organizations in understanding what’s going on. There may be looking at a customer or client’s data and helping them understand where they have some opportunities to optimize the medical benefits or optimize the disability benefits or potentially implement some safety changes with new safety equipment where individuals are working and perhaps getting injured because you can look at large data sets and see the frequencies and incidences and have those understanding. So I think that from my perspective, that’s pretty enjoyable work by helping organizations actually reduce injuries and illness in some settings.

So a little bit about, you know some of the contract opportunities, and who to work for. We’ve covered several of these from the perspective of, you know, who to work for might be an insurance carrier, could be a company, a manufacturing company, a hospital. All kinds of organizations may have a need for someone to do some consulting and to do some peer review work qualifications. You have to be pretty qualified from the perspective of being board-certified. For example, if it’s disability insurance, you know, having an understanding about insurance, medicine, disability assessments, return to work issues, some of the business challenges that employers have, so that as you provide your consultative service to them, you can have some foresight in having meetings or answering questions in a way which are going to be of value to all parties from a commitment standpoint. Turnaround time is key. If there’s someone out of work, and there’s an insurance carrier or a company, and they need to provide benefits to an individual or make a decision about, say, a company replacing that individuals out with other workers. They need to know for how long, etc., etc., and they may need a very quick turnaround on the review.

[In terms of desired specialties,] there’s really no children, right? So pediatrics would be the key one that’s not used [in disability reviews]. Radiology is not used very frequently [in disability reviews] because there needs to be assessment of work restrictions.  Radiology may be needed. If there’s going to be an interpretation of, say, some films and studies, or maybe some if it’s an oncology case, some of the treatment. But that would be extremely rare. Dermatology would typically be covered by internal medicine and family medicine. But there is a rare need for dermatologists, but the standard ones [used in disability insurance companies for file reviews] are going to be the most common conditions musculoskeletal in nature. So physical medicine, rehabilitation, orthopedic surgery, rheumatology. You know the musculoskeletal specialties, including neurology, followed by the general medical specialties and also mental health is another specialty which there’s a great need for as well.   As far as income goes, there is a range, and I think one has to look at what the service risk is. So, for example, legal work typically pays more because there’s a greater risk as far as getting deposed getting involved in having to take periods of time off if there’s court cases.

There are larger number of situations now where it’s fee for service versus hourly rate paid [for physicians performing disability file reviews]. I think fee for service can be challenging, because the complexity of the case that you are being asked to review often is not well defined. The number of pages that are being referred to you to review does not necessarily always reflect the complexity. The complexity of a claim may also be described by the number of diagnoses, the number of questions, the number of treating providers if you’re asked to call a treating provider.

So if one has a fee for service-based arrangement, I think defining the complexity of the cases, and having a fee schedule accordingly, would be advised. So my advice would be to always get an attorney or someone with experience and looking at contracts, you generally are not going to be an employee of the organization, but [you] need to understand what your role would be as an independent contractor, and there are a variety of parameters in contracts.

In some instances, the organization may indemnify you, cover the liability that you may have in doing this type of work. If it doesn’t involve treatment, then it’s going to be covered by errors and emissions. Cyber insurance/cybersecurity insurance is also a new one. Most of this work is done in electronic fashion, using web-based access, and as a result, many of the organizations do require that the peer reviewers have cyber insurance, and in some cases they may provide that type of coverage for you.

So how to get involved as a physician disability file reviewer?  One of the key tools I think to involve is just networking and demonstrating that you have the right credentials and experience. In most cases you need at least a minimum of years of clinical practice experience. And then things like board certification being academically based, demonstrating that you have the ability to write well written reports and demonstrating you are able to meet their needs from a commitment perspective – availability during your week during certain hours may be needed to meet with individuals, or maybe blocking out a whole day or half days a week. But networking with peers, I think, is the best way to identify these opportunities and also understanding who’s local to you, you know, collaborating with business people. 

You also may want to interact and collaborate with individuals in various business organizations that need docs. So for example, DMEC, the Disability Management Employer Coalition or Integrated Benefits Institute.  Maybe you can even give a presentation in one of those meetings so you don’t avoid or feel embarrassed about cold calling, emailing, introducing yourself. If you have a company in your region where you live and a lot of patients work at, call them up and see if you can get a tour. If you can meet with some staff and explain that you’re treating a lot of their employees, and so on. And many docs in this line of work get consultative roles with those organizations because they went and met with them, and then, when they have some needs or questions, they go ahead and they’ll call you because they’ve already met with you.

I wanted to give you a listing of resources that are available for you to learn, so you can attend meetings such as at SEAK. This organization, as you know, has several types of training opportunities. Also the various Specialty Society, for example, the American College of Occupational Environmental Medicine, the American Board of Independent Medical Examiners, and also various references. One in particular is the OEM Press. There’s lots of organizations that have a variety of books, but this particular one is dedicated to supporting the needs of physicians who do peer review independent medical exams and are involved in the occupational environmental medicine arena. 

So, Jim, you didn’t interrupt me. I don’t know that I gave some pauses, but I hope you took some notes, and if you have any questions, I’m available now, and we have some time to answer them.

Q: That is the madness in my method. So let’s talk about peer to peers where the disability reviewer has to talk to the treating physician. How often do you think that’s required on a percentage basis? I know it’s hard to generalize.

A: Yeah. Yeah. So I think the more complex a claim is, it’s required more typically.  In my experience where a peer reviewer will look at a case, there’ll be a need for some clarification of some information, maybe some discrepancy [or] interpretation of information. And you, as a peer reviewer, may feel then, you know, I should pick up the phone, perhaps, and get some clarification.

Many docs, I think, in this sort of line of work feel that’s challenging, or they’re not interested in doing that. But I think there’s huge, huge value. There are a number of cases I’ve been involved in where I’ve called the docs. I learned that me as a peer reviewer, maybe I didn’t have all the information right? So that’s going to be one scenario. The carrier may do their best job and getting the information from their claimant sending it to you. And then you’re looking at the record and say, well, you know, there’s something missing here, perhaps, or I don’t understand whether the doc is coming up with the opposite opinion than what I’m getting. Are we looking at the same things? That’s been extremely helpful.

In addition, there are situations where the treating provider may not have all the information. Many patients are treated by multiple providers. They may have their information, but they may not have others information [that I have as] as a peer reviewer. If I have more information than the doc, that may be a reason why we have discrepant opinions so engaging in a conversation with a provider, can also help identify that.

What we don’t want to do is get into situations where we violate HIPAA. There may be a restriction on speaking with treating providers by a claimant’s attorney, for example, or you know, a claimant may have just said, no, I want my privacy. I don’t want anyone speaking to my docs, so that’s also very important to consider. If you’re not able to speak to a treating provider, one of the pearls is to determine what questions you would have asked them and to share that information with the claims manager that you’re answering the questions for so they can decide if they want to send a letter, and sometimes they’ll ask you as a peer reviewer to send a letter to that to that treating provider.

Q: Thank you very much, doctor. Now, let’s take the flip side of this. I know it’s not exactly on on topic, but I have to ask. As you know, doctors, and as you mentioned, treating doctors are very busy. In your experience, will the disability companies compensate the treating doctors for doing a peer to peer, filling out forms and things like that? If the doctors ask, and if so, why?

A: It’s a great question. So the answer is, [often times] yes, they most often will [but] you have to ask. So I say most often [they] will, [but] there are a couple of scenarios which maybe that’s not reasonable and appropriate, right? So we don’t want to say yes, for all scenarios. So typically treating providers don’t have a contractual relationship with disability insurance companies.

The Treating providers may have a contractual relationship with a health carrier to provide care for the population, the health insurance carrier insures, and then there’s going to be a fee schedule contract, etc. But a disability carrier will typically not have a relationship with that treating provider. If a treating Provider returns a form with an invoice, and it’s a reasonable amount of money they’re requesting, then there is very little reason for an insurance company to not pay a bill. Now insurance companies don’t necessarily want to get treating providers upset. They want them to fill out the forms. So a nominal invoice, you know, a reasonable fee will be reimbursed. If the fee is outrageous, and I’ve seen some of those requests that I felt were unnecessary and too high. I think in most cases a nominal fee may be paid to that, Doc, but you know I sort of pause because I’ve seen some of those scenarios where docs were asked to fill out one page forms and billed thousands of dollars, you know, to those carriers due to misunderstandings and so on. So typically, as a chief medical officer, medical doctor. You might pick up the phone and call that doc and say, why are you billing $$$$ for a page form that likely took you, just, you know, a minute or to fill out. But if the [treating] docs don’t ask [to be paid to fill out disability insurance forms], typically it’s not going to be offered, because there is no contractual obligation, as a contract doesn’t exist between the [disability insurance company and the] treating physician.

Q: Is there any call [for doctors who work in disability review]?

A: Yes, so call yes, absolutely you know it’s not as frequent as perhaps, like emergency medicine or treating practice. There is some call on a limited basis, though.

Q: So last question. Can you tell us a little bit more about your current role at Group Health MD, and how you guys, if you do work with doctors who want to do you know, disability reviews?A: Yeah. Yeah. So one of the roles that many docs have, if they’re thinking about making some changes in the amount of clinical work they do might be starting up their own consulting business. So Group Health MD is my consulting business. It’s an LLC and at this moment in time I’m the chief medical officer last year is when I, you know, established this organization, and I am working with many physicians who are doing disability peer review, I am working to get them contracted, helping them understand peer review work. And also I have some clients who are sending this work to do peer review work. So it’s just one of the opportunities that came upon for me, and I’m excited about it, and it’s getting very busy.