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Fraud detection


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Current methods of fraud detection used by insurance companies are not cost effective. This presentation describes the inaccuracy of the MMPI, and presents a new test, which can predict who will had medical test abnormalites with 95% accuracy, and who wil not have medical test abnormalities with 85% accuracy (the fakers). Available in English and Spanish at

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Fraud detection

  1. 1. Fraud Detection inWorkers Compensation and Auto Accident CasesNelson Hendler, MD, MSCEO of www.MarylandClinicalDiagnostics.comFormer Assistant Professor of NeurosurgeryJohns Hopkins University School of MedicinePast president –American Academy of Pain ManagementFormer Clinical Director –Mensana Clinic
  2. 2. California Does a Poor Job of Combating Worker’s Comp Fraud (Workers Compensation Report, Vol 15, No. 11, p.206 May 17, 2004)• State Auditor Elaine Howle says the $30,000,000 annual assessment to combat fraud may be wasted.• Insurance companies cannot measure the effectiveness of their efforts using IMEs and surveillance.• The companies are relying on antedotal testimony from stakeholders in the workers compensation community, unscientific estimates, and description of local cases involving fraud.• The fraud division publishes statistics showing the number of investigations, arrests, convictions, and restitution, but cannot show if anti-fraud efforts are cost-effective.• See
  3. 3. Types of Chronic Pain Patients Hendler, Diagnosis and Non-Surgical Management of Chronic Pain, Raven Press, ‘81• There are Two broad Categories of Chronic Pain Patients• Objective Pain Patient: Good pre-morbid adjustment, objective findings, and goes through the 4 stages of pain (case study: Car Exec.) (87%-94% of all chronic pain patients)• Exaggerating Pain Patient: poor pre-morbid adjustment, minimal findings, and absence of depression (case study: hysterical scoliosis).• (Between 6% to 13% of all chronic pain patients)
  4. 4. What is a Normal Response toDocumented Severe Chronic Pain?• We need to study what normal is before we can understand what abnormal is• This is the same reason medical students study anatomy before pathology.• If you know what a normal response to a documented severe chronic pain is, you can appreciate that any deviation from that response is suspicious and abnormal
  5. 5. Objective (Valid) Pain PatientCase Study: A 56 year old executive for a Big Three auto maker was marriedfor 25 years, had three children all of whom were in college, and was earningover $1,000,000/year. He was working on his boat, when the engine fell, andtraumatically amputated his thumb. He went to work the next day, andcontinued to work, and he expected the pain to subside. However, after twomonths, the pain in his thumb became so severe, that he could notconcentrate, nor sleep. He was diagnosed with a neuroma in the stump of thethumb. Any sensation to the stump would cause severe pain to shoot up hisarm. When he was seen at a hospital in Baltimore, he had been suffering fortwo years. He scored 14 points on the Maryland Clinical Diagnostics PainValidity Test, putting him the Objective Pain Patient category. He was suicidal,sleeping only two hours a night, and was on three types of narcotics, sleepingmedication, and diazepam. He wanted to divorce his wife because he felt likea burden to her. He was severely depressed and had never been depressedbefore the onset of pain. He was so desperate to get rid of his pain that he hada thalamic stimulator put into his brain. Unfortunately, this gave him only partialrelief. Eight years after the onset of his pain, he was less depressed, was offnarcotics, and sleeping medication, and was getting four hours of sleep anight. He still had pain, but had adjusted to the pain. He had retired from theauto company. (Hendler, Diagnosis and Non-Surgical Management of Chronic Pain, RavenPress, New York, 1981).
  6. 6. 4 Stages of Chronic Pain in an Objective Pain Patient(Hendler, in Diagnosis and Treatment of Chronic Pain, Edited by Hendler, Long and Weiss, Wright-PSG, ’82)• Chronic pain patients go through 4 stages remarkable similar to the 5 stages a patient experiences when dying (Kubler-Ross-’69), just like the example.• Acute Stage 0-2 months –Pt. expects to get well, so no psychological changes (MMPI is normal).• Sub-acute stage-2-6 months- Pt. had anxiety and somatic concerns develop (MMPI scales 1 & 3 are elevated)• Chronic stage 6 months-8 years- Pt. is depressed (MMPI has elevated scale 2, called a pain neurosis by Blumer, pain prone patient by Pilling, low back loser by Sternbach)• Sub-chronic stage-3-12 years Pt. resets goals-adaptation (MMPI scales 1 & 3 elevated, hypochondriasis and hysteria)
  7. 7. Exaggerating Pain PatientA 43 year old woman was hospitalized in Baltimore, complaining of markedscoliosis, that had just developed, in the past year. Further evaluation did notverify the typical radiological findings seen with a constant scoliosis. She scored24 points on the Maryland Clinical Diagnostics Pain Validity Test, putting her inthe Exaggerating Pain Patient category. A trial with an Amytal (truth serum)interview failed to resolved the scoliosis, but when the patient was anesthetized,the scoliosis resolved temporarily. Further Amytal interviews revealed the patienthad a stormy marital relationship, and she avoided sex with her husband,because he was abusive. The patient was reassured she need not have sex withher husband if he was abusive. The next day, she walked upright, and continuedin this posture, until her husband visited. The day of the visit, the scoliosisreturned. Additional Amytal interviews revealed she had been abused as a child.She had a she had been afraid to seek divorce from her husband, but with socialworker intervention, she found the support to do so. The scoliosis resolved. Onfive year follow-up, she was divorced, and remained free of scoliosis. (Hendler, N,Filtzer, D, Talo, S, Panzetta, M, and Long, D, Hysterical Scoliosis Treated with AmobarbitalNarcosynthesis, The Clinical Journal of Pain, 2:179-182, 1987).
  8. 8. MMPI (Minnesota Multiphasic Personality Inventory) lack of predictive capabilities• Hagedorn et al from Mayo Clinic (Pain, ’84) followed 50,000 patients for 25 years. This is the only prospective study.• They all received the MMPI when they first entered the Mayo Clinic system.• 68 of them had back surgery.• No difference in pre-surgery MMPI between those who did do well or didn’t do well with surgery.
  9. 9. The MMPI Cannot Validate the Complaint of Pain• MMPI is not consistent in predicting the presence or absence of organic pathology. Not one single scale ever correlates, consistently, with the presence or absence of organic pathology (Hendler et al, Pain, ’85, Hendler et al J. Occ. Medicine,’88, Hendler et al J. Neurolog & Ortho. Med. & Surgery, ’85, Hendler Clinical Neurosurgery, ‘89)
  10. 10. Longitudinal Studies on DepressionA study of 83 patients admitted to Mensana Clinic77% of the chronic pain patients were depressed, as confirmed by Beck scores.However, 89% had never been depressed before the onset of their pain ( Hendler, Clinical Neurosurgery, ‘89)After six months or more, chronic pain produces depression (Hendler, J. Clinical Psych, ’84)
  11. 11. Overused Psychiatric Diagnoses in Chronic Pain PatientsMalingering: No statistics about frequency (Hendlerand Talo, Current Therapy of Pain, edited by Kathy Foley and Richard Payne, BC Decker, ’89).Pain Disorder is defined as a pain for which is there is no medical explanation. However, since 40%-67% of chronic pain patients are misdiagnosed medically, then these patients receive a faulty psychiatric diagnosis, because of a poor medical diagnosis.Depressive Equivalents: Depression causes pain.Circular logic in the diagnostic criteria in DSM-IV forsomatoform disorder, pain disorder, and depressiveequivalents. With a poor medical work-up, these “diagnoses” becomes self fulfilling prophecies.
  12. 12. Suicide and PainChronic pain patients commit suicide at a higher rate than the general population (Fishbain et al Clin. J. of Pain, ‘91).White males with pain complete suicide at a rate 2X higher than the general population.White females with pain complete suicide at a rate 3 X higher than the general population.White males with pain, involved in workers compensation litigation complete suicide at a rate 3 X higher than the general population.
  13. 13. Mensana Clinic Approach• Patients can have both psychiatric disease and organic pathology co-existing• Schizophrenics get brain tumors, and hysterics get disc disease. Psychiatric disease does not confer an immunity to medical disease.• Treat each patient as if they have organic pathology.• Give patient the benefit of the doubt.• See
  14. 14. What are the Questions?• Does the patient have a valid complaint of pain?• Variables: pre-existing psychopathology, resultant psychopathology, negative tests, positive tests that do not correlate with the anatomical complaint of pain (i.e. L5-S1 disc on MRI: pain in top of thigh = L2-L3)• KEY Concept: Severe chronic pain produces consistent psychological and sociological responses in a patient, regardless of pre-existing or co-existing psychiatric disease.• If the response to pain is normal, believe the patient, not the tests, and keep looking.
  15. 15. Available Help• Pain Validity Test is available on Internet to validate pain, and improve diagnostic accuracy, as a screening tool to help get an accurate diagnosis, and supplement the use of IMEs, and surveillance.• Preliminary studies (next slide) show an average cost savings of $1,654/case for answering the question – “Is the pain valid?” using Pain Validity Test for $300.• Average $97,000/case cost containment for “What is the diagnosis and treatment?” (Appendix A) using Diagnostic Paradigm.
  16. 16. Spotting Fraud• National Council on Compensation Insurance (NCCI) published a report Assessing Pain, Real and Imagined(11/29/98)• Hendler reports that 6% of non-litigant patients are exaggerating pain patients, 10% of LTD, and 13% of workers compensation.• For $300, The Maryland Clinical Diagnostics Pain Validity Test can identify exaggerating pain patients (• Average savings of $1,654/claim by eliminating IMEs, surveillance, and nurse case reviewer in the objective pain patient, and focusing the resources on the exaggerating pain patient.
  17. 17. The Pain Validity Test*• An Internet questionnaire, available in English and Spanish• Results are emailed to the requesting party within 5 minutes of completion of the test.• The Pain Validity Test can predict with 95% accuracy who will have an abnormality on objective medical tests, and predict with 85% accuracy who will not.*Hendler, N. and Baker, A., An Internet questionnaire to predict the presence or absence of organic pathology in chronic back, neck and limb pain patients, Pan Arab Journal of Neurosurgery, Vol. 12, No. 1, pp: 15-24, April, 2008• Costs $300 at
  18. 18. Scattergram of Computer Scored MCD Pain Validity Test.On the left, 3* is a severe abnormality, 2 a moderate abnormality, 1 a mild abnormality, and 0 is no abnormality on at least one objective medical test. At the bottom, 8-25 represent the score on the MCD Pain Validity Test. 17 or less is an Objective Pain Patient, 21 point or higher is an Exaggerating Pain Patient*3 65/69 = 94% 2 Exaggerating Objective Pain Patient Pain Patient1 11/13 = 84%0 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
  19. 19. Efficacy?• Do you have statistics?• A literature search using Google, Jeeves, National Library of Medicine, National Council of Compensation Insurers, AOL, Yahoo, etc. never revealed an article documenting the cost effectiveness of IMEs, surveillance, P.T., Functional Capacities Evaluations, and Case Reviews. There were lots of case reports.• 54 cases reviewed for “XZY” insurance had an average of 3.8 IMEs (1-7), and cases were still active, out of work an average of 3.9 years (1.5-12).
  20. 20. Richard Pimentel at National Council on Compensation Insurance Symposium,May 6,’04 (Workers’ Compensation Report Vol. 15, No. 11, p. 206, May 17, 2004)• Insurers hold the key to reducing claims duration with effective Return to Work Strategies• Currently: Worker goes to doctor, Worker files a claim with insurer, Worker doesn’t want to return to work, Insurance company contacts employer for a job description, and send RTW form to doctor, who fills out form and sends it to insurance carrier, who contacts the employer to to to get worker to RTW.• His plan: remove the insurer from the equation.• Having a supervisor of the worker from the company go to the doctor with the worker saved $1,400/claim.
  21. 21. Conclusions• The current methods of assessing fraud (IMEs, FCE, surveillance) are not cost effective, and not accurate.• Misdiagnosed patients cost insurance companies much more than fraudulent cases.• The Pain Validity Test is a reliable method for detecting fraud.• Physical therapy has not been documented as cost effective in chronic pain patient treatment.• Insurance carriers should demand Evidence Based Medicine = proof of efficacy of treatment.