Disability

Given the severity of mood and anxiety symptoms and some of the people we treat, we often deal with issues related to short-term or long-term work disability. In this post we will talk about common questions that come up when someone is impaired as the result of a psychiatric condition.

Functional Assessment

It often comes as a surprise to our patients that, although we spend what sometimes seems like an inordinate amount of time documenting our care of them, our notes typically do not contain what an employer or insurance company would consider a functional assessment, or an assessment of impairment.

This is generally true of physicians and other healthcare providers. The focus tends to be on problems or symptoms, and while problems or symptoms certainly relate to impairment they’re not at all the same thing.

Someone might have very severe symptoms (psychotic delusions or hallucinations) and yet be able to function adequately to work in certain settings. Whereas another person might have less dramatic symptoms (apathetic depression) and yet be completely unable to work, particularly in a demanding job.

A functional assessment generally takes a full session devoted just to that task. Many people think of this as something that the doctor should just do on his own, people will hand in the forms and expect them to get filled out and mailed in, but the kind of hurried response that that produces, lacking specific examples of impairments, is almost always inadequate.

The good news is that most insurance companies and the Social Security Administration will assume that the doctor’s assessment of functioning is accurate. The bad news is that the assessment has to be detailed, global ratings such as “can’t work” or even “unable to concentrate” are not adequate.

Levels of Impairment

An assessment of impairment looks at levels of impairment across a number of areas of functioning that are relevant to work function. Levels of impairment are defined as –

• Minimal – discomfort, but not disabling
• Very slight – detectable impairment
• Slight – noticeable impairment
• Moderate – marked impairment
• Severe – unable to perform work function

In many cases, insurance companies, employers, or the Social Security administration is looking for much more than just a one word summary. Generally specific descriptions of impairment are required.

Work Functions

Functioning is assessed across a number of areas of work function including –

1. Ability to comprehend and follow instructions

• the ability to maintain attention and concentration for necessary periods
• the ability to understand written or oral instructions
• the ability to do work requiring set limits, tolerances or standards

2. Ability to perform simple and repetitive tasks

• the ability to ask simple questions or request assistance
• the ability to perform activities of a routine nature
• the ability to remember locations and work procedures

3. Ability to maintain a work pace appropriate to a given work load

• the ability to perform activities within a schedule, maintain regular attendance and be punctual
• the ability to complete a normal work day and/or work week and perform at a consistent pace

4. Ability to perform complex and varied tasks

• the ability to the ability to synthesize, coordinate, and analyze data
• the ability to perform jobs requiring precise attainment of set limits, tolerances, or standards
• the ability to perform a variety of duties, often changing from one task to another of a different nature without loss of efficiency or composure

5. Ability to relate to other people beyond giving and receiving instructions

• the ability to get along with co-workers or peers
• the ability to perform work activities requiring negotiating with, explaining, or persuading
• the ability to respond appropriately to evaluation or criticism

6. Ability to influence people

• the ability to convince or direct others
• the ability to understand the meaning of words and to use them appropriately and effectively
• the ability to interact appropriately with people

7. Ability to make generalizations, evaluations or decisions without immediate supervision

• the ability to recognize potential hazards and follow appropriate precautions
• the ability to understand and remember detailed instructions
• the ability to make independent decisions or judgements based on appropriate information
• the ability to set realistic goals or make plans independent of others

8. Ability to accept and carry out responsibility for direction, control and planning

• the ability to set realistic goals or make plans independently of others
• the ability to negotiate with, instruct or supervise people
• the ability to respond appropriately to changes in the work conditions

Types of Disability Insurance

Short Term Disability

Short-term disability is usually defined as disability that is expected to last no more than a year. Short-term disability coverage is provided by an employer and is private insurance that the employer is mandated to provide but that can be purchased from many different insurance companies with varying degrees of professionalism.

Usually coverage for a couple of weeks of disability is more or less automatic and generally a letter from the doctor indicating that a person is no longer able to work is adequate.

Beyond that it may be necessary to do a functional impairment assessment and fill out other forms as well in order to document her ongoing disability coverage.

Insurance companies can also require or request copies of all of the progress notes can be reviewed by consulting doctors as part of the determination of eligibility for disability coverage.

Rarely a company may request an in person evaluation by an outside consultant.

As a general rule of thumb, the longer the period of disability the more important it is to do a very good job of documenting impairment as well as the treatment plan and the patient’s compliance with that plan.

Long-term Disability

While short-term disability is usually primarily provided by private insurers, the major source of coverage for long-term disability is the federal government through the Social Security Administration.

Social Security disability is divided into SSI and SSDI. SSI is for people who have not had significant work experience, and is most commonly the type of coverage for young people with serious and persistent mental disorders who’ve not been able to get employed. SSDI is the type of coverage for most people who have worked for quite a while and now are looking at a period of more than a year of disability.

Both of these types of coverage are based on an assessment of functional impairment, duration of impairment or anticipated duration of impairment of more than a year, and specific factors relevant to the diagnosis. For example, someone with bipolar disorder may meet the requirements for impairment if they are episodically impaired (due to mood cycles) but able to function in between the episodes, depending on the duration and frequency of the mood cycles.

The Social Security Administration is supposed to presume that the assessment of a treating physician (usually defined as someone who is providing ongoing care and has seen the patient at least four times) is accurate. In other words as long as the specifics of a functional assessment are in the documentation the claim should be approved.

In most cases spending a session to perform a functional assessment and then documenting that as well as providing documentation supporting the diagnosis and course of the illness is adequate.

Unfortunately, it remains our experience that in a significant minority of cases, claims for psychiatric disability are denied even when adequate documentation is present. If that happens we usually recommend that a person hire an attorney to assist in the process.