CASE STUDY

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CASE STUDY DOCUMENTS AVAILABLE, CLICK HERE and HERE

Client (disabled person) is a 41 year old male with the following mental, physical and employment limitations/restrictions listed in a Peer Review Report ordered by one of the major disability Insurance Carriers:

• Subject has undergone twelve (12) knee surgeries over the past fifteen (15) years stemming from an accident and subsequent failed surgery.

• Claimant’s last day of work was 3/7/95 according to the records after six years of employment.  Out of work one full year due to accident in 1991.
  

• Subject is left with significant patella femoral disease and does have significant problems with the use of his knees.  In addition he has developed reflex sympathetic dystrophy, has chronic pain management problems and is on long term heavy doses of Oxycontin.

• Fine finger manipulation may be limited due to medication effects.

• Chronic opioid treatment may cause impaired judgment related to work and travel

• Patient is unable to get back and forth to work because he is unable to drive due to inability to move legs and also because of ongoing use of Oxycontin

• Difficult for the claimant to ambulate or sit for extended periods.  Subject requires the ability to "frequently" move around from a simple sedentary position every ten to fifteen minutes for at least five minutes.

• Subject is unable to do any standing, climbing, balancing, stooping, kneeling, crawling or crouching.  Subject is not able to lift anything for any distance more than approximately 2 ft.

• Subject is receiving SSDI since 2001

 After paying benefits for ten (10) years a Transferable Skills Analysis (TSA) was ordered by CIGNA utilizing their wholly owned subsidiary, Intracorp.  The CRC never contacted the "client". The contents of the meager one and one-half page TSA in this complex case are as follows:

Work Experience:

DOT CODE: 274.157.010 - Sr. Acct Mgr Elevator    SVP-8  Yrs.- 8  Strength- S

Education:

BA- Speech Communication     MS- Management

Medical and Physical Restrictions

Bilateral knee problems with significant patella femoral disease and reflex sympathetic dystrophy, and chronic pain.

Wage Replacement: $2,250 monthly

Conclusion: The following occupations did transfer based upon the claimant’s work history and meet wage replacement. 

162.117-014---Contract Administrator SVP – 8 , Strength – S

163.167-010---Manager, Advertising    SVP – 8 , Strength – S

163.167-014---Manager, Circulation     SVP- 8, Strength –S

163.167-018---Manager, Sales  SVP- 8, Strength –S

239.137-010---Commercial Supervisor Instructor Tel SVP – 8  Strength – S

185.167-034---Merchandise Manager  SVP- 7 Strength – S

249.137-026---Supervisor, order-takers  SVP- 5   Strength  - S

END OF TSA -  It was signed by a Rehabilitation Counselor with a CRC certification and a state professional counselor license however not a member of IARP.

Investigative Notes Added by THETSASCAM.COM:

1.  The above TSA was the second TSA ordered by CIGNA during a lengthy,  two appeal, ERISA claim process that ended in an affirmed denial relying on the conclusions of the second TSA.  The first “INDEPENDENT” TSA performed by a CRC, MS, IARP member was completed seven months earlier and contained the following three assessments:

• The restriction/limitation requiring the ability to move around from a simple sedentary position approximately 10-15 minutes for at least five minutes would not be compatible with typical competitive work demands.  Moving away from the work station and walking for five minutes would not appear to be consistent with typical requirements for productivity and maintaining a work pace.

• It appears the claimant’s last employment was ten years distant.... The advanced education would not appear to allow for direct entry into a management or supervisory capacity given the last date of employment.

• Work Experience: DOT 247.157-010 Sales Rep. Mechanical Equip Elevators Strength - Light       SVP - 5
  

While the claimant refers to his position as “Sr. Account Manger”, it appears that the “management” function was related to his handling specific accounts in a territory.  It did not appear that he had a department or other personnel staff that he was overseeing.  The position appears to have been more related to field sales position of technical equipment servicing existing customers, prospecting new customers and providing technical expertise in terms of elevator operation. 

 

2.  Within the administrative file was a notation from the CIGNA's Registered Nurse Claim Manager ten (10) days before the second TSA was performed:

Received the Peer Review Report from orthopedic specialist who found that the provided medical records are sufficient to support R/L that would prevent sedentary activity during the time period in question.  Peer Reviewer notes that cx is able to sit at a desk but would require frequent position changes with changing position every 10-15 minutes, is unable to do any standing, etc.  Because of claimant’s ongoing use of Oxycontin he would be unable to work.

3.  It appears an internal TSA document and the final TSA document have two different referrers.  The internal TSA mentions a CRC ordered the TSA and provided the docs however the final TSA indicates a claim manager ordered it. 

4. The invoice for the second TSA indicates it was an "automated transferable skills analysis" however the TSA document does not mention what automation was utilized.

5.  The CRC performing the second TSA did not list the dates of the documents that were evaluated.  This is unacceptable behavior designed to shield the Insurer and the CRC from questions of bias and "selective review".  Any doubts that a CRC is willing to team up with an Insurer should be put to rest with this case.

6.  A Third TSA has turned up on this case. 

THETSASCAM.COM DISCUSSION:

1. The Rehabilitation Counselor (CRC) lists a DOT Code 274.157.010 and Occupational title “Sr. Account Manager” that do not match.  There is no such DOT occupational title as “Sr. Account Manager.”  In addition the DOT Code 274.157.010 which the Rehabilitation Counselor (CRC) listed in the TSA has an SVP rating of “5” not “8” and it is a “Light” strength rating not “sedentary.”

 2.  The rehabilitation counselor apparently complied with the Insurance Company instruction or coaching to avoid the subject of narcotic medications and their cognitive effects on "judgment".  This is illustrated by the fact that the TSA virtually cites word for word the Peer Review Diagnosis "subject is left with significant patella femoral disease and does have significant problems with the use of his knees.  In addition he has developed reflex sympathetic dystrophy" but then omits “has chronic pain management problems and is on long term heavy doses of Oxycontin" and substitutes "chronic pain".  In fact the TSA does not even address the numerous references  to the cognitive effects of narcotics on “judgment, work, transportation, driving or fine manipulation” contained in the medical diagnosis contained in the Peer Review Report.  Since when is a person taking heavy doses of narcotics too cognitively impaired to drive yet safely capable of "supervising" or "managing" employees.  If a person consumed a twelve-pack of beer before work and was too impaired to drive, would they be capable of safely "supervising" or "managing" employees? 

3.  There was no labor market survey performed or referenced. The rehabilitation counselor put forth absolutely no evidence, in such a complex case, that any of the occupations the rehabilitation counselor listed in the TSA actually exist in the labor market for an individual taking heavy doses of narcotics; who has been kept out of the workforce for more than a decade; who is “not able to get back and forth to work”; who is unable to do any standing; has no supervisory or managerial experience and who has no training or experience in circulation, merchandising, contract administration, advertising, utilities, telephone or waterworks. 

4.  CIGNA apparently chose a certified rehabilitation counselor (CRC) that had no problem reversing the findings of an independent colleague to facilitate the CIGNA's denial of benefits.  The reader will note that each of the occupations listed in the second TSA is a managerial or supervisory position; however, the subject, as noted in the first independent TSA, has no employment experience whatsoever in managing or supervising employees.  It defies logic that an employer would hire the subject in a managerial or supervisory capacity, particularly since, the subject’s disability kept him out of the workforce more than ten(10) years, has no managerial or supervisory experience and is prescribed “heavy doses” of narcotic pain medication to deal with chronic pain.   The Independent TSA (done the behest of the same CIGNA seven months earlier) pointedly addressed the unlikelihood that the subject would be able to transition from a decade lapse in employment into managerial/supervisory position: “It appears the claimant’s last employment was ten years distant….The advanced education would not appear to allow for direct entry into a management or supervisory capacity, given the last date of employment.” Additionally, the Independent TSA concluded that the restriction/limitation requiring the ability to move around from a simple sedentary position approximately 10-15 minutes for at least five minutes “would not be compatible with typical competitive work demands.  Moving away from the workstation and walking for five minutes would not appear to be consistent with typical requirements for productivity and maintaining a work pace.”  

TheTSAScam finds it simply mind-boggling that two certified rehabilitation counselors, hired by CIGNA to analyze the same client , could come up with two entirely different conclusions given the same criteria to evaluate.  Either the entire transferable skills process is a scam or the Insurance Industry has found willing partners that render the entire rehabilitation counselor profession a scam.

Are rehabilitation counselors supposed to be that malleable given there is a Code of Ethics? Are transferable skills anaysis that subjective? That unscientific?   That easy for the Insurance Company to influence the outcome? These two TSA's were not generated  by opposing sides in a legal battle, they were  ordered by CIGNA seeking to deny the benefits of the same claimant.   It is clearly evident the CIGNA did not get what they needed to deny the claimant's benefits from the first Independent  rehabilitation counselor  so they found a new CRC to give them what they needed.   The CRCC Code of Ethics for  rehabilitation counselors does not differentiate between  types of  counselors.  In fact the CRC Code of Ethics demands the following:

ORGANIZATION CONFLICTS. If the demands of an organization with which rehabilitation counselors are affiliated pose a conflict with the Code of Professional Ethics for Rehabilitation Counselors, rehabilitation counselors will specify the nature of such conflicts and express to their supervisors or other responsible officials their commitment to the Code of Professional Ethics for Rehabilitation Counselors. When possible, rehabilitation counselors will work toward change within the organization to allow full adherence to the Code of Professional Ethics for Rehabilitation Counselors.

Notably,  the rehabilitation counselor was given the benefit of the doubt that the first "independent" TSA and the notation from the Registered Nurse Claim Manager were withheld from the counselor's analysis by CIGNA.  The counselor (CRC) was forwarded the information but never rescinded, changed or modified the analysis indicating the CRC may have been aware of the documents.  Additionally, the rehabilitaion counselor was forwarded a letter from the treating physician that stated in no uncertain terms that the occupations identified in the TSA were unsuitable for the patient.  The letter stated "the patient remains on chronic opioid treatments which may impair his judgment relating to work and travel.  This is an extremely severe issue and needs to be taken into account for any type of activity using mental skills.  The patient clearly has physical disability which is compounded severely by chronic opioid issues that have been noted.  The suggestion that employment options that require clear sustained mental faculties are an option for this patient is inconsistent with that diagnosis." 

Again, the rehabilitation counselor never amended the analysis.  Have we reached a point where facts, diagnoses, science and codes of ethics are irrelevant in the Rehabilitation Counselor Profession?  This case certainly appears to indicate that is a very real possibility.

Questions for case study

Do you believe a Certified Rehabilitation Counselor should rescind a Transferable Skills Analysis if the CRC discovers they did not have "full" documentation and/or conflicting opinions existed that were withheld?

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