How to Deal with private disability, HMOS, medical insurance, and SSI
Medical Insurance Claims, HMOs
California Lyme Disease Association - Form letter in response to insurance denial: CALDA developed a form letter to send to insurance companies that deny you care. Go to the link, read through the brief description, download the forms, and add your personal information. CC your state's attorney general. They are becoming involved in cases where insurance companies deny care to sick people.
Patient Advocate Foundation -- A non-profit organization that helps people with insurance problems by mediating with insurance companies, employers, etc; supplying personal legal advice and assistance; and providing specific insurance information.
http://www.healthinsuranceinfo.net/ The Georgetown University Health Policy Institute has written A CONSUMER GUIDE FOR GETTING AND KEEPING HEALTH INSURANCE for each state and the District of Columbia. These Consumer Guides summarize your protections.
http://www.disabilitykey.com/ -- includes an e-book on how to claim disability. Written by a lawyer who went through the process herself and now helps others.
Disability Resources, Legal Info, and Forms anapsid.org
Insurance, Disability Claims, Health Costs, and HMO Issues and Lyme Disease See link "fighting a denial" (Includes "HMO HARDBALL") http://www.hmohardball.com/
Fight Bad Faith Insurance Companies at http://www.badfaithinsurance.org/ Ranks insurance companies, gives info about the insurance laws, lawsuits against companies, etc.
SSI informational board -- has attorneys etc. who are knowledgable. http://groups.yahoo.com/group/Disinissues/ Note: 1)Go to the files/links areas and print off those links so you can check them off as you read.
A template for your SSDI application (can also be obtained from disinissues site, files section, "useful advice for SSDI applications"): http://www.cfids-me.org/socsec.html NOTE: Print the ENTIRE post of the female doctor's statements detailing what she could NO longer do. Can be used as a template for your SSDI claim.
DOCMENTING DIABILITY - SIMPLE STRATEGIES FOR MEDICAL PROVIDERS can be found at: http://www.nhchc.org/ This is from the Nal. Health Care for HOMELESS Council
Site established by Linda Nee, a whistleblower who used to work as an insurance claims analyst. She can assist with disability claims, through the application, the investigation, and if necessary, the appeal, for either group or individual disability claims. Works with applicants and with their lawyers. http://www.disabilityconsulting.net
This site has Social Security Disability Benefits Law Information and Resources. Lots of legal resources and most any reference you would need to research POMS, HALLEX, listings, rulings, etc. http://www.severe.net/
From Insurance/Medicare Information from http://Lymeblog.com -- Ask the Insurance Guy
http://www.quickbrochures.net/ The Medicare Project. If you scroll down, you will see links by state. when you go to your state, it will show links to specific information that may help in the decision-making process.
This blog entry has some good information on all Medicare plans.
-- Service-connected contraction of Lyme disease may be possible, but you have to fight! Search for Military Lyme Support at Yahoo, or try [url=http://health.groups.yahoo.com/group/militarylyme/]militarylyme
Manuals, books, references, general collections http://www.nhchc.org/documentingdisabilities.html DOCMENTING DIABILITY - SIMPLE STRATEGIES FOR MEDICAL PROVIDERS. This 50-page manual is a guide to documenting mental & physical impairments in support of app of SSA's disabiliy benefits program. For use by medical & non-medical persons. This is PDF that can be downloaded.
FAIM, the Foundation for the Advancement of Innovative Medicine, doctors' and patients' rights, advocacy and education. http://www.faim.org/ (we should all be members)
also The Partnership for Prescription Assistance brings together America's pharmaceutical companies, doctors, other health care providers, patient advocacy organizations and community groups to help qualifying patients who lack prescription coverage get the medicines they need through the public or private program that's right for them. Many will get them free or nearly free. To access the Partnership for Prescription Assistance by phone, you can call toll-free, 1-888-4PPA-NOW (1-888-477-2669). https://www.pparx.org/Intro.php
The reason that it is so important is that it gives us a much-needed HEADS-UP!!! as far as what kind of recordkeeping we need to be doing.
We all want to think we will make a full recovery from the Lyme Disease Complex of Co-infections (LDCC) or that our children will.
But there is that nagging possibility that some of us won't.
Then when we are at our Most Feeble (speaking for self) we will have our first look at the requirements to get Disability payments and have the Shock of Our Life and say "Gee I wish I had known, I would have kept track all along!!"
The detail required is sobering, not rocket science, just *regularly* recording things such as names of doctors, dates seen, for what, etc.
**************
Connie's Guidelines for physicians writing letters for disability claims:
I wrote the following for my LLMD:
Guidelines for Use in Writing Letters/Reports in Support of Social Security Benefits for Patients With Tick-borne Diseases
By: Connie MS, CRC, CVE, CCM Disability Advocate
General principles of focus to consider when preparing this report:
1. The report/letter must have a longitudinal perspective that allows Disability Determination Services (DDS) to see the frequency, duration., and recurrence of major symptoms of tick-borne diseases. Medical records will generally show this, but a letter needs to state the general course of disability thus far, as well as the projected length of the disabling condition.
2. The report/letter must include descriptions of all treatment regimens and responses to therapy must be given. For example, oral antibiotics, and general response. Did this result in limited improvement, which necessitated the initiation of intravenous therapy?
3. The report/letter must include any significant restrictions the patient has experienced in his/her normal activities since the onset of the diseases. Here, we are asking the physician to describe changes in lifestyle, such as household, personal care, and social activities, as may be determined through history. Also, the physician can report any observed limitations such as walking, climbing, etc. as the patient functions in the exam room. A ``Incapacity Checklist'' can be helpful, and the physician can have the patient complete this for reference before the support letter is written. (A copy is at the end of this document). The patient needs to provide specific examples of limitations in function, which the doctor can document in the letter. The advocate can then obtain supporting statements from others (friends, family) to confirm what the patient has reported to the doctor.
4. The report/letter must report on any objective testing which has been done to determine the appropriate diagnosis. For example, any positive lab studies, and other supporting evidence such as positive SPECT scan results, positive findings of joint inflammation on x-rays, etc. Any testing which supports the presence of illness is acceptable. Includes the clinical examination, not just lab studies.
Once the above is established, the physician must then identify and describe the most significant and disabling symptoms frequently associated with TBD. For example:
1. Fatigue - the existence of chronic and/or recurrent debilitating tiredness, which is demonstrated by an inability to perform basic minimal tasks of daily living (ADLs).
2. Neuropsychological - the existence of forgetfulness and distractability, inability to concentrate, memory impairments, confusion, difficulty thinking, photophobia
3. Neurological - numbness and tingling, sensory impairment.
4. Pain - recurrent and chronic pain which significantly impedes the performance of ADLs and unrelieved by prescribed treatment. Location of such pain and any objective findings utilized to diagnose the origin of such pain. This includes chronic headaches and myalgia.
5. Sleep disorder - Any disruption of normal sleep patterns that is recurrent and does not respond to treatment.
6. Depression - Is depression primary or secondary? Is it related to the patient's reaction to the daily physical symptoms? Are there other psychiatric symptoms present which are apparent to the physician?
7. Cardiac - heart block, hypertension, other cardiac complications.
Sample Letter
Re: DOB:
Please be advised that I have provided medical care for Ms. Blank since 5/7/2003. Ms. Blank carries a diagnosis of persistent Lyme Disease made on the basis of a number of clinical features, including marked fatigue, chronic relapsing pain, CNS irritability, nonrestorative sleep and severe cognitive dysfunction. This patient is disabled by incapacitating fatigue and myalgias aggravated by repetitive or sustained physical activities. Her symptoms are consistent with her discase, which has been confirmed by positive IgM Western Blot in May of 2003. There is also evidence on examination of persistent disorganization of motor function as evidenced by peripheral nerve dysfunction. She frequently becomes confused during discussion of treatment recommendations, and must rely on others to insure she has information she needs to proceed with recommended treatment.
Ms. Blank has had marked impairment of her daily activities and finds it difficult to get out of bed on most days. She routinely requires assistance with showering and dressing. She uses a cane for ambulation. She cannot stand for more than 5 minutes to prepare meals, and must obtain assistance from others. She cannot lift or carry dishes or a gallon of milk. She cannot vacuum or mop or garden. She is unable to do laundry. She has difficulty managing her medication and must receive assistance from others to make sure she takes the recommended medications at the recommended times. She has difficulty getting in and out of a car and is unable to drive due to cognitive dysfunction.
Ms. Blank has been treated vigorously with oral antibiotics as well as supplements and other supportive care. There has been limited improvement thus far, and therapy with intravenous antibiotics is recommended for the near future.
By reason of the unpredictability of the frequency of her multiple physical symptoms, Ms. Blank has been totally and permanently disabled from engaging in, and more importantly, in sustaining any gainful employment activity, even light part-time sedentary work at home. Ms. Blank's status has been consistent since I first began seeing her in May of 2003.
It is my opinion that she is likely to remain disabled for the foreseeable future, but, in any event, for not less than 12 consecutive months. Prognosis remains guarded and uncertain.
2. Your ability to stand, sit or walk for a long period
3. Your ability to lift or carry weight
4. Your ability to understand, carry out, and remember instructions
5. Your ability to respond appropriately to your supervisor and coworkers
6. Other physical or psychological functional restrictions
7. Your ability to adjust to the stress of a work environment
Anyone who wants to provide this to their LLMD for use is more than welcome to do this. I have used this same format many times and DDS and ALJs seem to be receptive to it. It includes all the information SSA is looking for to help them allow claims.
Dealing with Hospital Bills -- advice from Bea Seilbert
Number one rule when dealing with medical bills -- do not pay anything without first knowing what your insurance policy rules are. You could be liable for a 20% copay or a deductible or there may be a stop loss (maximum amount you would owe in one year).
Get a copy of your insurance policy from your employer or insurance company. Sounds like you will be needing it in the future.
It takes forever to get a refund if insurance later pays based on appeal or any sort of error.
Call or go to the hospital billing department -- they may have billed you in error and not have filed a claim yet. Has happened to hubby before. Get an itemized copy of the bill if you do not have one.
Next, if the claim was denied call the insurance company. Find out the reason. Document who you talk to and what they tell you.
If the bill is large or the reason for denial does not make sense then file an appeal with the insurance company. Your odds may be 50/50 that the appeal will be decided in your favor. (This is for the first appeal. The longer you continue your appeal and the more documentation you have, the better your chances in my personal experience -- Minoucat)
[M]ost [hospitals] charge a couple of thousand per day plus docs and labs and meds and then there should be charges for the ER and maybe some other tests such as MRI or CT.
If you do end up owing money you may be able to negotiate a lower amount with the hospital. Or they can probably set you up on some sort of payment plan.
Do you belong to an HMO or preferred provider network? If the hospital is outside of the network you can still probably get the bill covered because of the emergency situation. May require an appeal though.
Also get copies of your medical records from the hospital -- may be a small fee. You should get a copy of all labs and tests and the patient history and discharge summary. You might also need the progress notes -- this is where the doc summarizes day to day things.
Usually do not need the nurses notes -- can always request them later if needed. And don't forget to get the records from the ER as well. Keep a set of all these records and give a copy to your LLMD and/or PCP.
The hospital would probably send the records to your doc for free, but due to HIPPA some docs won't make you a copy if the records are mailed directly to them.
Other advice from Minoucat, based on personal experience:
I'll just add -- the insurance companies count on you not contesting their decision.
Fight this through to the bitter end, keep excellent documentation of all communications with the hospital and insurance company, certify/return receipt all the mail you send them (and if you send a fax, ALSO send it certified mail).
Keep a phone log of every conversation and make sure you get the names of whom you talk to. Stuff like "Spoke with Karen X on May 13 2008 and discussed X,y,z. Karen said A,B,C."
Make sure you know what your doctor is saying, get your records from him, and if necessary (if the doc doesn't want to do the paperwork) write up a full account yourself of why this was a medical necessity and give it to the doctor to put in your husband's medical file. Do this at once -- once the file goes to appeal, you can't add to it.
And, although this is hard to do -- be very very nice to whomever you talk to. Human intervention on their end is possible and may save you a lot of heartache. Although it often doesn't seem like it, there are actually good people on the other end who will help you enormously IF you can find them.
[ 06-20-2009, 08:39 PM: Message edited by: minoucat ]
Posted by trails (Member # 1620) on :
FABULOUS! Thank you for updating and reposting!
Posted by pq (Member # 6886) on :
Mino, excellent collation of links!
Posted by bettyg (Member # 6147) on :
minou,
Thanks again for updating your valuable list.
I think these 2 things should be added too for disability benefits!
RFC - residual function capacity Q/A showing how you can use your hands, stand, hold, sit, bend, crawl, etc. .... done by you primary care physician
MFC - MENTAL function capacity Q/A to be completed by physichologist! This helped me the most getting approved for SSDI.
Do you have any links for these showing what the forms are like Q/A?
thanks minou!
Posted by AP (Member # 8430) on :
Sooooo helpful.... Thank you, thank you, thank you!!!
Posted by bettyg (Member # 6147) on :
Minou,
Thanks for the nice compliments on what I added to your post in medical. YES, you are welcome to copy/paste it here as well.
I went to SSA.GOV site and did a seach on RFC form; got 250+ links; I looked at 1st page only...no luck on finding a FORM. I'll try to remember this after I get some sleep, and check one other place.
Thank YOU for creating and organizing this very helpful post for all lymies/other illnesses. Posted by bettyg (Member # 6147) on :
Minou/Carol,
Here are comments I just typed to Rene's SS & neuro testing post...thought they might be helpful on YOUR disability link...
Also, Minou, you have my blanket approval to copy/paste any of my disability comments, etc. to YOUR disability site, etc. It's nice to have ALL info in ONE thread vs. all over the boards and going back months & years!
I won't have time today to see if I can find the RFC AND MFC web sites since they both had 250+ areas to check. Do you happen to live in a city where YOUR LOCAL SS office is? If YES, would you call them and ask for the 2 direct links? It would save me hours of looking at sites for the BLANK FORM....thanks a million.
Pam, I totally agree with you $5300 to the lawyer when it's approved, but how MANY HOURS of work did lawyer/staff do for you?
Pam using your example, here are my personal feelings. You mentioned you had NOT seen your file or the DDS' dr. they sent you to.
EVERYONE, you have the right to see your file by contacting your local SS office! Use that time to review what other drs. reports you have NOT seen or read. MAKE COPIES OF THESE OTHER DRS. REPORTS and DDS' RFC and MFC, residual and mental function capacity reports they do based upon reading what our treating drs. submitted!
Remember also when you review any file at any location, ALL EYES are watching you: how you are dressed, walk, stand, how many times you stretch, how long you sit without moving, how many times you go to the bathroom, etc. you've got the idea now.
fyi, So my 1st claim I submitted myself & was turned down initial step, that's when I hired Phoenix lawyer, Scott Davis, who specialized in fibro & chronic fatigue. I did ALL the work for almost 4 years. He withdrew/dropped me at the time of my lyme dx. "They couldn't please me."
No, when you fax something or send duplicate copies in the mail, and they WILL NOT even send an email saying they got them, and then NOT responding for 8-12 months; that is NOT the type of people I want to be paying big bucks. When I tell them I made copies for myself, & they are sending me DUPLICATES which they are going to charge me for ... NOT good service!
When I submitted my 2nd claim when 1st when to appeals council (& BTW, Scott NEVER submitted a brief to appeals council stating why ALJ was wrong on denying me!), no one told me I could NOT have my 2nd ALJ hearing before 1st was decided.
Des Moines DDS office sent him/me a letter about this, but NEITHER of us got this at all.
It was when I pursued my June 05 hearing date that I was told this. So I wrote a very angry email to the head of the Des Moines DDS office who forwarded it to Kansas City bureau chief. They both sent me emails back promptly. I sent my comments to the HEAD of SS in DC; they sent brief note back saying the Des Moines office would be contacting me.
Well, the CHIEF ALJ in DM wrote Scott a 2 page letter stating that his secretary had called their DM office about 2nd ALJ hearing date. She was told there would be none until AC decided mine.
ALJ also stated that it was HIS job to fill me in on these things, and I shouldn't be contacting ALJ office directly. Scott did NOT like the scolding the judge gave him; "you made me look bad in judge's eyes." No Scott, you created that situation.
So then lawyer's office called me & told me this. I hit the ceiling! She quoted me a HALLEX rule, which I eventually found with the help of our local SS office. They printed off that section of rules.
In CHIEF ALJ's letter, he mentioned my writing them and how clearly upset I was, which he could understand why. He stated they had sent us a letter in 1-05 explaining this all.
In my angry note to them, I asked why they hadn't told me/us this upfront. They did; that's the LOST letter explaining what all the options were.
The one good thing when Scott quit me, he WAIVED all expenses occured to date: his travel expenses to DM for 1st hearing and misc. costs for copying, postage, etc.
Do you remember the LOST letter I mentioned above? When secretary got their fax, she OVERNIGHTED it to me costing $2.50 vs. using 37 cents for a 6-month old DATED letter which we had discussed over the phone. They sent many things overnight at $15 - $20 per mailing.
Scott did RETURN both file copies at $24 postage to him. But it was a learning experience! For the 2nd ALJ hearing, he was going to charge me $7200 vs. $5300 as he figured up my lost wages & used the 25% max figure. So I saved myself $7300 by representing myself. Sorry, I got to rambling.
Bettyg, Iowa
Posted by valymemom (Member # 7076) on :
We are very lucky to have all of this so well organized. Thank you for all of the resources.
Posted by bettyg (Member # 6147) on :
Found this info in my paper clutter to do pile.
A new publication, 2005, is available to the public for assistance in applying for disability benefits.
DOCMENTING DIABILITY - SIMPLE STRATEGIES FOR MEDICAL PROVIDERS can be foundat:
ACTIVITY DAILY LOG, ADL link is: http://f4.grp.yahoofs.com/v1/oHfvQzZLYvcfvmUv V4L_ayW4_l5PFECbH9UA2BR_YfE66JZ0ZSxttbcO7NZqu HpjUfnUxG9wWuH7WPXAzrR7YqCnrsO80V5hSxJwduQ/ Activities%20of%20Daily%20Living%20questionnaire
At moment, can NOT find MFC questionnaire, but look at site on links/files. It is there but not visible to my eyes presently.
Would you let Tree know your site is now updated now as of 2-12-06 with RFC, ADL, and good lawyer list. Thanks Carol.
Bettyg, Iowa
Posted by pq (Member # 6886) on :
UP
Posted by lou (Member # 81) on :
Is this in the newby links? Guess I better go look. I recently posted the ins issue of LT info because people still are posting questions about ins problems. Guess they aren't looking in links or searching archives. Anyway, cat, this is a such a good thing you have done.
I wonder if you might want to add the url that takes you directly to the special issues of LT. It was rather hard to find, in my opinion, and I emailed them to see if it could be made more prominent.
Posted by bettyg (Member # 6147) on :
To enable your PM, go to MY PROFILE and chose EDIT with the long list of Q/A. Find PM, private message and show YES to get messages.
Also change the setting to for LONGEST TIME PERIOD vs. default of 30 - 60+ days. This helps when you are doing a search for specific topics and they are older than the 60 days. It will bring up top 300 posts on that subject area. It's a life saver feature. Bettyg ************************************************
SSDI, SSI, LTD procedures:
Here is what I post for all on SSDI/SSI/LTD... I tried the link of the female MD ``template''; you are right; it's no longer good!
2 alternatives: use what I provide below as guidance since you have LYME disease and not filing for chronic fatigue.
OR go to the bad web site, click on REFRESH, and go to that site! Ask Mary, web owner, the question since she posted this on disinissues; SHE started that site! It was her close friend who okd to post her info for others.
TRYING TO GET SSDI, SS DISABILITY INSURANCE BENEFITS OR LTD:
Hi! I know what you mean about memory & typing, etc....it's the pits!
I do suggest you join the FREE DISINISSUES and read thoroughly or just print it all off of the FEMALE MD with chronic fatigue, etc. she gives wonderful, detailed examples that DDS, disability reps, want to approve/deny you.
Also have you looked thru the ADULT APPROVED LIST OF IMPAIRMENTS? That's critical also!
note 1.04; look at the rest of the 14 other specific areas too....
I printed off 1-14 sections showing what brief guidelines were for each section. I used that against ALL my medical reocrds, 3" thick!! Then I went to their DETAILED specifics for the sections that applied to my illnesses!
TIMECONSUMING....TOOK ALL 7 WEEKS from my notice of my ALJ hearing date!
So you have NOT submitted your INITIAL APP TO SS OFFICE, correct? Good, you want this to be as complete as possible so they can NOT turn you down on the 1st step as they do us all!!
============================================= What I did with an online friend was this:
prepared a chart noting the specific section of 1 - 14 that my diagnosed illnesses showed the wording, dr. seen & date.
Example, 14.09 LYME disease is mentioned in but doesn't give any examples. So I showed 14.09 with my drs. name & date plus specific details about each visit where lyme symptoms were stated..
I hope you have a copy of ALL MEDICAL REPORTS: drs., xrays, all blood labs, etc.
It's critical that you KEEP A COPY FOR YOURSELF ! ================================================
On mine, I showed the date mailed to ALJ & LAWYER PLUS I kept a copy on EACH set of records.
Example, if there were 3 sheets for dr; i showed date mailed to alj & lawyer plus my copy on PAGE ONE ONLY of 3 sheets. This move saved countless hours at local SS office when I reviewed my file there BEFORE ALJ HEARING. keep reading for more!
Then I went to copy center nearby & copied and mailed promptly to lawyer per his request.
WHY THIS IS IMPORTANT:
if you have an ALJ hearing, request thru your local SS office to REVIEW your complete SSDI app at THEIR local office!
When you see things you submitted with your writing on, don't look at them!
Look & read only the secretative ``RFC & MFC'' done by the the in-staff DDS DRS & PSYCHOOGISTS!
You want to make copies of ALL the stuff they have & other stuff you don't have so you can use that info against them!
NOTE: I'D DO THIS DIFFERENTLY NOW! *********************************
SEND 1 COPY TO ALJ and 1 to your lawyer!
Lawyer did NOT SEND MY REPORTS TO DDS STAFF PROMPTLY;
they didn't see many things when they denied me although I had good medical info!
Examples, 2 RFC, residual function capacity done by PCP dr. of 26 yrs. & rheumatologist;
plus 2 MFC, mental function capacity, done by psychiatrist & psychologist....the 1st person was the one judge used in APPROVING my 2nd claim for severe depression/effective disorder & anxiety.
ALJ's don't like working with LYME, FIBRO, CHRONIC FATIGUE. MENTAL is on approved list of adult approved impairment list! So don't fight it, go with it!
================================================== IF YOU ARE TRYING TO GET SS DISABILITY INSURANCE BENEFITS ==================================================
This message is sent upon subscription, and again monthly. Please let the moderators know if any of the links have changed.
There are many more links, as well as advice, in the "useful" messages in the Files area of the website. Go to http://groups.yahoo.com/group/Disinissues and click on Files.
BETTY NOTE: Look at the female MD''s DETAILED BACKGROUND right below this paragraph. Print off her detailed responses as to why she could NOT do her job, and then apply that to YOUR own job as to why you no longer can do any type of sustainable work now nor in the foreseeable future!
[b] NO LONGER GOOD 5-17-06: ]http://www.cfids-me.org/socsec.html
These links are a compilation of several areas of interest which are commonly requested and mentioned. They reflect the collected wisdom of this group.
Check them out - you just might find the information you were looking for!
Take a look at Files that are not specific to your situation, because they might be helpful anyway - what works for Social Security may work for LTD claims, what applies to CFS may apply to your medical condition.
The Welcome Message and Group Guidelines are also in Files, if you need a refresher on how this group works.
You must register with Yahoo to use the website, but note: Be careful not to permit your address to be put into the directory when you register. Put as little as possible into your public profile. You do not need a Yahoo address to use the website. Your email address is what Yahoo calls your "alternate address."
Your use of Yahoo! Groups is subject to the Yahoo! Terms of Service. *************************************
An online friend of mine from disinissues web site posted this info today, so I have copied it over here.
Subject: fibro/CFS disability info [Disinissues] what does an Functional Capacity Exam entail? ********************************************
Lyme, fibro, & CFS support group members who are/will be filing for SS Disability insurance benefits, please go to the web page shown below.
There were 9 pages of info I printed below area where you can order from fibro network a 70 page packet.
I too plan on including this info when I send my FINAL packet of info to chief ALJ before my June 16, 2005 hearing...my last chance! =======================================
Please read the site mentioned on: WHY DISABILITY TESTING FOR FMS IS OFTEN MISLEADING ADVICE FOR FM/CFS PATIENTS AND THEIR DISABILITY TEAM.....
Also after this article are the following articles:
WHAT COULD BE CAUSING DELAYED-PHASE FLARES?
BENNETT'S METHOD FOR ASSESSING FUNCTION IN FMS..
TECTONIC CHANGES IN DISABILITY LAW by lawyer Joshua Potter, CALIF.
MEDICALLY DETERMINABLE IMPAIRMENT REQUIREMENTS FOR CFS & FMS
DOCUMENTIONATION...VIEW IT AS AN INSURANCE POLICY
I printed this out in larger print for my eyes....9 pages! Will read it thoroughly and mark up 2nd copy to go to ALJudge for my 2nd hearing as medical evidence also....
[ 09. February 2007, 02:40 AM: Message edited by: bettyg ]
Posted by bettyg (Member # 6147) on :
Hi Minout, this info came from DISINISSUES today, 7-31-06; I didn't see it in your list unless I overlooked it.
This site has Social Security Disability Benefits Law Information and Resources. Lots of legal resources and most any reference you would need to research POMS, HALLEX, listings, rulings, etc. http://www.severe.net/ Posted by bettyg (Member # 6147) on :
Minou, I'm pleased to be adding Connic Mc's wonderful detailed instructions on preparing a MD's letter for SSDI, social security disability insurance, SSI purposes, etc.
I'll also copy this to Treepatrol's for a special heading of "SSDI MD LETTERS TO DDS".
Connie gave her permission for us to use any way we chose too.
It's her words as written. I just used many bullets for important points so they would not get lost !
Connie Mc, lymenet.org
I wrote the following for my LLMD:
Guidelines for Use in Writing Letters/Reports in Support of Social Security Benefits for Patients With Tick-borne Diseases
By: Connie MS, CRC, CVE, CCM, from www.lymenet.org Disability Advocate
General principles of focus to consider when preparing this report:
1. The report/letter must have a longitudinal perspective that allows Disability Determination Services (DDS) to see the frequency, duration, and recurrence of major symptoms of tick-borne diseases. Medical records will generally show this, but a letter needs to state the general course of disability thus far, as well as the projected length of the disabling condition.
2. The report/letter must include descriptions of all treatment regimens and responses to therapy must be given; example:
oral antibiotics, and general response. Did this result in limited improvement, which necessitated the initiation of intravenous therapy?
3. The report/letter must include any significant restrictions the patient has experienced in his/her normal activities since the onset of the diseases.
Here, we are asking the physician to describe changes in lifestyle, such as: household, personal care, and social activities, as may be determined through history. Also, the physician can report any observed limitations; such as, walking, climbing, etc. as the patient functions in the exam room. A ``Incapacity Checklist'' can be helpful, and the physician can have the patient complete this for reference before the support letter is written. (A copy is at the end of this document). The patient needs to provide specific examples of limitations in function, which the doctor can document in the letter. The advocate can then obtain supporting statements from others (friends, family) to confirm what the patient has reported to the doctor.
4. The report/letter must report on any objective testing which has been done to determine the appropriate diagnosis. For example, any positive lab studies, and other supporting evidence such as positive SPECT scan results, positive findings of joint inflammation on x-rays, etc. Any testing which supports the presence of illness is acceptable. Includes the clinical examination, not just lab studies.
Once the above is established, the physician must then identify and describe the most significant and disabling symptoms frequently associated with TBD, tick-borne disease. For example:
1. Fatigue - the existence of chronic and/or recurrent debilitating tiredness, which is demonstrated by an inability to perform basic minimal tasks of daily living (ADLs).
2. Neuropsychological - the existence of forgetfulness and distractability, inability to concentrate, memory impairments, confusion, difficulty thinking, photophobia
3. Neurological - numbness and tingling, sensory impairment.
4. Pain - recurrent and chronic pain which significantly impedes the performance of ADLs and unrelieved by prescribed treatment.
Location of such pain and any objective findings utilized to diagnose the origin of such pain. This includes: chronic headaches and myalgia.
5. Sleep disorder - Any disruption of normal sleep patterns that is recurrent and does not respond to treatment.
6. Depression - Is depression primary or secondary? Is it related to the patient's reaction to the daily physical symptoms? Are there other psychiatric symptoms present which are apparent to the physician?
7. Cardiac - heart block, hypertension, and other cardiac complications.
Sample Letter
Re: DOB:
Please be advised that I have provided medical care for Ms. Blank since 5/7/2003. Ms. Blank carries a diagnosis of persistent Lyme Disease made on the basis of a number of clinical features, including: marked fatigue, chronic relapsing pain, CNS irritability, nonrestorative sleep and severe cognitive dysfunction.
This patient is disabled by incapacitating fatigue and myalgias aggravated by repetitive or sustained physical activities.
Her symptoms are consistent with her disease, which has been confirmed by positive IgM Western Blot in May of 2003. There is also evidence on examination of persistent disorganization of motor function as evidenced by peripheral nerve dysfunction.
She frequently becomes confused during discussion of treatment recommendations, and must rely on others to insure she has information she needs to proceed with recommended treatment. Ms. Blank has had marked impairment of her daily activities and finds it difficult to get out of bed on most days. She routinely requires assistance with showering and dressing. She uses a cane for ambulation. She cannot stand for more than 5 minutes to prepare meals, and must obtain assistance from others. She cannot lift or carry dishes or a gallon of milk. She cannot vacuum or mop or garden. She is unable to do laundry. She has difficulty managing her medication and must receive assistance from others to make sure she takes the recommended medications at the recommended times. She has difficulty getting in and out of a car and is unable to drive due to cognitive dysfunction.
Ms. Blank has been treated vigorously with oral antibiotics as well as supplements and other supportive care. There has been limited improvement thus far, and therapy with intravenous antibiotics is recommended for the near future.
By reason of the unpredictability of the frequency of her multiple physical symptoms, Ms. Blank has been totally and permanently disabled from engaging in, and more importantly, in sustaining any gainful employment activity, even light part-time sedentary work at home.
Ms. Blank's status has been consistent since I first began seeing her in May of 2003.
It is my opinion that she is likely to remain disabled for the foreseeable future, but, in any event, for not less than 12 consecutive months. Prognosis remains guarded and uncertain.
Sincerely,
Name: ____________________________Date: _________
Incapacity Checklist
How does your condition affect:
1. Your daily activities
2. Your ability to stand, sit or walk for a long period
3. Your ability to lift or carry weight
4. Your ability to understand, carry out, and remember instructions
5. Your ability to respond appropriately to your supervisor and coworkers
6. Other physical or psychological functional restrictions
7. Your ability to adjust to the stress of a work environment
Anyone who wants to provide this to their LLMD for use is more than welcome to do this.
I have used this same format many times and DDS and ALJs seem to be receptive to it. It includes all the information SSA is looking for to help them allow claims. Connie
[ 14. August 2006, 12:00 AM: Message edited by: ConnieMc ] bettyg outstanding info above! Posted by bettyg (Member # 6147) on :
Hi Minou,
Can you put this info somewhere in your many links here?
From Cave to me, Betty today, 8-19-06,
Tree, Betty suggested that you enter this under Minoucat's disability section. Or if not there, someplace you think is correct.
Neurologic Exams (Earmarks Narrative and Examination)
The Earmarks of an Insurance Company IME (Independent Medical Examiner) Hired Gun: "Narrative" and "Examination"
1) It will *almost* conform to the truth. but, over all, it will be inconsistent with itself and with known and measurable fact.
2) The IME will not read like what you remember from the examination. The actual examination will be perfunctory and short, including a few attacks with pins and hammers to make it look official.
The report will call this a "complete neurological examination". Radiologicals will be gone through quickly and casually.
Radiologists' reports will be criticized, their findings declared unimpressive or inconclusive, and dismissed. No conclusive tests will be either recommended, suggested or ordered. Often they will even be advised *against*.
3) There will be innuendoes concerning your physical symptoms or aspects or your personality.
Unimportant things will be declared "interesting". The patient's symptoms might even be subtly ridiculed, even being referred to as bizarre.
The point of this is, of course, being to call you a liar, without actually doing so.
Implications will be made that you are either stupid or delusional, by comparing what you may have said about a particular test, and what the IME states actually happened; what he states happened will, of course, be a total fabrication.
Of course, the IME hired gun is the expert and knows better than the patient and the patients extensive list of treating doctors who actually treat patients on a daily basis with the disease under analysis by a doctor that may have treated one case in his entire career.
4) Innuendoes can be conveyed simply by putting certain words like "pain" or "stress" in quotes, implying, without saying, that that these symptoms are not real, or may not exist.
A distinction will be made, said outright or implied by innuendo, between pain and pseudo pain, stress or pseudo stress, as if the two were objectively distinguishable; they are not.
Pain is pain. The word stress is used in vague ways, that will confuse heavy duty stress with minor annoyances so as to make your serious stress *appear* to be a minor annoyance.
There is no way (not even in autopsy) of distinguishing between pain and "pseudopain" (quotes meaning to imply that there is no such thing).
5) Quotes will be attributed to you; about half will be erroneous in one way or another, sometimes quoting you as saying the opposite of what you actually did say.
Sometimes a slight change of word or phrase that by itself appears harmless. Nothing that a medical IME does is harmless. Many times in your records you will find that they have lied out right about test results and clinical results.
6) There will only be results reported that are subjective to the to the examiner, like reflexes and muscle strength.
No objective evidence will be present, even though some numbers may be present.
No objective tests will be made. The examiner simply makes up the numbers anyway he chooses.
7) Irrelevant remarks will appear such as "the patient didn't elaborate". (Of course, the whore will not have asked for elaboration.) while important statements by you will be completely ignored and absent from the narrative.
You might see, "I found it interesting that, ..." purporting to cast doubt on a particular result, or an importance where there is none. The report will consist mainly of what was "apparently" felt or said by you the patient (ignoring any existing documentation) and what was "interesting", without any explanation ofwhy a particular thing may have been interesting; more innuendo.
8) Any previous diagnosis will be denigrated indicating that your complaints are not due to the disease or that your problems may even have been caused by a treating physician.
The key word here is "iatrogenic". The most perverse tactic is simply the declaration .
9) The IME will occasionally step out of the room and bounce back into the room with a patronizing remark to illicit a quick response.
10)There will be a high density of "medical" assertions with few if any corroborative facts or explanations. Assertions and conclusions may often exceed the actual area of alleged competence of the "examiner".
A neurologist is NOT a psychiatrist. An orthopedist is NOT a rheumatologist, etc.
11) Scientists cite literature references, IME's never do.
12) There will be *no* suggestions for further tests ruling out other possibilities. The whore knows what the answers "are" before ever laying eyes on you; he does not want the truth known.
13) There will be an attempt to shift a physical cause to an ill defined psychiatric cause, which is not so secure with regard to damages in court.
The key words here are "psychosomatic" (rarely used) and "somatoform", the implication being that there is nothing physically wrong with you.
14) Laboratory tests will be said to nbe "inconclusive" or "equivocal" even if the tests results show the highest positives for the diseases yet reported. The hired gun is paid to discredit you and your injury
******************************************
"Independent Medical Examiner experts & expert witnesses - A physician not otherwise involved in the examinee's care who performs an impartial examination to evaluate injury, disability, or impairment in regard to legal or insurance issues"
And
"IMEs are not done for the purpose of treating a patient's medical condition, but to provide information to the client who requested the evaluation."
Hm-mm-mm. Now, I just wonder if an IME would still get paid if he found *against* the client (the person who hired the IME).
Food for thought "Since a treating physician/patient relationship is not created, it's more appropriate to refer to the subject of the evaluation as the "examinee" rather than as the "patient."
The examinee waives the right to the traditional doctor/patient confidentiality, so the report includes information gathered from the examinee that may be conveyed to the client requesting the exam.
Results of the IME that are sent to the requesting authority include:
Overall medical history
History of injury or illness with summary of the treatment and recommendations
Updated medical evaluation
Recommendations regarding possible need for further diagnostic studies
Assessments of whether the injury is permanent or temporary, if modified duty assignments are appropriate, and if rehabilitative services may be beneficial.
****************************
And for a bit of money you can buy that will teach you how, as an IME, you can receive practical solutions to everyday problems and challenges associated with IMEs such as dealing with:
challenging examinees,
minimizing risks and liabilities,
assessing symptom magnification and malingering
structuring your practice in the most cost-effective manner,
writing excellent reports,
better promoting your expertise,
and generating and collecting a premium fee in a timely manner."
You'll also learn this: "Dealing with uncooperative examinees"
Here is the view of an attorney who is acting for a patient in a medical dispute :
"Some physicians who perform independent medical examinations, however, perform hundreds of these each year for the insurance industry, and make this service a large part of their practice.
Their bias for the defense is notorious. It is not unusual for some of these physicians to charge between $500 - $1,000 for such examinations and record reviews.
If they give testimony, the bill doubles or triples. How much can they earn in a week, month or year doing such examinations? You do the math. It pays better than clinical medicine in some cases!"
And "Such physicians often present an obstacle to a just resolution of the controversy, because they predictably and regularly come to conclusions, write reports, and provide testimony quite slanted in favor of the defense and against the claimant.
And " The modus operandi of some of these examiners to defeat the claim is obvious - attack the credibility of the claimant, making the claimant out to be dishonest." -------------------- cave76 [email protected] ---------------------------------------------- Posts: 6025 | From: Santa Rosa CA | Registered: Mar 2001 | IP: Logged
Posted by treepatrol (Member # 4117) on :
Putting this in here too.
2/3 way down Page 4 in Newbie Learning Help Links.
Timaca's Appeal Letter to Insurance Company on IV COVERAGE
DETERMINING DLI, DATE LAST INSURED when self-employed for SSDI purposes, 10-10-06 by disinissues member
You have to have 20 quarters of work credit within the last 10 years (40 quarters), so the point when you reach five years since your last quarter is likely to be your Date Last Insured.
Social Security can tell you when your DLI will be, or was.
As a self-employed individual, I paid my Social Security tax via my IRS filing each year. When I had to stop working, I qualified for "own occupation" disability insurance, but not for SSDI.
I did not earn any more work credits, since I was not working. A number of years later, I had a different disorder and I filed a Social Security claim before my "20 quarters out of the last 40" expired.
If you are past your date (that is, your coverage has already ended per the "quarters" calculation), you may still be able to file.
You'll need to show that you were disabled within the period of time that you still had coverage.
You'll need to have your doctors establish that you had limitations that they felt were disabling at a time PRIOR to your DLI.
Your drop in earnings may help establish disability, especially if you had any colleagues or a supervisor - or even friends or neighbors - who can write statements about how your abilities changed at a certain point.
A lawyer who handles Social Security claims would be able to advise you on what your alleged date of disability should be.
Your claim will not be approved or denied because of the date you select. If DDS or the judge agrees with the date, fine. If not, they'll change it.
Just try to provide as much evidence as you can that you were disabled prior to your DLI. This is really best discussed with a Social Security lawyer.
But if you call Social Security, you should be able to get the information as to the last date you are covered.
YOU should know your DLI BEFORE any consultation with a lawyer. If you need to establish disability as of a certain date in the past, s/he should write your doctors to explain that, as mine did.
This member approved my posting his posts without his name shown. Bettyg Posted by cgooge (Member # 7922) on :
My wife and I wrote a letter to our US Senate reps about the disability attempts...They wrote to the judge in the case. Our case was marked as having "Congressional Interest" and the hearing was moved up.
I saw the Congressional Interest stamp on the case file and our attorney said it did speed up the process.
We were awarded disability 2 weeks after the hearing....All told the process took 2 years. Hope this helps.
Posted by OptiMisTick (Member # 399) on :
[ 25. February 2008, 12:59 AM: Message edited by: OptiMisTick ]
Posted by bettyg (Member # 6147) on :
carol, i went thru this all again; i deleted all my posts showing up or just a few words with no advise on them! OUTSTANDING info collected by all of us to help ALL OTHERS!
so glad it's all in one place plus treepatrol's newbie archive.
i also added minoucat's link to my newbie links/advise since i've devoted around 20 pages to disability info! this will really help them more! COLLECTED WISDOM!
[ 09. February 2007, 02:47 AM: Message edited by: bettyg ]
Posted by bettyg (Member # 6147) on :
hi minou!
what specific links did you add to your top post? Suggestion: would be nice to show that info here too so at a quick glance we can tell what was added LATELY vs. before.
sure helps! treepatrol does this for me/others on his updates....
thanks for ALL THE WORK you have put into this valuable link of yours! Posted by bettyg (Member # 6147) on :
true blue,
my suggestion is going to the DISABILITY web site and check files there! link is at the top of Minoucat's many links.
you should find answers; if you are NOT a member, join, and in next 2 days you are allowed to post 1st post. Posted by just don (Member # 1129) on :
Just a note to add to the MILLIONS of good ideas here.
In reference to Betty's post of Oct 16---06 post where she is talking credits for SSDI Purposes.
I couldnt read it all,I am in a hurry this morning and having reading probs myself.
What I found out the hard way,before , I applied is you HAVE to show income in every quarter for credit. That may sound easy for the working person.
For the self employed their ae a MULTITUDE of reasons you dont show income,,,bad markets, didnt sell much product, drought, just cause, ANY reason, increased expenses due to___. Anyway when you do not declare a minimum type income(I am believing from memory that is $4,000 PER YEAR,,,you lose those credits for that year. AND when you lose 5 credits of the last __ so many credits you dont qualify for SSDI any more.
I guess the ONLY way I see is NOT to claim that much expense,,,so you ALWAYS show enough income OR you are out!!!NO SAFETY NET!!!!
We always think keeping our incomes minimal so we dont pay taxes,,,or too much,,,nobody can figure out with certainy what their income and expenses are,let alone good enough with all this to function THAT well. Or even CARE!!!
Dont fall into this trap,,,very important!!!
Gotta go, back later,,,GREAT thread,,,says --just don--
Posted by bettyg (Member # 6147) on :
minou, hi there!
would you add daise's links about SSDI, veterans stuff to YOUR ENOURMOUS WEALTH OF INFO LINK HERE?
i'm sure we have not had anything or it was before i come online here! thanks for our consideration in implementing her VA homeless vet SSDI experience here.
i also think it will be needed for our VETS returning from afghanistan and iraq! sad to say! Posted by daise (Member # 13622) on :
Hi Minou,
This is a massive, valuable thread.
I wonder if this information could be put in it's own page, or section.
What I'm driving at is, could it be put at the top of forums (in the header section) and on the home page to alert newbies immediatly, in such a way that they can't miss it ... or for those new to Lyme and even though they're not registered here, they are browsing.
Thank you so much for this thread. It's a labor of love.
Daise
Posted by minoucat (Member # 5175) on :
Daise -- dunno. It's in the newbie links, but I guess it could be put up at the top of General as a permanenet link--I think the moderators have to do this. I haven't asked.
I try to bump it up a couple of times a month.
Glad you found it helpful. Yep, it is a labor of love -- I wish the links would all stay stable!
Posted by bettyg (Member # 6147) on :
TIP SHEET INDEPENDENCE MEDICAL EXAM where DDS sends you to these!!
Posted by bettyg (Member # 6147) on :
minou, i think you indicated here or on someone's instructions you added something to this valuable link,
i remember clicking on them in the WEE am hours, and i could NOT find specifically what you are referring to; could you expand on exactly what we are looking for when going to the 2 sites you referenced??
thanks my friend! I'm always trying to learn more. Posted by bettyg (Member # 6147) on :
TO BE ADDED TOO:
DDS-arranged doctor appointments ... IMPORTANT!! Posted by: "V" Date: Tue Feb 19, 2008 11:08 am ((PST))
In my experience, Sarah's post is 98% right. I learned the hard way that there are doctors who do Consultative Examinations who are just as hostile as Independent Medical Examiners and who write just as nasty reports as the ones IMEs write.
* I applied for SSD before joining this group, so I did not know that I needed to ask my doctor to provide specific information about my condition. * My doctor did not fully explain why I should be considered disabled under Social Security rules. * DDS sent me for a Consultative Examination with a doctor who ran a Medicaid mill and who did IMEs. This doctor spent two minutes examining me and wrote a report that was filled with lies and distorted facts, every bit as nasty as any IME report I have ever seen. My claim was denied based on that report. * For my reconsideration, I hired the biggest, baddest lawyer who handles Workers' Compensation and Social Security Disability cases in my region. This time, DDS treated my case differently. * The second worker took the time to carefully develop the case, which the first worker did not do. * She sent me for a second Consultative Examination, but this time with a doctor who spent 45 minutes examining me. At the end of the examination, he told me that he would write a report supporting my claim.
* A year later, I befriended a retired DDS claims examiner from the office where my claim was processed. She told me that DDS keeps two lists of Consultative Examiners. There are some doctors who consider doing CEs to be a public service.
These doctors take the time to do a proper examination and to write detailed reports, even though the fee DDS pays barely covers the cost for a secretary to type the reports. She said that DDS workers send these doctors only those claimants whom they suspect are disabled under Social Security rules but whose documentation is lacking in some way.
According to my friend, the majority of doctors in my state who do Consultative Examinations spend five minutes examining the patient. They can't afford to spend the time to properly examine the claimant, given the pittance DDS pays, and don't even need to respect you as a patient.
They are generally not top-notch doctors in the community!
* Sarah gave excellent advice, to have a summary of your medical history with you, along with an outline of how your medical condition prevents you from working.
When I needed my own doctor to provide documentation for a Continuing Disability Review, I did the same thing.
I prepared a summary of my case along with examples of why I could not work. She thanked me for saving her a lot of time reading through my extensive case file to find dates and facts.
Posted by bettyg (Member # 6147) on :
Sat, 12 Apr 2008 17:50
Hi there,
You have my permission to post my experience in your materials to Lyme patients.
Thanks for letting me make an impact in any way I could. Marti Z ********************
I got help from this group and then received SSDI two months after I applied. (Shocking, I know!)
I waited four years after I stopped working before I finally applied. That is not advisable!
Here is my advice, based on my experience. ******************************************
Before you apply for disability benefits, look at your Social Security Statement, showing your earnings history and benefits estimate, that is sent to you every year.
You can get a copy at your local SocSec office if you don't know where you put yours.
This is the document that shows your wages over your lifetime.
Check it carefully, and get corrections made if needed.
Once you apply, they will not/cannot give you this statement. I found out that my file was frozen while I had an open claim.
Once it was approved, I was able to get my statement.
Make sure all your work income is on there, as that determines your benefit amount.
Apply as soon as you can and don't let the application expire.
Retroactive benefits are paid for only ONE year back from the date of your application. Build up a medical file.
I used the local county's indigent care program to get FREE medical care since I did not qualify for Medicaid.
If you need financial help to see doctors, find out if your area has this type of program.
You could contact a public hospital and ask them if they are aware of any programs like the one I was on, offered by your city, county, or state.
I had to submit financial information and a denial from Medicaid, so that was my first step and quite easy.
You must see doctors to build a documented case for your claim..
Give detailed examples of your limitations.
One of the questionnaires is about your limitations; examples:
spending time on this, be specific about how your life has changed, how easy/difficult it is to care for yourself, your family, your house, working, sleeping, eating, showering.
Mention how it affects your friendships, relations, hobbies, & quality of life.
I was very specific - I used several pages to detail even how I have to lie down after I take a shower, to rest before getting dressed.
I registered with the Dept of Rehabilitation Services.
I insisted that I wanted to work (which I did - and still do!)
I was accepted as a client, then I was sent for various evaluations to determine my limitations and abilities.
Their doctors determined that I was not a good candidate for work - the money they would spend to help me work from home or have a special accommodations at a job would be wasted, as I would get too sick too soon.
I was scheduled for a test of my physical ability.
As it turned out, my SSDI claim was approved the week before I was supposed to go in for the testing, but I made sure that they knew my mom was coming in from out of town to care for me and my son after I crashed, since I knew I would.
I requested that the testing be done over several days, but they refused.
I made a big deal about that. I can't be sure, but perhaps the fact that I was willing to do the test but concerned about the post-exertion fatigue would have helped support my case if it hadn't already been approved.
If you get referred to a psychologist, ask to be sent to a NEURO-psychologist.
The one I was sent to did the usual mental interview plus the IQ tests.
She also did the hand grip test.
I think this was a big key in approval of my disability claim. It proved weakness in my upper arms.
I stressed that I would have post-exertional fatigue, and I requested an appointment the next day so they could document the change.
I made a big deal about that - how the test was not fair because they were not tracking me the next day.
They refused the request for the next-day retesting, but I think my concerns were noted.
I attached the document: SSR 99-2P, POLICY INTERPRETATION RULING
TITLES II AND XVI: EVALUATING CASES INVOLVING CHRONIC FATIGUE SYNDROME to my package.
(The link is on the Disinissues website.)
I attached a form from my state Dept of Health & Human Services on which my doctor rated me with temporary disability.
My doctor was not very helpful and would not help me in any way with my medical file or write any reports, but this was a simple form that he just signed.
He didn't have to write up a report. I don't know if that helped but I imagine that it did, despite its being rather lukewarm about my being unable to work.
I had help filling out the questionnaire and I noted that.
Also, I made a big deal of needing ample time to fill out any paperwork and asked my SocSec rep to send me any required forms EARLY as it would take me forever to fill things out due to brain fog.
Marti Z, 4.12.08 *****************
I've added her tips to my newbie package of info! Bettyg
[ 15. April 2008, 12:42 AM: Message edited by: bettyg ]
Posted by bettyg (Member # 6147) on :
for anyone who may COPIED it to their files on my above post from MARTI, she requested today I delete her full late name to show MARTI Z.
so if you copied this, please change it to MARTI Z also; thanks everyone! xox Bettyg Posted by bettyg (Member # 6147) on :
``VALUE'' OF A ``VOLUNTEER'' HOUR! From DISINISSUES 4-23-08
I read on another group about the "value of a volunteer hour." The estimated dollar value of volunteer time is $19.51 per hour for 2007. By state, the value ranges from about $10 to over $30 per hour. (See website below for more details.)
Does this "value" apply to those with SSDI? Can the "value" of our volunteer work be counted as work for SSDI or LTD?
Re: value of volunteer hour Posted by: MODERATOR "Sarah Shapiro" [email protected] insuranceissues Date: Thu Apr 24, 2008 1:49 am ((PDT)) .
Can the "value" of our volunteer work be counted as work for SSDI or LTD?
Not monetarily, but, as work, yes. ***********************************
Whether it matters for SSDI or LTD benefits depends on:
* how often * how long you work * what work you do, * what role you have in doing the work (such as managerial or not), * what schedule you keep, * whether the volunteer work is similar to actual work you could be doing.
You could use the value of a volunteer hour as a guideline for yourself to see if what you are doing is the equivalent of ``SGA''! Sarah
Posted by bettyg (Member # 6147) on :
If your neuro-psychological exam was the basic mental status examination (count backward from 100 by 7, do a couple basic math problems, explain some proverbs, name three recent presidents, remember a short series of numbers or words five minutes later, etc), then you need more comprehensive neuropsychological testing.
There is a battery of tests you could undergo which would measure cognitive testing and the testing would involve IQ testing, reading comprehension, etc.
and search "immune system" under 2008 volume 73 search link.
I went to a conference this past weekend and this was covered. Certain parts of the listing will also help document the impairment due to herx reactions. Pretty detailed stuff, and not for the brain impaired, that's for sure. But for those working on their cases, I personally believe these listings will be beneficial to Lyme patients seeking disability.
I understand there were quite a few public comments during the development of this revised listing and that is very apparent in the narrative parts that explain the changes.
I will try to pull together more definitive info when I have the time so this can be used by those with Lyme. In the meantime, I just wanted to put this out there as a resource.
Posted by bettyg (Member # 6147) on :
qEEG test will show cognitive deficits **************************************
Date: Thu May 8, 2008 12:31 am ((PDT))
Although not used as frequently as neuropsychological exams, there is another objective cognitive test which can be very valuable as adjunctive, supportive evidence of cognitive impairment.
It is called a Quantitative EEG (qEEG).
This test is usually administered by a neuropsychologist or psychophysiologist.
I recommend it be done only by someone with a PhD or MD, for purposes of disability claim defense.****************************
QEEG testing reflects cortical electrical activity or "brainwaves".
Conventional EEGs are done with the patient in a resting, eyes-closed position and do not illustrate the cognitive abnormalities that occur during concentration or awake mode.
The QEEG, by contrast, can be conducted during eyes-open conditions and performing mental tasks (such as reading, repeating back information, etc.) during the recording of data.
The QEEG will typically reflect the abnormal, slow wave brain activity that occurs during these periods of concentration.
It shows that the brain is functioning as though it is asleep, even though the patient is awake.
The experience of having the QEEG Exam can not only be helpful for disability cases, but also be profoundly illuminating in understanding
brain fog, memory and concentration abnormalities,********************************
as well as other neurally-mediated physical symptoms throughout the body.
Posted by daise (Member # 13622) on :
This was emailed to me by Colleen Nicolson at Military Lyme Support, Yahoo Groups. It's from Phyllis (of CALDA?)
Original thread title, from the general forum: Social Security Disability New Starter Kits People MUST Know About.
I would like to draw everyone's attention to the NEW Disability Starter Kit that is online at the Social Security website. It is important that ALL of us have a look at it.
There are kits to download for Adults and for children.
The reason that it is so important is that it gives us a much-needed HEADS-UP!!! as far as what kind of recordkeeping we need to be doing.
We all want to think we will make a full recovery from the Lyme Disease Complex of Co-infections (LDCC) or that our children will.
But there is that nagging possibility that some of us won't.
Then when we are at our Most Feeble (speaking for self) we will have our first look at the requirements to get Disability payments and have the Shock of Our Life and say "Gee I wish I had known, I would have kept track all along!!"
The detail required is sobering, not rocket science, just *regularly* recording things such as names of doctors, dates seen, for what, etc.
It would be difficult to go back and reconstruct this including for family members who might be at a distance, or doctors who might be retired, or staff that no longer remembers you or is not so cooperative or has thrown out datebooks or archived files, because one has "moved on" and etc.
It would take perhaps months to do all of this and payments may be backdated to the day of the completed application *if* granted, which the applications usually are not first time around due to *lack of detail* which delays the date that payments are calculated from.
Payments do not necessarily coincide with the date of the start of your disability.
Please take a look at these new streamlined Disability starter kits. While it may seem daunting, the important thing is to notice what details are required, then get a notebook and start recording that information.
Do not rely on computers. We all have those computer horror stories - keep hard copy too.
I would like to see *all* LDCC people get what they are entitled to. If we did, besides the personal need, it would certainly alert the government to allocate more research dollars when the cost of ignoring the disease starts to rise, as with AIDS.
PS keeping a notebook can also be useful if you ever decide to take some aspect of your case to court...
Colleen Nicholson Research Assistant to Dr. Burrascano, MD Founder, Military Lyme Support
Posted by bettyg (Member # 6147) on :
for anyone just joining here, i have redone my complete newbie package, and 25_+ pages on SSDI, disability have been reorganized with most important info listed first ....
it can be found in my signature line below...!
with the info there and wisdom of ALL who contributed, you can WIN 1ST TIME, 1ST STEP with their needed forms completed by SUPPORTIVE DRS YOU ARE SEEING! Posted by bettyg (Member # 6147) on :
July 21, 2008
Social Security Launches New Retirement Estimator
Social Security is proud to announce the new ``Retirement Estimator'' at
Getting a personalized online estimate of your future retirement benefits is now easier than ever before.
The Retirement Estimator is a planning tool that allows you to get an immediate and personalized estimate of your potential Social Security retirement benefit.
The Retirement Estimator is convenient. Since it is tied to your actual Social Security earnings record, there is no need to manually enter years of earnings information.
The Retirement Estimator is also interactive, allowing you to compare different retirement options by changing your ``stop work'' dates or expected earnings.
The Retirement Estimator is secure. To protect your privacy, only your benefit estimates are provided online.
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Posted by ConnieMc (Member # 191) on :
The table at this link shows the average wait time for hearings from the point where the request for hearing is filed to the hearing itself at every ODAR in the country as of August 2008. This time does not include the time at the initial or reconsideration levels of the claim:
Has anyone had experience appealing an insurance rejection of a $10,500 SPECT Scan coverage?
I am using Lorraine Johnson's letter in Lyme Times insurance issue as a basic template, but when I looked at her research studies attachment, I noticed that the most recent study was in 2004.
The denial of coverage was based on the insurance company's contention that SPECT Scans in treatment for Lyme are investigational and experimental and not a medical necessity.
Lorraine's template primarily addresses the medical necessity issue, not the investigational and experimental one.
So I am looking for a recent list of research that supports the use of SPECT Scans in treatment of Lyme.
The insurance company listed studies to support their denial that are dated 1999 and before.
I did a google search and nothing relevant came up.
Thanks ahead of time for your assistance!
Posted by minoucat (Member # 5175) on :
You might try http://www.columbia-lyme.org/ -- this is the organization that Dr. Fallon, specialist in neurological Lyme disease, founded.
http://www.lymeinfo.net/neuropsych.html might be a good resource too; you can email them to see if they have anything newer, or if they know whom you could contact.
Also suggest posting in the Medical forum; more eyes will see this.
Best of luck. Please let us know how it goes.
Posted by bettyg (Member # 6147) on :
great info on APPEALING ONSET DATE AFTER SSDI IS APPROVED from disinissues website today!
information for APPEALING ONSET DATE after BEING APPROVED FOR SSDI! From disinissues site 3-8-09
My wife recently faced this problem. They approved the disability claim but used the wrong date of disability onset.
Her situation was that she was receiving STD payments from her employer, which do NOT count as SGA.
I never would have discovered this if I had not requested a copy of her file. About a month after she requested it, they sent her the entire file on CD.
It was on a small section of the application for SSDI that I noticed the field office entered the date of her disability onset.
As for the risk of appealing the onset date, after multiple calls to SSA and the DDS office, a knowledgeable field office manager told me that since the claim was approved and she was requesting a disability review only from the earlier onset date to the date they picked, her entire claim would not be reviewed and the approval from the later date could not be overturned.
Best case scenario is that the DDS would agree with the earlier onset date. Worst case scenario was they would not agree and nothing would change.
To start with, you must get a copy of your file ASAP.
In those initial forms you filled out when applying for disability benefits, you will find the date that the Social Security office indicated should be the date of onset of disability.
That is the date that DDS office used when reviewing your medical history.
The copy of your file will also have all the DDS information.
If there is little doubt about the date you became disabled, and you have the medical history to support it, you have every right to fight for it.
Once you file the appeal for the correct date of onset, you should also contact your local congressman/woman to help push it along.
You need not tell the whole story of why you are disabled - just state your claim is in appeal for corrected date of onset and they will follow its progress.
If your case was approved on the first attempt, you will file an appeal for reconsideration.
If it was approved on reconsideration, then you are going to have to file for a hearing, which will take a long time. For two years' worth of benefits, you should not hesitate to appeal.
Posted by jt345 (Member # 19638) on :
Hey this is great info. I was trying for 5 years. One dead end right into another. One day a letter came telling me I was going to have my final hearing sometime in the next 6 months. Well that went over really good . So I called my congresman,told one of his people what had been going on,the guy says We will call You back tommorrow. When I hung up the phone I thought here we go again.
Much to my surprise,My congressman called me Him self the next day ,and told me I had a hearing set for one week from that day. When all else fails,go right too the top. You have paid for disability,It is your right Do not take no for an answer.
This worked for Me,I hope it would work for You all. appleseed
Posted by jt345 (Member # 19638) on :
Hey Kids
This is great !! there is so much info here. What ever You do ,Do not give up.
After 5 years of fighting,I was finally given a hearing in frount of a circuit Judge. The only problem was I would have too wait for 6 mounths.
I think They were just wishing I would die before the trail date.
I could not wait,so I contacted my Congress Man.His office called Me the very next day,and within one week,I had a hearing for the next week.
The Judge told Me it was the best case of chronic lyme that had ever crossed His desk.
Moral of this story Do not give up.
Wishing all well. Be as well as You can be today
appleseed
Posted by bettyg (Member # 6147) on :
copying this over to here; minou, can you show the update of 6-2-09 and new amount of $6,000 in the upper parts of your info? thanks!! betty
ConnieMc Frequent Contributor (1K+ posts) Member # 191 posted 03-05-2009 11:29 AM
FYI
At this point, the max fee for representatives is $5300. Effective June 2, 2009, it will go up to $6000. *****************************************************
If a representative, attorney or non-attorney, wants to go for a higher fee, for example, for a case that requires much more work than typically required, a representative can file a fee petition with detailed records of all work done on a claim.
The ALJ or an office in MD handles these requests. I have never done it, or requested a higher fee than allowed - which is 25% of past due benefits or $5300 maximum.
These limits are for good reason. I had one claim which took years to get to hearing and by the time the claimant won, she was entitled to about $130,000 in back pay for herself and her dependents. Yes, I would love to have 25% of that, but wouldn't be fair at all. My fee was $5300.
Posts: 2116 | From NC | Registered: Oct 2000
Posted by bettyg (Member # 6147) on :
copying this here .... from connie mc !!
ConnieMc, Member # 191, posted 07-05-2009 09:10 AM ________________________________________
DDS is not allowed to tell a claimant or representative a decision on a claim.
Once a decision is made at the initial or reconsideration level, it is sent back to a processing center at SSA and they send out a letter.
If it is an allowance, the local SSA office processes the case. If Supplemental Security Income (SSI) is involved, the SSA office generally contacts the claimant and asks them to come into the office so thay can confirm that the financial situation is the same as it was when the initial application was filed.
If it is Social Security Disability Insurance (SSDI), a letter is issued to notify the claimant of the allowance, then the claim is actually processed at one of the payment centers.
It is true that in a SSDI only claim, the claimant sometimes finds their back pay in their account before they even receive their letter notifying them of their allowance.
MADDOG, since you worked for years and paid into the system, your claim is likely an SSDI only claim, so you could find money in your account before you are notified of the claim decision.
When a decision is made at DDS, the decision is issued.
A claim would not be "closed", but would either be sent for processing (payment) or remain in limbo for 60 days waiting for the claimant to appeal.
Don't get discouraged if you receive a denial. Keep your claim active by appealing immediately, and by all means do not wait and risk letting the claim lapse.
Follow the instructions on the letter exactly and leave a paper trail. Make sure you have proof you filed the appeal and file it away in a safe place. And good luck!!
Posts: 2117 | From NC | Registered: Oct 2000
Posted by Keebler (Member # 12673) on :
Tips for getting insurance when you have a pre-existing condition
Excerpts:
1. Become a group of one.
In about a dozen states, you can be a group all by yourself for insurance purposes. What this means is that you become, in effect, just like any other company, and insurers can't deny you insurance or charge you higher premiums because of your pre-existing condition, according to Lembo. "You'd be surprised at the number of folks who open their own landscaping business" to get the group of one, he says. . . .
2. If you've been laid off, get COBRA. . . .
3. When you lose your employer-related insurance, apply for new insurance within 63 days. . . .
4. Find out whether your state has a high-risk pool. . . .
5. See whether your professional organization offers group insurance.
Some professional groups, such as those representing real estate agents and freelance writers, offer health insurance. Check and see whether your profession does the same. Here's another piece of advice, offered somewhat tongue in cheek: Move to Maryland, Massachusetts, New Jersey, New York or Vermont.
"In those states, everyone has to sell to you," said Cheryl Fish-Parcham, deputy director of health policy at Families USA. Not only do insurance companies have to sell you a policy in those states, there are limits on how much they can charge you, she says.
For more help in finding insurance when you have a pre-existing condition, you can contact the Cover Me Foundation at 877-678-7631 or Coverage For All at 800-234-1317. . . .
. . . . -
[ 04-14-2010, 12:26 PM: Message edited by: Keebler ]
Posted by bettyg (Member # 6147) on :
minou, without going thru all of this, do you have advise on DIVORCE LAWS; steps to take, etc.
deafromlyme needs help; thought of your links here as well. big thanks! if you do; comment on her NEED MASS. ATTORNEY FOR DIVORCE post xoxox
Posted by minoucat (Member # 5175) on :
Betty -- PM'd you, need more info on what's wanted.
Posted by bettyg (Member # 6147) on :
Hi gang, I FINALLY found my old password so I could sign in and say "Hi!" I had messages in there from 2006 that people wrote me that I never knew were there. Oops! [Smile]
I hope you all are doing well. Lymetoo...over 40,000 posts??? Wow, lady, have you been busy or what? [Wink] However, you are badly needed to give advice and keep everyone's spirits up so keep it up!
Bettyg, thanks for the message. Like I said, I got it but I couldn't find my password and didn't have time to look until now. Looks like you've also been busy...over 25,000 posts! You and Lymetoo are dedicated! [Smile]
OptiMisTick, hello old pal, how are you doing? [Smile] I'm doing a little better and have just returned to school.
It's been so long since I've worked that I am auditing some prior classes for a review. Hopefully, I can do that for a while and then, if I am fortunate and can pass the GMAT, I hope to be on to grad school for my MBA or MACC.
If anyone is interested, I'm going through Vocational Rehabilitation so if anyone out there is receiving SSDI and feels like attempting a return to work but would like a review or more training, call them up, they LOVE it when we are willing to head back to work and are very helpful in providing accomodations (like special desks or chairs), computers, software, paying for classes and books.
It's pretty cool and, in the long run, it is much cheaper for the government to get us back on our feet and back to work than to keep paying benefits.
If I can, I'd much rather work - as would you all, I know. It has taken me 8 years to get to this point. What the heck, may as well give it a try. [Smile]
-------------------- I surf to serve! Posts: 1987 | From Charlotte, NC, US | Registered: Sep 2001
********************************* great story, wasn't it? betty
Posted by JesseS (Member # 20776) on :
We are very lucky to have all of this so well organized. Thank you for all of the resources.
Posted by bettyg (Member # 6147) on :
here you all go from trishee's info ....
i posted in my good lawyers' list i started and brought it back up to top; will post it also in MINOUCAT'S DISABILITY link in support .... great info!!
our member trishee was sent this information below and also his letter stated this,
Betty,
"My letter does include helping me or "any Lyme disease awareness or advocacy organization" help in submitting disability claims. *************************************
He mentions 15 years experience before starting his own practice a year ago."
Offers his help with lyme disease claims. ************************************************
Lyme Attorney is George Thompson
Sager & Schaffer LLP
182 Turnpike Rd.,Suite 250
Westborough, MA 01581
508-898-9900
Fax:508-898-9889 *********************
i also showed this in my good lawyer's list i started 2-3 yrs. ago Posted by seekhelp (Member # 15067) on :
Wow, there is a LOT of info here. Pretty smart Lymies. Posted by bettyg (Member # 6147) on :
seek, we just need people to LEAVE MEDICAL and look around at the other forums...SUPPORT has outstanding info at top, and this is the BEST THERE IS !! $$$$
Posted by bettyg (Member # 6147) on :
dream22 posted this for a newbie today, and i didn't want to see these good links go to waste, but be shared with others needing it.
Here's one on the need for clinical judgment in the diagnosis and treatment of lyme disease. Good synopsis: FALL 2009
There are 2 standards of care re: lyme disease. The most important part being that treatment is based on informed choice of the patient. Ultimately, your treatment is up to you:
Look up stats for your ALJ - the following link will take you to a SSA website which lists every Administrative Law Judge in the country and provides stats for each ALJ. I use this site every time I have an ALJ I do not know assigned to one of my claims.
As you can see, there is wide variation in stats from one ALJ to another. Some ALJs are quite liberal with their allowances and others allow below 50 of their claims. You can arrange the data in each column by clicking on the column headings.
Interesting stuff.
Connie Accredited Disability Rep Lyme patient
Posted by METALLlC BLUE (Member # 6628) on :
Minoucat or anyone else who has supplied abundant information about insurance company information, would you be willing to review the rewritten Lyme Disease Guide that I have? The guide was originally the one Betty had put together -- though it now is significantly transformed.
Any help would really be great.
Posted by Keebler (Member # 12673) on :
- If some accommodations at work could help, search out:
Tips applying for SSD - disability benefits you paid into through your participation in payroll deduction with each paycheck under the Social Security Administration . . . -
[ 07-06-2016, 05:49 PM: Message edited by: Keebler ]
Posted by Keebler (Member # 12673) on :
- * VESTIBULAR ? If you have ANY inner ear disorder (balance, tinnitus, hyperacusis) that may be considered as a separate condition. Depending upon the degree, vestibular disorders - alone - can be the basis for some help from SSD.
Your LLMD may know of a LL neurotologist or other vestibular specialist for you to consult - if you have any symptoms that seem to either be caused by or include this system. There are very specific tests for the various vestibular disorders.
* MCS ? Multiple Chemical Sensitivities can also be considered separately, depending upon the severity.
=============
All about EARS: ------------------
For those who are sensitive or pained by even normal or soft sounds (sounds not even at noise level):
Click here (at the link) for the Selected Bibliography of Research Articles. - six pages of studies and articles on chemical sensitivity published in peer-reviewed journals.
Click here (at the link) for a copy of the QEESI questionnaire, which is useful for evaluating a person's level of chemical sensitivity or intolerance.
Topic: Social security disability and lyme disease - good info -
Posted by Keebler (Member # 12673) on :
- About whether "chronic lyme" even exits - and the "need" for on-going treatment.
Not discussing all that but - we need to know how doctors think and what the professional medical organizations' official stance is on this diagnosis.
I just stumbled upon this "blog of concern" (how else can I describe this?). This doctor is so against the idea of lyme but today, from a medical journal this summer - we do need to be aware of this:
. . . Some persons have advocated use of the term chronic Lyme disease (Table 5) to describe the persistence of nonspecific signs and symptoms in patients with or without clinical or laboratory evidence of Lyme disease.
These advocates suggest that patients with the so-called post-Lyme disease syndrome (category 4) or antibiotic-refractory arthritis have a latent intracellular infection that may require months to years of antibiotic therapy for eradication. . . .
. . . Although controversy exists regarding post-Lyme disease syndrome and chronic Lyme disease treatment, four randomized clinical trials found no evidence that prolonged antibiotic therapy is of benefit.
Therefore, the
1) American Academy of Pediatrics,
2) American Academy of Neurology,
3) American College of Rheumatology, and
4) IDSA
do not recommend prolonged antibiotic therapy.
A recent survey concluded that 97 percent of primary care physicians in Lyme disease-endemic areas did not diagnose or treat patients for chronic Lyme disease.
Disability Claims and Lyme Disease, Part III: Overcoming the Hurdles:
How to defend against the various justifications for denying coverage, including the mental illness defense and the claim that chronic Lyme does not exist or is not objectively verifiable.
Scott Riemer, Esq - DVD is $15. You can see a four minute video preview at the link above.
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