Medical Validity

Client

The largest supermarket division of Midwest-based retail conglomerate retained Work & Well to help manage excessive intermittent FMLA usage. Work & Well uses many methods when abuse is suspected including sending employees for second opinions with Occupational Medical Doctors and/or specialists for an independent medical exam (IME).

Situation

An employee took excessive time off for his FMLA case due to a previous injury. The employee’s healthcare provider certified FMLA for flare-ups, two to three times per month for one to five days per episode. The employee’s actual usage was over 15 days a month. Work & Well’s clinical team reviewed the case and questioned the medically validity of the case, specifically:

  • Was the amount of time designated by the healthcare provider correct?
  • Had the employee’s condition changed whereas he needed to take more time off than originally certified?

Work & Well scheduled the employee for a second medical opinion to answer the above questions.

Results

The second opinion examiner confirmed the employee’s diagnosis, however, the time used and time out designated was deemed to be excessive. The independent medical examiner certified the employee to be out of work only three to four times per year vs. the original certification of two to three times per month. Since the second medical opinion, this employee has taken no time off for FMLA; however, the employee filed a complaint with the Department of Labor (DOL).

DOL Conclusions

The DOL investigated this case using Work & Well’s extensive case documentation. The DOL ruled in favor of the employer. Despite the fact that the employee was certified for a specified amount of time, the request for a second opinion did not violate his rights. Employers and/or administrators have the right to question the medical validity of a claim.

Savings

The second medical examiner’s new certification resulted in a significant reduction in time out of work, approximately 52 days. This provided the employer with many positive results including overtime savings, increased productivity and improved morale.