WSI doctor says he was pressured on claims

Issue at a glance

• The impartiality of medical reviews of benefit claims has come into question with reports that the medical director twice rebuffed managers’ attempts to get him to change his opinions.
• Further questions are raised by a whistle-blower employee’s suspected fraud report that a nurse case manager’s electronic notepad entry, with information favorable to a worker’s claim, was ordered deleted.
• The allegations go to the heart of claims decisions. Workforce Safety and Insurance, North Dakota’s monopoly workers’ comp program, is charged by law with ensuring benefits claims are handled fairly and with safeguarding the financial health of the fund – two roles critics say often conflict.

FARGO – The chief doctor who reviews injured North Dakota workers’ compensation claims said he twice resisted efforts by agency managers to alter his medical opinion.

Dr. Luis Vilella, the medical director for Workforce Safety and Insurance, said he refused to change his medical opinions when asked to do so on two occasions in February or March of 2010.

The issue surfaced publicly when The Forum ob-tained a copy of a letter Vilella recently wrote to state medical licensing officials that also concerned his independence as a doctor. In the letter, he said a proposed WSI policy could allow bureaucrats to direct his handling of medical reviews.

“Apparently, WSI sees no conflict with their proposal to dictate how medical opinions are to be transcribed, documented, or recorded,” Vilella wrote in a letter to medical examiners dated Feb. 15 that The Forum obtained through an open records request.

Medical opinions by WSI’s three physicians are an important part of the agency’s ultimate decision to accept or reject claims from workers seeking medical care or disability payments for injuries or illnesses they contend are work-related.

Vilella, who said he never intended the issue to become public, wrote the letter seeking guidance from officials because he was concerned his medical license could be in jeopardy if he bowed to pressures to alter a medical record.

Specifically, he said in an interview, he was worried about certain provisions in state law listing grounds for disciplinary action against physicians, including use of any “false, fraudulent, or deceptive statement in any document connected with the practice of medicine.”

Doctors also can be punished for “lack of appropriate documentation in medical records for diagnosis, testing and treatment of patients.”

“I needed to consult the board for guidance,” Vilella said. “I need all of this to be clarified by the board of medicine.”

WSI denies pressure

Vilella and two consulting physicians provide internal medical reviews of claims and issue opinions, but the decision to accept or deny a claim is made by other officials in the agency’s claims division.

“You have the medical opinion, you have the administrative opinion, you have the legal opinion,” Vilella said. “They all have to come together.”

Bryan Klipfel, director of WSI, said an internal review found no instances in which a medical opinion was altered at the request of a claims official or lawyer. He rejected the notion that “undue pressure” was applied to change opinions.

“That’s illegal,” he said. “You don’t change records.”

Also, he said, WSI had planned all along to submit its draft policy to the board of examiners for input, but Vilella had done so on his own initiative before the agency did.

“This is a draft policy,” Klipfel said. “We were going to have some work done on it. We want to make sure the policy we have reflects the longstanding policy that legal never drives medical in handling our claims.”

Klipfel’s statement that WSI had intended to seek input from the board of medical examiners came on Feb. 17, the day The Forum obtained Vilella’s letter in an open records request made with the State Board of Medical Examiners.

“I was not aware of that intention,” Vilella said, adding that Klipfel informed him of that plan on the day The Forum obtained his letter. “That was the first time I heard that.”

The day before, on Feb. 16, Vilella hand-delivered his letter to the examiners.

Deletions questioned

Months earlier, a WSI staff member who works closely with Vilella raised similar concerns about managers trying to interfere with medical evaluations of claims.

Barbara Frohlich filed a report with WSI’s internal fraud hotline detailing her concerns on Aug. 31, citing an instance in which a claims supervisor ordered a computer notepad record to be deleted from a claim file.

Puzzled about the deletion, Frohlich later asked a co-worker why the notation had been ordered deleted and was told the director of claims had said, in so many words, it “weakens our position,” she wrote in a summary.

The deleted notepad entry was favorable to the worker’s claim, she said. She would not reveal details, however, because she said the record involves confidential medical information.

Frohlich also reported two instances she became aware that Vilella was asked to alter his medical opinion.

“In one of the incidents, he told me his originally composed medical review was presented to him in written form with a circle of red ink surrounding the paragraph that he was directed to delete,” she said in a written summary of the incident she provided The Forum.

Beyond confirming he was twice asked to change a medical opinion, Vilella declined to comment on the incidents.

Frohlich, who has a background as a medical laboratory professional and manager, works as a liaison between WSI and medical providers who care for injured workers.

An internal review by WSI of Frohlich’s allegations found no wrongdoing, Klipfel said. The review report examined notepad entries from Jan. 1, 2010, through Oct. 14, 2011.

It documented 20 requests to delete notepad entries, 13 involving instances where information was placed in the wrong worker’s file, one involving removal of confidential information and six removals that were not explained.

“It has been determined that the ‘deletion’ of the notepad entry was neither unlawful nor a violation of internal agency policy,” Klipfel wrote Frohlich on Jan. 25 about the deletion she complained about.

That letter was the culmination of months of internal prodding by Frohlich to remedy what she viewed as wrongdoing by certain WSI officials in pressuring Vilella and others in reviewing claims or handling records.

On Jan. 24, Frohlich wrote Attorney General Wayne Stenehjem and Richard Riha, the Burleigh County state’s attorney, informing the prosecutors of the deleted notepad entry and two attempts to get Vilella to alter a medical opinion. Neither has taken action on Frohlich’s complaint. Riha says he hasn’t been shown evidence of a crime. A spokeswoman for Stenehjem said his office doesn’t have jurisdiction.

In her letter, Frohlich mentioned her meetings with high-ranking WSI officials to expose what she saw as “intentional efforts to conceal records involving injured workers.

“I also expressed to them I was concerned about the potential of each set of incidents not being isolated but part of a ‘culture’ of inappropriate attitude and behavior regarding the adjudication of claims,” Frohlich wrote in her letter to the prosecutors.

Similar concerns noted

The crux of the rift over the draft policy involves language that would not require so-called “counterarguments” to be included in a medical review.

According to Vilella and Frohlich, a counterargument is information that could be favorable to supporting a worker’s claim.

Vilella’s recent letter to the North Dakota State Board of Medical Examiners echoed concerns he first raised two years ago in internal WSI discussions.

On Feb. 10, about the time Vilella said he was twice asked to alter his opinions, he wrote the agency’s top lawyer about his autonomy and the medical director’s ethical obligation to impartially weigh information while evaluating an injured worker’s benefit claim.

He made the same point in calling the policy proposal to the attention of the medical licensing board.

“Professional medical standards demand the use of fair and just criteria when making care-related determinations,” Vilella wrote in his letter to state medical examiners. “How can a medical director employed by the state of North Dakota reconcile this principle when asked by his employer to consciously withhold important information from a claimant’s file, information that plays a critical role in the adjudication of the claim?”

Klipfel said despite a few requests, no medical opinions were changed. However, there are times when claims or legal officials discuss pending claims with medical reviewers.

“I don’t know if you can classify it as undue pressure or just a discussion,” Klipfel said. “So the discussion, I have no problems with that.”

Vilella’s letter will be brought before the State Board of Medical Examiners, all physicians, when it meets March 23, said Duane Houdek, the board’s executive secretary.

Readers can reach Forum reporter Patrick Springer at (701) 241-5522

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