Patrick Springer, Published March 10 2012
Doctor disputes report that he wasn’t pressured on workers' compensation claims
Dr. Luis Vilella, medical director for Workforce Safety & Insurance, told The Forum he twice refused requests from the agency’s managers asking him to delete information from his medical review of workers’ claims.
“There’s no question pressure was applied on me to delete an entire paragraph of the conclusion of my medical opinion,” Vilella said.
The doctor was reacting to a March 1 memo from Bryan Klipfel, director of Workforce Safety & Insurance, to Gov. Jack Dalrymple. The governor had asked for the report after The Forum first reported Feb. 26 on Vilella’s allegations that he was twice pressured to alter his opinion.
In his memo to the governor, Klipfel referred to an internal report exploring Vilella’s allegations and finding nothing improper.
“The internal review found no evidence, or even suggestion, that Dr. Vilella or any other physician was asked to change their professional opinion,” Klipfel wrote Dalrymple.
In an interview, Klipfel repeated his insistence about the autonomy of WSI’s doctors in reviewing claims. “We’ve never, ever changed our doctor’s opinion,” he said.
Klipfel does not disagree, however, that Vilella twice rebuffed requests to delete information from the doctor’s medical reviews, but he maintains that doesn’t amount to asking him to change his medical opinion. Both claims were ultimately approved.
“Based on my conversations with Dr. Vilella, the pressure that Dr. Vilella felt relating to his medical reviews related to two cases in which he had set out his opinion and then at the end of that opinion listed several possible counter-arguments or alternative opinions without discussion of why he had rejected these other interpretations,” Klipfel wrote in his memo.
“In both cases, he was asked to delete the bare recitation of counterarguments,” the memo continued. “In spite of this, no changes were made to the text of the original medical review.”
Rather than a “bare recitation,” Vilella said the paragraphs he had been asked to delete were part of his analysis of the claims.
“I provided a careful analysis of relevant information of circumstances that may or may not have contributed to the worker’s problem,” he said.
To avoid future problems or misunderstandings, WSI is working on a new standard format for medical reviews, which help claims adjusters decide whether to approve a claim for medical or disability benefits.
In that proposed new format, a doctor’s “counter-arguments” – information that could suggest a decision contrary to the doctor’s opinion – will be included in the body of the medical review, not at the conclusion.
“The message I have given to Dr. Vilella is that if a possible counter argument is important enough to mention in an opinion, it is important enough to explain in greater detail, in his documented medical review prior to issuing it, why he had considered it,” Klipfel wrote in his memo to the governor.
Klipfel added: “In each of these two cases, Dr. Vilella’s medical opinion recommended denial of coverage. In neither case was Dr. Vilella’s opinion requested to be changed, and in the end they were not.”
Vilella strongly disagreed with Klipfel’s assertion that he recommended denying the two claims in question, an action he said goes beyond his role and scope of authority.
“This is not correct,” Vilella said. “I do not adjudicate, deliver judgment or give judgment in accepting or denying any claim at WSI. I do render opinion on medical necessity, appropriateness of treatment,” or whether an injury or illness is work-related.
Klipfel, who agreed that the medical opinion is information claims adjusters and others use to decide a claim, said he hadn’t intended to misconstrue the process in his memo.
WSI is committed to improving its procedures, Klipfel said, and he welcomes suggestions from staff members to achieve that goal.
“I want to get this resolved,” he said. “If there’s something we’re not doing right,” the agency will take steps to correct the problem.
That’s why WSI will ask the North Dakota Board of Medical Examiners, which licenses and disciplines physicians, to review the new standard format for medical reviews, Klipfel said.
In a letter sent Feb. 15, Vilella asked the medical board to review WSI’s medical review procedures. He has told The Forum he is concerned he could violate his medical ethics if he was directed to change his medical opinion.
The medical board is expected to consider the issue at its next regular meeting March 23 in Bismarck.
Meanwhile, North Dakota criminal investigators have received a complaint by a WSI employee who is concerned about the deletion of an electronic record involving a worker’s claim.
Barbara Frohlich, who acts as a liaison between WSI and medical providers, filed a fraud hotline report about the incident last August. She said the deleted electronic notepad entry made by a nurse case manager was favorable to a worker’s claim, and constituted tampering with a public record.
Dallas Carlson, head of the state Bureau of Criminal Investigation, wrote Frohlich on March 7 to acknowledge receipt of her letter, and will keep it on file. “You should note, however, that investigations are protected under North Dakota law; thus, you will not receive separate notification if such an investigation is initiated,” Carlson wrote.
A spokesman for Dalrymple said the governor wants to be satisfied that the issues raised about WSI’s medical reviews of claims have been resolved.
“He’s told Bryan (Klipfel) to make sure he’s gotten to the bottom of this issue,” said Jeff Zent. “He wants to be sure that there’s no stone left unturned here.”
Zent noted that Klipfel’s report made clear that the two worker’s claims involving the proposed deleted paragraphs were approved and said the agency is working to improve its procedures.
“We’re committed to making improvements,” Zent said.
Readers can reach Forum reporter Patrick Springer at (701) 241-5522
Meeting to review WSI evaluations
The North Dakota Legislature’s Workers’ Compensation Review Committee will meet Wednesday in Devils Lake. The meeting agenda includes reports about a performance evaluation of Workforce Safety & Insurance, workers’ compensation claim trends, a report in pilot programs for rehabilitation services and a review of a worker’s compensation claim.
The meeting begins at 9:30 a.m. at Lake Region State College, 1801 College Drive N., Chautauqua Gallery.