Mental health fraud is a significant problem in North America. It is potentially easier to commit than any other kind of healthcare scam. Malingering, the feigning of an illness in order to receive compensation or avoid duties, is of particular concern to the insurance community. Malingering is often associated with personal injury claims involving psychiatric or psychological disorders, such as mild traumatic brain injury (MTBI), post-traumatic stress disorder (PTSD) or depression.
In the evaluation of any mental or emotional injury claim, the possibility of malingering or symptom exaggeration must be considered. One authority, J. Randall Price, has identified the following five types of malingering that should be considered in claims involving compensation:
- Simulation – The citing of symptoms that do not exist.
- Dissimulation – The concealment or minimization of existing symptoms.
- Pure Malingering – The citing of a disease that does not exist at all.
- Partial Malingering – The conscious exaggeration of existing symptoms or the assertion that prior genuine symptoms are still present.
- False Imputation – When authentic symptoms consciously recognized to have no relationship to the injury are attributed to it.
There is a sixth component of malingering that also needs to be considered by a claims evaluator: iatrogenic imputation, which occurs when an examiner or treatment provider attributes genuine symptoms unrelated to an injury to that injury.
In 1980, in response to the growing concern of malingering, the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) published an index of suspicion for malingering on pages 331-332 which states:
The essential feature is the voluntary production and presentation of false or grossly exaggerated physical or psychological symptoms. The symptoms are produced in pursuit of a goal that is obviously recognizable with an understanding of the individual's circumstances rather than of his or her individual psychology. Examples of such obviously understandable goals include: to avoid military conscription or duty, to avoid work, to obtain financial compensation, to evade criminal prosecution, or to obtain drugs.
Under some circumstances malingering may represent adaptive behavior, for example, feigning illness while a captive of the enemy during wartime.
A high index of suspicion of malingering should be aroused if any combination of the following is noted:
- Medicolegal context of presentation; e.g., the person was referred by his attorney to the physician for examination
- Marked discrepancy between the person's claimed distress or disability and the objective findings
- Lack of cooperation with the diagnostic evaluation and prescribed treatment regimen
- The presence of antisocial personality disorder.
These malingering criteria have essentially been unchanged and were brought forward into the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR).
Each psychological or neuropsychological injury claim should be evaluated for these four factors. The following guide may aid in investigating such claims.
Medicolegal context of presentation
Examine for the presence or absence of the following: Patient is attorney-referred for evaluation or treatment; the case is clearly identified as in litigation or subject to a workers' compensation claim; the case is referred for disability evaluation; an attorney is being billed for treatment or is being copied on all correspondence; the treatment provider documents meeting with the claimant's attorney. The presence of any of these would suggest that the medicolegal criterion has been met.
Marked discrepancy between claimed stress or disability and objective findings
Examine for the presence or absence of the following: normal MRI, CT scan, EEG or X-rays; physician releases from treatment; a low impairment rating given by a physician; the person is released to return to work and does not return; there are no abnormal psychological or neuropsychological tests; recovery curves are not consistent with research literature; the claimant continues to get worse or doesn't get better at all.
Lack of cooperation
Examples of this criterion would include the patient not reporting prior psychiatric or psychological treatment, previous medical evaluations, history of mental illness, or substance abuse; the patient failing to comply with prescribed medication protocol or other recommended treatment; the patient distorting prior academic or work performance; and evidence of any invalid psychological and neuropsychological tests.
The presence of antisocial personality
Examples of this criterion may include diagnosis of any type of personality disorder; criminal history; multiple marriages; erratic work record; or history of substance abuse.
In addition to using the foregoing guide for evaluation of malingering, the claims adjuster would do well to look for the following red flags.
Background and Character Weaknesses Examine for greater than typical need for financial support; desire to avoid or escape job situation; being a marginal member of mainstream society; having a poor work history, poor credibility or dishonesty; indications of antisocial, narcissistic or borderline personality disorder; past employment in healthcare, insurance or legal fields; reared in a family with a disabled role model; cohabiting with a disabled adult; substance dependence/abuse; previous incapacitating injuries; and prior claims for an injury or claims litigation.
Abnormal Responses to Examination or Treatment Red flags may include refusal to be examined; missing or canceling an examination or treatment appointment; refusal of hospitalization or treatment; non-responsiveness to treatment; adamance that treatment will not succeed; evasion of questions and avoidance of direct answers; exaggerating confidence to examining doctors before an opinion is rendered; threatening doctors or claims managers; attempting to control medical examinations by intimidating or bizarre behavior; continually making statements obviously designed to enhance credibility; depicting prior functioning in excessively complimentary terms; criticizing examiners for their performance; and submitting to examination only in response to a court order or termination of benefits. Any of these red flags could indicate a lack of claimant credibility.
Disposition at Claims Interview Some malingerers display sketchy tendencies during their claims interview. Determine if the patient is involved in litigation or criminal proceedings, has obvious secondary gains from having a deficit (avoiding work, obtaining money), claims a severe disability following a minor injury, refuses employment under partial disability, or doesn't follow through on available treatments. Some of the behavioral red flags at an interview include: a lack of or inconsistent cooperation; suspicious, aloof, uneasy or unfriendly behavior; evasion or many "I don't know" answers; unusually great detail of events surrounding the cause of injury; an unusually large number of symptoms or inconsistent or absurd reporting of them; non-selectivity of physical, emotional, or cognitive symptoms; and an over-idealized functioning or lack of reasonable difficulties before accident.
Questions that can draw out evidence of malingering should focus on participation in activities not consistent with the reported deficit; a discrepant capacity between work and recreation; significant financial stressors; and the pursuit of examinations and treatments without consulting experts, which might indicate an attempt to treat a non-related problem. Sometimes, malingering patients present as "victims" and will tip their hand by blaming others or attributing all life's problems to the injury.
Clinical Picture Embellishment of symptoms is a red flag that a claimant may be engaging in malingering. Note if the patient is overly eager to discuss and call attention to symptoms, magnifies them, endorses rare or more blatant than subtle symptoms, shows unrealistic accuracy or attributes unrelated symptoms to the event under investigation. Sometimes the ailments described or the course of the disorder will be inconsistent with research literature, or the symptoms will "worsen" under observation. If the patient's focus is on the degree of impairment rather than the condition or if he rarely acknowledges the ability to learn new skills or perform modified jobs, malingering should also be considered.
Psychological and Neuropsychological Tests Vagueness, inconsistencies, lack of memory, evasiveness, and bizarre responses to tests can be red flags, but they can also be signs of real problems. The same holds true for random wrong answers or decreasing effort as test items increase in difficulty. If a patient's testing results raise suspicion or they score high on direct measures of malingering, further evaluation by a specialist is warranted.
Fraudulent claims in mental health and exaggerated claims in personal injury are fairly pervasive. In an article by Mittenberg, Patton, Canyock, and Condit titled "Base Rates of Malingering and Symptom Exaggeration," the authors reported that the base rate of malingering by referral type was 30.43% for personal injury claims and 32.73% for disability or workers' compensation claims. What the evidence indicates is that about a third of personal injury claims for compensation are likely to be embellished or be consistent with malingering. This high rate compels the claims examiner or adjuster to carefully scrutinize cases for malingering. When a problematic case is identified, those claims should be referred for more stringent evaluation.
David R. Price
, Ph.D., is president of The Forensic Network
in Greenville, S.C. email@example.com