Current methods of fraud detection used by insurance companies are not cost effective. This presentation describes the inaccuracy of the MMPI, and presents a new test, which can predict who will had medical test abnormalites with 95% accuracy, and who wil not have medical test abnormalities with 85% accuracy (the fakers). Available in English and Spanish at www.MarylandClinicalDiagnostics.com

1. Fraud Detection in
Workers Compensation and
Auto Accident Cases
Nelson Hendler, MD, MS
CEO of www.MarylandClinicalDiagnostics.com
Former Assistant Professor of Neurosurgery
Johns Hopkins University School of Medicine
Past president –American Academy of Pain
Management
Former Clinical Director –Mensana Clinic

2. California Does a Poor Job of
Combating Worker’s Comp Fraud
(Workers Compensation Report, Vol 15, No. 11, p.206 May 17, 2004)
• State Auditor Elaine Howle says the $30,000,000 annual
assessment to combat fraud may be wasted.
• Insurance companies cannot measure the effectiveness of
their efforts using IMEs and surveillance.
• The companies are relying on antedotal testimony from
stakeholders in the workers compensation community,
unscientific estimates, and description of local cases
involving fraud.
• The fraud division publishes statistics showing the number
of investigations, arrests, convictions, and restitution, but
cannot show if anti-fraud efforts are cost-effective.
• See www.MarylandClinicalDiagnostics.com

3. Types of Chronic Pain Patients
Hendler, Diagnosis and Non-Surgical Management of Chronic Pain, Raven Press, ‘81
• There are Two broad Categories of Chronic
Pain Patients
• Objective Pain Patient: Good pre-morbid
adjustment, objective findings, and goes through
the 4 stages of pain (case study: Car Exec.)
(87%-94% of all chronic pain patients)
• Exaggerating Pain Patient: poor pre-morbid
adjustment, minimal findings, and absence of
depression (case study: hysterical scoliosis).
• (Between 6% to 13% of all chronic pain patients)

4. What is a Normal Response to
Documented Severe Chronic Pain?
• We need to study what normal is before
we can understand what abnormal is
• This is the same reason medical students
study anatomy before pathology.
• If you know what a normal response to a
documented severe chronic pain is, you
can appreciate that any deviation from that
response is suspicious and abnormal

5. Objective (Valid) Pain Patient
Case Study: A 56 year old executive for a Big Three auto maker was married
for 25 years, had three children all of whom were in college, and was earning
over $1,000,000/year. He was working on his boat, when the engine fell, and
traumatically amputated his thumb. He went to work the next day, and
continued to work, and he expected the pain to subside. However, after two
months, the pain in his thumb became so severe, that he could not
concentrate, nor sleep. He was diagnosed with a neuroma in the stump of the
thumb. Any sensation to the stump would cause severe pain to shoot up his
arm. When he was seen at a hospital in Baltimore, he had been suffering for
two years. He scored 14 points on the Maryland Clinical Diagnostics Pain
Validity Test, putting him the Objective Pain Patient category. He was suicidal,
sleeping only two hours a night, and was on three types of narcotics, sleeping
medication, and diazepam. He wanted to divorce his wife because he felt like
a burden to her. He was severely depressed and had never been depressed
before the onset of pain. He was so desperate to get rid of his pain that he had
a thalamic stimulator put into his brain. Unfortunately, this gave him only partial
relief. Eight years after the onset of his pain, he was less depressed, was off
narcotics, and sleeping medication, and was getting four hours of sleep a
night. He still had pain, but had adjusted to the pain. He had retired from the
auto company. (Hendler, Diagnosis and Non-Surgical Management of Chronic Pain, Raven
Press, New York, 1981).

6. 4 Stages of Chronic Pain in an
Objective Pain Patient
(Hendler, in Diagnosis and Treatment of Chronic Pain, Edited by Hendler, Long
and Weiss, Wright-PSG, ’82)
• Chronic pain patients go through 4 stages remarkable
similar to the 5 stages a patient experiences when dying
(Kubler-Ross-’69), just like the example.
• Acute Stage 0-2 months –Pt. expects to get well, so no
psychological changes (MMPI is normal).
• Sub-acute stage-2-6 months- Pt. had anxiety and somatic
concerns develop (MMPI scales 1 & 3 are elevated)
• Chronic stage 6 months-8 years- Pt. is depressed (MMPI
has elevated scale 2, called a pain neurosis by Blumer,
pain prone patient by Pilling, low back loser by Sternbach)
• Sub-chronic stage-3-12 years Pt. resets goals-adaptation
(MMPI scales 1 & 3 elevated, hypochondriasis and
hysteria)

7. Exaggerating Pain Patient
A 43 year old woman was hospitalized in Baltimore, complaining of marked
scoliosis, that had just developed, in the past year. Further evaluation did not
verify the typical radiological findings seen with a constant scoliosis. She scored
24 points on the Maryland Clinical Diagnostics Pain Validity Test, putting her in
the Exaggerating Pain Patient category. A trial with an Amytal (truth serum)
interview failed to resolved the scoliosis, but when the patient was anesthetized,
the scoliosis resolved temporarily. Further Amytal interviews revealed the patient
had a stormy marital relationship, and she avoided sex with her husband,
because he was abusive. The patient was reassured she need not have sex with
her husband if he was abusive. The next day, she walked upright, and continued
in this posture, until her husband visited. The day of the visit, the scoliosis
returned. Additional Amytal interviews revealed she had been abused as a child.
She had a she had been afraid to seek divorce from her husband, but with social
worker intervention, she found the support to do so. The scoliosis resolved. On
five year follow-up, she was divorced, and remained free of scoliosis. (Hendler, N,
Filtzer, D, Talo, S, Panzetta, M, and Long, D, Hysterical Scoliosis Treated with Amobarbital
Narcosynthesis, The Clinical Journal of Pain, 2:179-182, 1987).

8. MMPI (Minnesota Multiphasic
Personality Inventory) lack of
predictive capabilities
• Hagedorn et al from Mayo Clinic (Pain,
’84) followed 50,000 patients for 25
years. This is the only prospective study.
• They all received the MMPI when they
first entered the Mayo Clinic system.
• 68 of them had back surgery.
• No difference in pre-surgery MMPI
between those who did do well or didn’t
do well with surgery.

9. The MMPI Cannot Validate the
Complaint of Pain
• MMPI is not consistent in predicting the
presence or absence of organic
pathology. Not one single scale ever
correlates, consistently, with the presence
or absence of organic pathology (Hendler
et al, Pain, ’85, Hendler et al J. Occ.
Medicine,’88, Hendler et al J. Neurolog &
Ortho. Med. & Surgery, ’85, Hendler
Clinical Neurosurgery, ‘89)

10. Longitudinal Studies on Depression
A study of 83 patients admitted to Mensana
Clinic
77% of the chronic pain patients were
depressed, as confirmed by Beck scores.
However, 89% had never been depressed
before the onset of their pain ( Hendler,
Clinical Neurosurgery, ‘89)
After six months or more, chronic pain
produces depression (Hendler, J. Clinical
Psych, ’84)

11. Overused Psychiatric Diagnoses in
Chronic Pain Patients
Malingering: No statistics about frequency (Hendler
and Talo, Current Therapy of Pain, edited by Kathy
Foley and Richard Payne, BC Decker, ’89).
Pain Disorder is defined as a pain for which is there is
no medical explanation. However, since 40%-67%
of chronic pain patients are misdiagnosed medically,
then these patients receive a faulty psychiatric
diagnosis, because of a poor medical diagnosis.
Depressive Equivalents: Depression causes pain.
Circular logic in the diagnostic criteria in DSM-IV for
somatoform disorder, pain disorder, and depressive
equivalents. With a poor medical work-up, these
“diagnoses” becomes self fulfilling prophecies.

12. Suicide and Pain
Chronic pain patients commit suicide at a
higher rate than the general population
(Fishbain et al Clin. J. of Pain, ‘91).
White males with pain complete suicide at a
rate 2X higher than the general population.
White females with pain complete suicide at a
rate 3 X higher than the general population.
White males with pain, involved in workers
compensation litigation complete suicide at a
rate 3 X higher than the general population.

13. Mensana Clinic Approach
• Patients can have both psychiatric disease
and organic pathology co-existing
• Schizophrenics get brain tumors, and
hysterics get disc disease. Psychiatric
disease does not confer an immunity to
medical disease.
• Treat each patient as if they have organic
pathology.
• Give patient the benefit of the doubt.
• See www.MarylandClinicalDiagnostics.com

14. What are the Questions?
• Does the patient have a valid complaint of pain?
• Variables: pre-existing psychopathology,
resultant psychopathology, negative tests,
positive tests that do not correlate with the
anatomical complaint of pain (i.e. L5-S1 disc on
MRI: pain in top of thigh = L2-L3)
• KEY Concept: Severe chronic pain produces
consistent psychological and sociological
responses in a patient, regardless of pre-existing
or co-existing psychiatric disease.
• If the response to pain is normal, believe the
patient, not the tests, and keep looking.

15. Available Help
• Pain Validity Test is available on Internet to
validate pain, and improve diagnostic
accuracy, as a screening tool to help get
an accurate diagnosis, and supplement the
use of IMEs, and surveillance.
• Preliminary studies (next slide) show an
average cost savings of $1,654/case for
answering the question – “Is the pain
valid?” using Pain Validity Test for $300.
• Average $97,000/case cost containment
for “What is the diagnosis and treatment?”
(Appendix A) using Diagnostic Paradigm.

16. Spotting Fraud
• National Council on Compensation Insurance
(NCCI) published a report Assessing Pain, Real
and Imagined(11/29/98)
www.NCCI.com/painreal.html
• Hendler reports that 6% of non-litigant patients
are exaggerating pain patients, 10% of LTD, and
13% of workers compensation.
• For $300, The Maryland Clinical Diagnostics
Pain Validity Test can identify exaggerating pain
patients (www.MarylandClinicalDiagnostics.com)
• Average savings of $1,654/claim by eliminating
IMEs, surveillance, and nurse case reviewer in
the objective pain patient, and focusing the
resources on the exaggerating pain patient.

17. The Pain Validity Test*
• An Internet questionnaire, available in
English and Spanish
• Results are emailed to the requesting party
within 5 minutes of completion of the test.
• The Pain Validity Test can predict with 95%
accuracy who will have an abnormality on
objective medical tests, and predict with 85%
accuracy who will not.
*Hendler, N. and Baker, A., An Internet questionnaire to predict the presence or absence of organic
pathology in chronic back, neck and limb pain patients, Pan Arab Journal of Neurosurgery, Vol. 12,
No. 1, pp: 15-24, April, 2008
• Costs $300 at www.MarylandClinicalDiagnostics.com

18. Scattergram of Computer Scored MCD Pain Validity Test.
On the left, 3* is a severe abnormality, 2 a moderate abnormality, 1 a mild abnormality,
and 0 is no abnormality on at least one objective medical test. At the bottom, 8-25
represent the score on the MCD Pain Validity Test. 17 or less is an Objective Pain
Patient, 21 point or higher is an Exaggerating Pain Patient
*3
65/69 = 94%
2 Exaggerating
Objective Pain Patient Pain Patient
1
11/13 = 84%
0
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

19. Efficacy?
• Do you have statistics?
• A literature search using Google, Jeeves,
National Library of Medicine, National
Council of Compensation Insurers, AOL,
Yahoo, etc. never revealed an article
documenting the cost effectiveness of IMEs,
surveillance, P.T., Functional Capacities
Evaluations, and Case Reviews. There were
lots of case reports.
• 54 cases reviewed for “XZY” insurance had
an average of 3.8 IMEs (1-7), and cases
were still active, out of work an average of
3.9 years (1.5-12).

20. Richard Pimentel at National Council on
Compensation Insurance Symposium,May 6,’04
(Workers’ Compensation Report Vol. 15, No. 11, p. 206, May 17, 2004)
• Insurers hold the key to reducing claims duration
with effective Return to Work Strategies
• Currently: Worker goes to doctor, Worker files a
claim with insurer, Worker doesn’t want to return to
work, Insurance company contacts employer for a
job description, and send RTW form to doctor, who
fills out form and sends it to insurance carrier, who
contacts the employer to to to get worker to RTW.
• His plan: remove the insurer from the equation.
• Having a supervisor of the worker from the
company go to the doctor with the worker saved
$1,400/claim.

21. Conclusions
• The current methods of assessing fraud (IMEs,
FCE, surveillance) are not cost effective, and not
accurate.
• Misdiagnosed patients cost insurance
companies much more than fraudulent cases.
• The www.MarylandClinicalDiagnostics.com
Pain Validity Test is a reliable method for
detecting fraud.
• Physical therapy has not been documented as
cost effective in chronic pain patient treatment.
• Insurance carriers should demand Evidence
Based Medicine = proof of efficacy of treatment.