3 Critical Questions to Ask About your Qualified Medical Exam

This is article is meant for injured workers’, medical providers, qualified medical examiners (QMEs), insurance adjusters, and other stakeholders in a California workers’ compensation claim.

When a medical condition has reached Maximal Medical Improvement (MMI), the QME (Qualified Medical Examiner) is required to perform an impairment rating exam.

The impairment exam consists of a series of detailed questions and measurements defined by California law and the American Medical Association (AMA) Guides, 5th Edition.

An accurate and correct impairment exam leads to faster settlement and delivery of benefits, whereas an incorrect exam leads to delay, confusion, and or costly litigation.

As a stakeholder in the system, here are three simple questions you should ask in order to determine the accuracy of your orthopedic medical exam.

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David and Goliath: RateFast sets a new standard for accuracy in California Impairment Rating

An underdog tale of a physician armed with a simple tool

David vs Goliath

Not so long ago, a certain patient with a work-related injury was sent to a state Qualified Medical Examiner (QME) by the insurance carrier. The QME gave the patient a 0% whole person impairment rating. The QME charged the medical-legal fee schedule, which is approximately twice the primary treating fee schedule.

Then, the patient’s primary treating physician (PTP) performed an impairment rating exam using RateFast.  Guided by the RateFast app, the physician obtained a complete history and measurement set. Four body parts were evaluated: neck, right shoulder, right elbow, and right wrist. After the exam and measurements were analyzed by RateFast, it was determined that the patient had a 17% whole person impairment—compared to the 0% WPI assigned by the QME.

The insurance company was understandably confused. The patient couldn’t have both a 0% and a 17% impairment rating. So which rating was correct? The rating that was calculated by the qualified medical examiner? Or the number produced by the treating physician?

In search of answers, the insurance company showed the RateFast report to the QME and asked for a review. The QME responded that he had not actually performed any of the required exams, or measured the range of motion for the injured body parts. After reviewing the RateFast report, the QME advised that the insurance carrier discard his own 0% rating, and instead adopt the 17% impairment rating from RateFast.

The RateFast report was then shot like a pebble from a sling into the heart of the the California state disability evaluation unit (DEU).

The RateFast report was accepted by the DEU, and the case prepared for settlement.

What can we learn from this story?

A qualified medical examiner’s process is not necessarily any more accurate than reports created by primary treating physicians. The main factor that separates good reports from bad reports—and excellent reports from good reports—is the tool used to document, collect, and analyze data from the patient’s examination.

When the QME and the stakeholders were confronted with overwhelming documentation and actual measurements supporting the findings, there was a little else to do but accept the RateFast report as correct—for the benefit of all. Correct reports that deliver the right value the first time serve all stakeholders—the injured worker, the insurance carrier, and the employer. Incorrect reporting invites frustration, litigation, delay, and skyrocketing costs.

RateFast invites you to get on the right side of impairment rating—while at the same time increasing efficiency and profitability in your medical clinic. You can contact us for a demonstration.

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Sub Rosas in Workers’ Comp

This article is for medical providers, insurance adjusters, and attorneys who want to better understand the process of a Sub Rosa within the context of a workers’ compensation case.

What is a Sub Rosa?

Sub Rosa is a fancy latin term that literally means “Under the Rose.” In workers’ compensation, however, it means secret investigation—surveillance. During a Sub Rosa investigation, usually an investigator is sent out to survey the injured worker. The investigator attempts to observe what level of physical activity the injured worker can or cannot perform. The second, and less common use of Sub Rosa in work comp is to investigate a doctor, an employer, work sites, and/or working conditions. 

What are the stakeholders looking for in a Sub Rosa?

When insurance adjusters, employers, or medical providers require a Sub Rosa investigation, they are normally looking evidence that an employee can perform observable physical activities that are in excess of what they claim they can do.

 For instance, an injured worker may report that they can’t lift anything, or can’t bend over, or can’t walk without a cane. The fundamental purpose of this surveillance is to verify or disprove the validity of what the person is claiming in regards to their physical or psychological conditions. 

Sometimes a patient may claim that they have good days and bad days. In these cases, their limitations ambiguous. It’s very important, therefore, that Sub Rosas span several, separate days, to provide an accurate view of the patient’s conditions.

What should the doctor do while viewing surveillance footage of a patient?

Most surveillance tapes are dead-boring. It is advisable for the doctor to dictate what she observes the patient doing while she watches the tape. It’s also important for the doctor to state whether she can clearly identify that the person being filmed is the patient in question, or whether she knows it is certainly not the patient, or whether she can’t tell.

When should an attorney consider requesting a Sub Rosa?

An attorney may consider a Sub Rosa to be useful if one or more of the following are present:

  • Is the patient off from work for a much longer time than is typical for their condition?
  • Does the patient have a history of workers’ comp cases where this has been a trend?
  • Do physical findings corroborate with the patient’s description of their symptoms?

Should a doctor confront the patient with apparent discrepancies before recommending a Sub Rosa?

Yes. There is a lot that can be gained from a frank discussion with the patient about their symptoms and physical findings. Here at RateFast, we are committed to remaining non-partisan—we believe the ultimate goal of a workers’ compensation claim should be to get patients safely back to work. Therefore, we recommend an open and honest discussion with the injured worker before considering surveillance.

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RateFast’s Roadmap to Apportionment

Apportionment is one of the top three decisions which can delay a WorkComp claim from closing. This is understandable, as it’s a tricky subject. Nearly all medical providers have a different idea about how apportionment should be arrived at. Insurance companies want to pay the injured worker the right price, the injured worker needs to be adequately compensated… And the employer only wants to be responsible for the part of the injury which was caused at work.

Bottom Line: There are no clear rules with apportionment. Although the law defines that only “permanent disability” is to be apportioned, there are no instructions on how the medical provider is to actually do it. Is it functional disability (eg. could lift 20 pounds before the injury and now lifts only 10 pounds)? Is it “permanent disability” from a permanent disability rating (PDR) that results from an impairment measurement (eg. %Whole person impairment, which may or may not result in true permanent functional disability). Or, is it a change in treatment burden such as medications, therapy, and or other measurable medical support that is now needed, new, or increased from a pre-injury condition to maintain the new level of function? Which one is a correct method? They can all be used clinically with equal defensibility when correctly explained and supported.

There are a few things which can be referenced when deciding apportionment, in order to keep consistent, objective impairment reports.

Let’s start with some definitions.

  • Apportionment is one of the subsets of the PR-4 report.
  • It’s a section where the medical provider is asked to make a determination if the permanent disability that results from the work injury may be attributed medically to any other conditions.

Now time for a real-world example.

A gentleman who is 25 y/o is lifting a box at work. He injures his back and receives treatment. At the conclusion of the report the doctor is going throught the case history and it turns out that the worker had a pre-existing injury to his back. This placed him on a restriction from listing more than 20 pounds. After this new injury he can only lift 10 pounds.

Is apportionment present and if so, what %?

The answer is yes. He is 50 % apportioned to his permanent disability from the old, unrelated event when he hurt his back.

In this case we’re lucky enough to have a clear a baseline of pre-existing disability, we know the worker is at MMI, and now there’s a new level of permanent disability. This makes the apportionment determination much simpler, and helps with the timely closure of the claim. Remember apportionment is no walk in the park, so if you’re looking for any advice feel free to Submit a PR-4 report for review today!

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8 rules for taking the perfect workers’ comp patient history

This article is intended for medical providers who need to write a history of a work-related injury.

The quality of a patient’s injury history can make or break the accuracy of an impairment rating. Read our eight rules on conducting a complete patient interview,  including how to let silence be your friend, and the one comment that every good medical history should include.

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What is a PR-4 Permanent & Stationary Report? (for patients)

What is a PR-4 report? What is a permanent and stationary report?

The significance of a PR-4 report can be confusing to patients. This video below explains the significance of PR-4 reports for injured workers. This video introduces the topic of PR-4 reports. I’ve shown it to a few of my patients before the actual PR-4 examination takes place. It answers about 80% of the common questions that patients have about the report and the exam—a real time saver for everybody.

If you’re a patient and you have a work injury, then this video will cast some light on how your work injury is going to be evaluated and rated.

If you’re a medical provider or office manager at a medical clinic, please feel free to use the video to help explain the significance of the permanent and stationary report to injured workers that you are going to examine. Send your patients the link to this post via email, and they can watch it on their home computer—or on their cell phones while they’re in the waiting room.

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Automatic billing for your PR-4 reports! How to use the RateFast Billing Calculator

Update for 2021: RateFast Express is an even easier alternative to the wonderful RateFast software. Try RateFast Express today!

Accurately sending your bill for a PR-4 report can be a time consuming process, but it doesn’t need to be.

The RateFast PR-4 Billing Calculator counts the amount of pages in your PR-4 report, asks some basic questions, and then prints out a bill at the end of your report.

This article describes how to turn on the billing calculator and how to use it correctly.
Continue reading Automatic billing for your PR-4 reports! How to use the RateFast Billing Calculator

RateFast Welcomes Phil Walker

Phil-Walker-An-Introduction-250x375New Podcast

Over at the California Work Comp Report podcast, we’ve just released an episode featuring workers’ compensation attorney Phil Walker. 

Phil will be joining us for more podcasts as we explore the intersection of law, medicine, and patients’ needs in work comp.

You can check out the episode called “Attorneys in Workers’ Comp: A Historical Perspective” here, and you can also read a complimentary blog post.

About Phil

Phil has over 30 years experience in several different workers’ compensation systems from Canada to Mexico to the Rockies.

He is an expert on the AMA Guides, 5th edition (which California currently uses for evaluating and rating work injuries). Phil helps employers figure out if doctor’s work-comp reports are correct.

For more information about Phil and his services, you can visit his website here

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