Check out our PowerPoint slideshow on using data crunching technology to improve workers’ compensation.
From how to use an inclinometer correctly to understanding why a panel QME gets involved in a work injury, read up on the best workers’ compensation content of the past year.
- What’s A QME?
- Muscle Atrophy
- Exacerbation vs. Aggravation
- Activities of Daily Living
- How to use an Inclinometer
Do you have a workers’ compensation topic you’d like to see covered? Email us and we’ll put our best people on it!
RateFast automates the impairment rating process, giving providers and injured workers the ability to generate accurate analyses of occupational injuries based on the AMA Guides to Impairment Rating.
But how is it done?
Listen to the podcast or keep reading to discover how CPA Josh Moore applies knowledge from accounting to the development of the RateFast impairment rating system.
A QME is a medical professional who is credentialed by the state to perform qualified medical examinations required for certain workers’ compensation cases. For a more detailed look at what a QME is, take a look at this article.
Recently on the RateFast Work Comp Report podcast we interviewed Dr. Nissen about being a Qualified Medical Examiner (QME). Dr. Nissen discussed what he called “the art of the QME”—a skillset that involves using creativity and critical thinking to overcome several unique challenges.
A few of these challenges are described below.
Understanding the American Medical Association Guide to Impairment Rating and Evaluation.
Using the huge tome commonly known as the AMA Guides demands a depth-of-knowledge that few physicians take the time to develop. In order to serve as an effective impartial examiner, the QME is responsible for knowing the Guides back-to-front. This knowledge directly informs all other aspects of QME’s work with the claim, from performing the physical exam to determining impairment.
Assessing previous medical charts.
Medical charts for a single patient are often hundreds of pages long, and the ability to review them for relevant information takes practice, insight, and real-time analysis.
Performing an accurate physical evaluation.
The QME evaluates the patient according to the Guides, reviewing all thirty-four activities of daily living, and taking repeated measurements depending on the type of injury. A correct evaluation requires extensive knowledge of the Guides and rigorous attention to detail.
Creating a precise and correct impairment rating.
All of the relevant medical charts and all new information generated by the QME’s physical exam must be collected into the QME’s report. This data must be accurate; after all, the QME’s role is to bring objectivity to the claim, so reproducibility of results is key.
Dr. Nissen argues that in order for QME reports to truly benefit injured workers, physicians need a system for collecting consistent data. Accurate and meaningful data results in less legation, and ultimately the speedy close of the workers’ compensation claim.
Fortunately, such a system has been developed. RateFast is a total workers’ compensation solution that helps providers perform perfect exams, document patient medical histories, format and organize reports, and determine impairment ratings according to the AMA Guides. We urge medical providers, QMEs, and anyone who is interested in improving workers’ compensation to join RateFast for free.
This article is for medical providers, insurance adjusters, attorneys, and injured workers who want to understand common causes of inaccurate impairment ratings.
Correct impairment ratings save time and money for all stakeholders; they result in correct apportionment for subsequent claims, and allow predictable trends and costs for data analysis and work risk assessment. Of course, the inverse is also true: inaccurate impairment ratings cause claims to consume the time and resources of everybody involved.
One of the best things you can do to check the accuracy of an impairment rating is to make sure that you’re working with a complete data set. In other words, make sure that the provider—or whoever is doing the impairment rating—has all the necessary information.
A complete data set supports an accurate rating, which decreases the risk that the rating will be contested, which means a faster, easier workers compensation claim for all parties.
So why don’t all workers’ compensation claims have complete data? Here are three common circumstances that lead to incomplete data sets:
- Sometimes the required information is not obvious. This is especially common in cases involving the spine with patient symptoms such as radiculopathy.
- The importance of some data about the injury isn’t always clear to medical providers, so they don’t ask the necessary questions or take the necessary measurements. For example, if an employee has injured her left shoulder, then the provider might not ask detailed questions about the pre-existing history of the right shoulder. However, for upper extremity injuries, the history of the uninjured side of the body can actually affect the impairment rating of the injured body part.
- A stakeholder might omit data in order to intentionally increase or decrease the impairment rating. This is considered fraud by the state of California, which you can read more about here.
Let’s look at an example. A twenty-year-old old delivery driver has a back injury. When she reaches maximal medical improvement, a provider examines her. She is pain free and takes no medication, has no problems with her activities of daily living, and takes no medications. It seems as though her injury has not impacted the employee at all, and so the provider concludes that there are no ratable findings. The provider skips the medical history and assigns the patient a 0% whole person impairment. Is this correct?
No. The rating assessment was incomplete. If the provider had taken the full history, then they might have discovered that the patient had L3 dermatomal sensory loss directly after the injury, with imaging showing a concordant herniated disk at that level. Although there were no ratable findings at the time of the final exam, the AMA Guides 5th edition mandates a 5% whole person impairment because she had radiculopathy, even though it is now gone (Category II, Table 15-3, Page 384).
However, only providers who are intimately familiar with the AMA Guides will check for radiculopathy.
In summary, incomplete data are more common than you think. For this reason, we recommend using a tool such as RateFast to ensure that all the relevant questions are answered. Get your free account today.
Whether you’re a medical provider, an injured worker, a claims adjuster, or an attorney, this article is relevant to you if you’ve encountered a 0% whole person impairment rating in a California PR-4 or QME report.
If you receive a report—or are writing a report—with 0% WPI (whole person impairment), this number should raise some flags.
Because, when it comes to the AMA Guides and impairment rating, a 0% WPI is a very special number.
If a report claims that a patient has 0% impairment, then it needs to meet some specific requirements. If it doesn’t meet those requirements, then the number is inaccurate—and as we all know, an inaccurate impairment rating can lead to unnecessary delay, litigation, and expense for all stakeholders.
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.
In occupational medicine the terms aggravation and exacerbation are often mixed up. This article explains the technical definitions for aggravation and exacerbation, and why the difference matters.
This article is intended for anybody who is interested in learning about the role of a QME in California workers’ compensation.
Question: Dr. Alchemy, Based on limited range of motion for the neck in the PR-4 exam, can the injured worker return to usual and customary work duties? (This worker was provided an impairment rating WPI value, but no work limitations were clinically indicated). Sincerely, DS
Answer: Dear DS, Impairment and disability are two independent concepts. Impairment value is a loss of an organ system or function to which a number value is assigned, whereas, “disability” is an ability to meet social or occupational demands. An individual may have impairment but no disability, or the reverse may be true.
A great example here is a knee injury with a meniscus tear. If I choose to not have surgery, but have range of motion above the ratable guidelines, I have a non-ratable knee, BUT I may not be able to stand, squat or lift to the requirements of the job. So, no impairment, but disability (eg. work limitation).
Same knee example as above, but I have surgery this time and a partial meniscus debridement is performed. My knee is perfect post operatively and no pain. I return work no problems. My impairment, however, is 1% WPI based on DBE table rating in Chapter 17, Lower Extremity Table 17-33 etc.
Summary, when an impairment value is incorporated into the California Permanent Disability Rating (PDR) calculation, true “disability” may or may not be present.