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.