There’s a part of the workers’ compensation impairment report that is oft-ignored. The issue is apportionment, which means what part of the residual functional loss of the injury is industrial vs. other things. It’s confusing and hard to understand, and often left out of reports for this reason. As a result, many physicians don’t address it, or if they do it is incorrect and this delays claims.
We are of course referring to apportionment. The AMA Guides to Evaluation of Permanent Impairment can be used to understand how multiple conditions are scored and weighted to make apportionment more relevant and objective for the stakeholders.
What is apportionment?
When collecting data to calculate apportionment, physicians will gauge the limitations caused by the pre-existing condition, and measure it against the patient’s current level of limitation, to determine, in a percentage, how much of the overall limitation was caused by the workplace injury.
The percentage of apportionment is inversely proportional to the amount of compensation that is reduced from the claim. The higher the apportionment. the less the insurance pays out.
An example
An example would be: Say a patient suffered an injury to their shoulder, resulting in a 90 degree range of motion by the time of impairment rating. The doctor takes measurements, and asks the patient if they have had an injury to their shoulder before, to which the patient says yes, they hurt their arm pitching in baseball years ago, and ever since then they could move their shoulder most of the way, but not as much as their other shoulder.
The physician may measure the patient’s estimated range of motion prior to the injury and may determine that the injury has 10% apportionment. If all parties agree, the apportionment is accounted for in the final compensation, and all parties are satisfied… well, satisfied enough not to take legal action or do anything else which would lengthen the time of the claim.
How apportionment can cause dispute
Any factor introduced into a workers’ comp claim invites another element of potential dispute. Apportionment is indeed a large factor of many of the disputes that do happen.
As previously mentioned, the PTP may forget to include apportionment in their report altogether, which will send up flags for the insurance company, and will likely result in a denied report. Another case may be, that if the physician ascribes 0% apportionment to the injury, and the insurer does their due diligence and finds that the patient had a previous injury to that body part or system (remember, it could be an injury that happened outside of the workplace as well).
Moreover, when apportionment is given, it’s possible that the insurance adjuster determines that the apportionment should be greater than the physician has placed in the impairment report. When this percentage reaches around 30% or more, stakeholders may simply contest the accuracy due to “standards” that have been subjectively propagated with past experience and not really based on facts or science at all. The patient may then contact a workers’ compensation attorney in order to dispute insurance company’s determination, as it has significantly reduced the amount of compensation the patient receives.
Conclusion
There are a few things that the patient and the physician can do to ensure that apportionment is calculated well.
- Remembering to include it in the report.
- Asking the patient about any pre-existing conditions.
- Getting as much data as possible about the pre-existing conditions
- Accurately calculating apportionment
Of course, this doesn’t ensure that the insurance company will accept the report. or suggest a different percentage of apportionment. When this happens, if the patient is dissatisfied, they can consider the option of finding a workers’ compensation attorney. The patient must make this decision on their own, as it is against the law for a physician to suggest or recommend that the patient seek an attorney. = Of course, this doesn’t ensure that the insurance company will accept the report. or suggest a different percentage of apportionment. When this happens, if the patient is dissatisfied, they can consider the option of contacting a state agency (eg. DEU) or finding a workers’ compensation attorney to help them with the claim settlement. The patient must make this decision on their own, as it is against the law for a physician to make a legal recommendation; so leave that up to the attorneys! .