Understanding Disability: For Insurance Adjusters

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.

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Adjuster’s Corner: For Insurance Adjusters

Introducing the RateFast “Adjuster’s Corner”.

Adjuster’s Corner is brought to you by, well, adjusters. This series of newsletters are based on real life letters and questions from insurance carrier adjusters seeking clarity and knowledge of the AMA Guides 5th Edition impairment rating situation in California.

Our responses are provided by Dr. John Alchemy, MD, DABFP, QME, CIME. Dr. Alchemy’s credentials include:

A) A current Qualified Medical Examiner (QME) for the State of CA

B) A certified educational provider for the State of CA DWC Medical Unit, specifically approved for content in the AMA Guides 5th Edition, Chapters 1,2,15, 16 and 17, in addition to advanced impairment report writing (12 hrs CME).

C) Currently certified by the American Board of Independent Medical Examiners (ABIME) as a Certified Independent Medical Evaluator (CIME) and have successfully passed a proctored written exam demonstrating competency in the AMA Guides 5th Edition rating system.

Got a great rating question? Send it in (info email link here)!  We love questions almost as much as answers.

Case Study #1 Submitted by adjuster DS:

Question: Dr. Alchemy, why did the cervical spine rating come out so high for a non-surgical neck?

Answer: Dear DS, Do not fall into the trap of responding to impairment values based on the result value. If one reads the rating criteria, surgery is only a subset of the DRE categories, and in no way, a single gateway for rating inclusion etc. Additionally, surgery plays only a subset in the rating determination when using the ROM spine rating.

Rather, I would urge you to focus on the data set that is presented, the validity of the measurements, and the application of the results to the tables and figures. The goal in providing AMA ratings is to provide the stakeholders a numeric value  based on statistical rigor, objectivity, and reproducibility.

If you have specific questions as to the validity of a number or the application of a table/figure, please let me know specifically which part of the data set is appears inconsistent and let’s have learning opportunity.

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Digitization of Workers’ Compensation

The process of digitization is taking information from  the real world and overlaying it with a set of digital perimeters, which allows that information to be put into a system.

This allows for meaningful content to be created for consistent conclusions across large numbers of users.

Electronic Medical Records (EMRs) have gained wide popularity over recent years, but to what extent have Workers’ Compensation reports been digitized in a similar way?

There really hasn’t been a concerted effort to digitize WorkComp by any one group or entity.

There are some impairment reporting softwares out there that will give you the header of the section of the report you’re supposed to fill out. But in these cases, the user is left with a blinking cursor to ask the questions and perform their own physical exam, at their current level of understanding.

We’re talking about guiding the patient and medical provider through a very specific process to make sure reports are as complete and compliant with the law as possible.

Digitization of Workers’ Comp means getting every part of the WorkComp reporting process standardized, using computer technology.

With the rise of cloud computing and centralized and data repositories, the time is now to start this process.

This benefits everyone in the workers’ comp process, but most importantly, it benefits the injured worker. Injured workers get caught in a spiral of inefficiency and errors which draws their cases out much longer than they need to be.

Digitization means faster and more accurate reports; there is currently no penalty for turning in wildly inaccurate reports. Once this process does get digitized any missing information will become blatantly clear.

Has this happened elsewhere? Yes- take a look at the automobile industry. As soon as cars appeared on the market, both new and used, there needed to be a system for determining their value. This guy Les Kelley showed up, of Kelley’s Blue Book– he didn’t have a computer, but he used a specific set of questions that determined how much a car’s value was worth and how much its resell value was. Within a couple of years he took over, his system was an industry standard.

So what does this look like in an Impairment Exam? Let’s have an example:

A QME is doing an exam for a right shoulder injury. The QME took two measurements with the goniometer in all planes of motion. This report gets submitted, and the report is digitized, meaning that someone takes the information and places it into a standardized format to confirm the opinion of the QME. However, what the QME either forgot or wasn’t aware of, is that in upper extremity injuries, you need to measure both the injured and uninjured parts of the body. Therefore half of the functional measurement set is missing, as no measurements were taken on the left shoulder. With digitization the data that’s missing is made extremely clear. This will improve accuracy and consistency in monetizing work injuries.

A study from 2006 found as much as 79% of reviewed reports for the low back were incorrect. Hopefully with the process of digitization this number will significantly decrease. Questions or comments on digitization? Write us at info@rate-fast.com

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Stay Out of Fraud’s Way with RateFast

Last year the California Department of Industrial Relations, Division of Workers’ Compensation (DWC) sent out a letter to the workers’ compensation community regarding fraud. You can read the full letter from 2014 here. But in order to keep things simple, RateFast has created an easy to follow guide for understanding regulations and making sure your practice isn’t making common mistakes.

Workers’ Compensation fraud can be committed by all parties in the workers’ comp process. This includes medical providers, attorneys, claims adjusters, and employers. Below are details and real-world examples of what fraudulent activity might look like for Medical Providers. For a full discussion and review of the 2014 Fraud warning notice, please listen to our podcast “Staying Out Of Fraud’s Way”, available on the iTunes store.

Fraudulent activity for medical providers includes:

  • Billing for services that weren’t performed/ billing for procedures that weren’t indicated.

  • This can occur if an office is not in the practice of correctly documenting the amount of time a provider has spent with the patient.

  • Employing Individuals to Solicit New Patients

  • Using another individual in the community to funnel cases to you.

  • Unnecessary treatment.

  • A patient is authorized for a cortisone injection, and it doesn’t work. If the doctor continues to provide cortisone injections, that may be viewed as unnecessary treatment.

  • Self-interested referrals.

  • If a provider has stock or ownership in a physical therapy group across the street and the provider sends their patients over there, then they make an additional profit on that patient.

  • Failure to report a work injury.

  • Employers are required to report work injuries. If a doctor is not reporting an injury then be in favor in employer, then insurance premium doesn’t go up.

  • If a doctor is aware that a work injury has occurred they have to report it whether or not the patient wants to continue treatment.

Let’s take a look at a fictional, but quite possible real-world scenario:

An employer brings in an injured worker and they have a laceration on their arm. The medical provider examines the wound and makes a determination that the wound needs to be closed with sutures. If sutures are used it becomes a reportable case. If it’s closed with surface tape, the injury falls under first aid. The employer states that they would like it to be closed with butterfly tape. They will pay the provider cash for this and also promise to send other injuries to the provider’s clinic.

If the doctor complies and places the butterfly tape, then fraud has occurred because the medical recommendation was for stitches. The doctor knowingly changed their medical treatment plan to provide a first-aid remedy as opposed to a reportable one. This can be very difficult to prove after the fact.

Bottom line for medical providers concerned about fraud? Simply remember to be careful about processes in the office:

  • How you assign medical codes

  • How you interact with employers

  • What something might look like to a third party

Understand the law, familiarize yourself with the annual fraud notice, and you’ll stay out of fraud’s way!

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