Workers Compensation Medical Treatment

If the medical treatment you need for a work-related injury requires anything more than a few stitches to close a cut or a bag of ice to reduce swelling, take a deep breath and settle in. You might be in for a long process to get a final (and fair) resolution to your workers compensation case.

There are a lot of moving parts to a workers compensation settlement, especially one that involves “indemnity,” which is a fancy way of saying “money.” Be forewarned: This is NOT a quick, easy-to-figure process. Workers want to be compensated fairly when they get hurt on the job and insurance companies want to be sure the injuries they’re paying for are legitimate.

That’s how things are supposed to work and, in most cases, that is how it works. However, there are exceptions and the reasons for dispute come from several angles.

There are times when the insurance company disagrees with the treating physician’s evaluation and orders an independent medical examination (IME). Or it could be that the patient says he can’t lift loads he used to and must go through a functional capacity exam (FCE) to prove it. Or, neither side can agree on just how severe the damage from the injury is and an impairment rating evaluation (IRE) is ordered to determine if the patient is disabled and to what extent.

If it feels like your head is spinning in bowl full of acronym soup, revisit the first paragraph about taking a deep breath. Understand that both sides have justifiable concerns about being taken advantage of, which explains why the medical treatment process for workers compensation can be tedious. Here is a walk through some of the hurdles you might have to clear to get what you think you deserve.

First Steps: Meet with a Physician

The initial treatment is done either by the employee’s physician of choice (in 29 states) or by a physician chosen by your employer or their insurance carrier (in 21 states).

If all goes well, the employee heals properly, his medical bills are paid, he has received two-thirds of his wages while off the job and is ready to go back to work.

But things do not always go well. There are some levels that have to be assessed (Maximum Medical Improvement) and statuses evaluated (impairment vs. disability) and exams to be taken: IME, FCE and IRE.

Nurse Case Managers

Like some doctors, Nurse Case Managers get paid by the insurance company to monitor the care for the injured worker. It makes sense that they will have some loyalty to the people that pay their salaries. Just like the insurance company doctors, the nurse case manager may have an incentive to get you back to work as soon as possible to save the insurance companies money.

Also, if you let the nurse case manager go with you to your appointments, you will lose your “medical privilege” with your doctor. In that case, it’s important to know how to deal with workers comp doctors because everything said between you and your treating doctor gets shared with the insurance company.

Here is why that matters:

• Nurse case managers may have reason to minimize your injuries
• They may influence your doctor’s medical opinions and treatment decisions
• They could push you to return to work too quickly

If you are sent back to work before your full recovery, it may harm both your health and your claim.

Keep in mind: You do not have to allow the nurse case manager to attend your medical appointments.

End Goal: Maximum Medical Improvement

The goal of a physician is to get the injured worker to the point of Maximum Medical Improvement, but that doesn’t always mean the patient makes a full recovery.

For some injured workers, the pain or dysfunction of an injured body part does not go away, despite the best medical efforts applied in his treatment. At some point, however, the treating doctor will say the patient has achieved Maximum Medical Improvement, meaning all reasonable medical treatment has been offered and neither significant improvement or decline is anticipated. In other words, this is as good as it gets.

If the doctor says you’ve achieved MMI, the next step is to either return to work or request a workers comp medical exam to determine whether your benefits will be extended or rescinded.

Types of Workers Comp Medical Exams

When an injured worker has been treated and there is disagreement on their physical status and future ability to perform their job, there are three types of examinations to help provide an answer.

The three medical exams are:

• Independent Medical Examination (IME)
• Functional Capacity Examination (FCE)
• Impairment Rating Examination (IRE)

Each one has a distinguishing purpose to it and how it helps a worker qualify or is disqualified from receiving benefits.

Below is a look at what’s involved with each one.

Independent Medical Exam

An independent medical exam is an evaluation by a “neutral” third part to assess an injured worker’s medical treatment, ability to return to work or eligibility for additional workers compensation coverage, benefits or a settlement.

The reason “neutral” is in quotes is because an IME is paid for by one side or the other in a dispute over benefits. It is difficult to be “neutral” when one side is paying you for an answer.

Typically, an IME is ordered by the employer’s insurance company, when it disagrees with the treatment or recommendations of the treating doctor.

An injured employee who disagrees with the treatment or recommendations he/she received, also can ask for an IME and must pay for it themselves.

The IME documents the workers treatment, current condition and includes recommendations on whether he/she is fit to return to work and at what level. The IME physician will discuss your medical history, conduct tests, ask questions and observe the patient’s movements before compiling a report.

The purpose of an IME is to assess factors that are crucial in determining whether workers compensation benefits should be extended or terminated.

A 2018 study by the New York Workers’ Compensation board showed that 87% of IME examinations took less than 30 minutes, but only 42% of respondents said the report submitted was a fair representation of the exam.

Functional Capacity Exam

When an injured worker has reached MMI and there is uncertainty about whether he/she can meet the physical requirements of their job, a Functional Capacity Examination (FCE) could be ordered by the attending physician, the insurance carrier or the employee.

An FCE measures the workers’ ability to perform a series of tasks common to their job. For example, if lifting is part of their normal work routine, an FCE will evaluate how much they can lift in comparison to what they lifted before the accident.

FCE tests are conducted by physical therapists, not doctor to evaluate an employee’s performance in these areas:

• Range of motion
• Physical strength
• Endurance or stamina
• Flexibility
• Physical effort

The exams usually take between four and six hours to complete, but depending on the job involved, may stretch over two days. There is no standardized FCE test because there are so many job types requiring so many different physical skills that it would be impossible to have a uniform exam.

The findings are sent back to the treating physician and become part of the recommendations on whether the patient can return to work and in what capacity.

Impairment Rating Evaluation

The Impairment Rating Evaluation (IRE) is the most difficult examination in a workers compensation case because so much is riding on it and so much of the test is subjective.

A physician is asked to confirm whether the person is at Maximum Medical Improvement (MMI). The doctor conducts tests to measure your condition and the level of impairment you are suffering from one or multiple parts of your body.

The physician then offers an assessment of your whole body impairment on a percentage scale of 0-100. If the impairment rating assigned says that more than 50% (in most states, check your state’s laws to be sure) of the workers’ body is impaired, the worker could receive Permanent Total Disability benefits for the rest of his/her life.

If it’s less than 50% (in most state, check your state’s laws), it could change to Permanent Partial Disability, which usually has a time limit of somewhere around 500 weeks for collecting wage loss benefits before those benefits expire.

In most states, the IRE test is based on a version of the American Medical Association’s Guidelines, which is in its sixth edition. Several states have developed their own guidelines, most of them based on the AMA’s version.

The IRE report will recommend which of the four categories discussed below the injured worker qualifies for. Workers have the right to appeal the IRE results.

Impairment vs. Disability

It is critical for injured employees to understand the medical and legal differences between an “impairment” and a “disability.”

The American Medical Association’s Sixth Edition Guides to the Evaluation of Permanent Impairment, defines impairment as a “significant deviation, loss or loss of use of any body structure or body function in an individual with a health condition, disorder or disease.”

In practical terms for workers compensation, an impairment would be the loss of a specific body part or function such as eyes, a hand, a leg, or perhaps memory because of a work-related injury.

A disability is defined as “activity limitations and/or participation restrictions in an individual with a health condition, disorder or disease.”

A disability for workers compensation would be the inability to perform normal daily activities such as walking, lifting, remembering, communicating, etc. because of an injury.

A good example of both of these terms this would be two people who suffered a serious back injury. One is delivery driver, but the pain from his back no longer allows him to drive or lift boxes. The back injury has made him disabled. The other person is an accountant. He sits at a desk all day and can do his job with no problem. The back injury is an impairment for him, but does not prevent him from doing his job.

There often is a very fine line between the two. That line is often drawn after getting one of the following examinations.

Four Types of Impairment

For most employees, the long and short of workers compensation is how much money will they receive when injured on the job? Like so much of workers compensation law, the answer is complicated.

The starting point for figuring out the amount of money you receive for a work-related injury is determined by whether you fall in the category of temporary or permanent and whether your considered partially or totally disabled. That’s four categories with four different formulas at work to identify indemnity (cash) benefits.

The category you are in is determined by the IRE physician after he has declared that you have reached MMI, or maximum medical improvement.  He then offers an impairment rating and that rating determines what category, if any, you fit in.

If you disagree with the rating, you may appeal the decision.

Temporary Partial Disability (TPD)

If you get hurt on the job, but aren’t hurt so badly you can’t do some work, temporary partial disability could be the category you fall into. In TPD, the treating physician believes you can spend at least part of the day doing your job and you’ll get paid for that. If it’s less than eight hours, workers compensation kicks in to make up for some of the lost wages.

Temporary Total Disability (TTD)

If a worker suffers a job-related injury that leaves him unable to work until he gets through rehab and recovers, he could fall in the temporary total disability category.

TTD means the injury was severe enough to prevent the employee from working for days, weeks, months or even years, but there is an expectation he will recover and return to work. During recovery, the worker will have medical bills paid and receive two-thirds of his average weekly wages.

Permanent Partial Disability (PPD)

To qualify for permanent partial disability, the employee must have suffered an injury that  permanently prevents him from working at full capacity.  Back injuries are the most common problem in this category, but shoulders, knees, hearing and amputation of limbs also can fall in this group.

The fact that the injury left you “partially” disabled means the doctor believes you can return to work in some capacity. Many times, the job available is lower on the pay scale, but there is a formula used to help make up the difference between what you were making before the injury and what you are making at the new job.

Permanent Total Disability (PPD)

This is the one impairment that is exactly what it sounds like: You are totally disabled and there is no expectation that you will ever recover and go back to work. Workers in this category can receive annual payments for two-thirds of their wages and medical care throughout their lifetime or work out a settlement for a one-time payout.

Ideally, no worker would ever have to go through the examination process to find out how severe an injury is and whether it will cost them a job. Unfortunately, accidents do happen everywhere, especially in places of work.

It is wise to know your options BEFORE you get hurt so you don’t make a rushed, ill-informed decision on what steps to take if an injury occurs. Consult with your company’s Human Resources department about what benefits are available and what steps to take to make sure both sides come away with a favorable outcome.

If you’re not satisfied with the answers you receive, consult a workers compensation lawyer. Most offer free consultations to outline your choices.