How Impairment Rating Evaluation Can Help in Workers’ Comp Claims
An IREuses medical records review and helps solve disputes in a workers’ comp claim related to a worker’s ability to return to work, and extended benefits.
MOS Medical Record Reviews 8596 E. 101st Street, Suite H Tulsa, OK 74133
Medical review services are useful to independent medical examiners evaluating the injury sustained by an injured worker at his/her workplace. In fact, it is especially important to understand the extent of the injury because it is on the basis of this that benefits are determined. Two important considerations in this regard when it comes to social security disability benefits, workers’ compensation claims, and other possible benefits are whether the worker is unable to return to work because of the health condition and whether they can return to some type of different, lighter work. The employer and employee may differ in this regard with the employee claiming she cannot return to her job and the employer claiming she can and therefore doesn’t qualify for extended disability benefits. The Post-injury Scenario and Impairment Rating Evaluation What happens after a worker sustains an injury at the workplace? An IME or independent medical examination may be ordered to understand how seriously the worker is affected by an injury. A functional capacity evaluation or FCE may also be ordered to decide what jobs the employee can do after his/her injury. The independent medical examiner should provide an unbiased view of the injury so that disputes can be settled about what happened. This helps to move a legal or insurance claim forward. Employers and insurers are very concerned about workers’ comp insurance fraud and exaggeration of injuries through which employees may claim benefits not due to them. Such practices increase costs for employers and others. Medical impairment rating or impairment rating evaluation (IRE) is used to address this situation. In this an independent medical professional would give a rating between 0 and 100 to the level of impairment. This will help the worker, employer and insurer to clearly understand the extent of injury and how much the impairment will affect work. This will also help determine how long a person may receive benefits, how much the benefits will be and whether he is expected to return to work. •
A worker whose medical impairment rating shows she can return to work at a lower paying and less stressful job is considered partially disabled. The rating will be used to apply for benefits to compensate the income loss.
•
A worker whose impairment rating shows she is unable to return to work is considered totally disabled. The rating can be used to help her secure benefits to pay for day-to-day expenses.
www.mosmedicalrecordreview.com
(800) 670 2809
Typically, an IRE is conducted after a person has received 104 weeks of benefits. An IRE will be performed only if the impairment is considered permanent and the patient has reached maximum medical improvement. The IRE helps to determine the extent of the disability. •
It helps decide whether the worker can return to his job and earn the same income or whether she should be assigned to a less demanding job because of her disability and receive lesser earnings.
•
A rating of less than 50% will result in the worker being limited to benefits for no more than 500 weeks.
•
A rating of more than 50% will entitle the employee to continue receiving benefits for as long as required.
Impairment rating guides vary among different states, and the system of compensation also differs. However, the rating is the basis of every state’s disability workers’ compensation system. In most states, the physician will refer to the AMA’s Guide to the Evaluation of Permanent Impairment to assign a rating. Permanent vs. Temporary Impairment and Partial vs. Total Disability The issue of impairment is important in a workers’ compensation claim. It is a problem that affects the functioning of a part of the body and makes someone unable to use that part in the same way as they did before the injury. These impairments could be mental as well and be permanent or temporary, severe or mild. The type of impairment can have a significant impact on the claim. •
Permanent or temporary impairment
•
Partial or total disability
Permanent impairments and total disability situations could ensure more compensation for a longer period of time. Impairment and disability are not the same with regard to benefits. •
Impairment is the problem that affects the neurology or physical condition of the person
•
Disability signifies the limits and restrictions on a person’s ability to complete tasks.
The Impairment Rating Evaluation Process ➢
The employee receives a letter requesting him/her to attend an IRE.
➢
The employee makes an appointment for the IRE.
➢
He/she will arrive for the IRE and be examined by a doctor. Examination would include physical examination, review of medical records, and medical tests if required.
www.mosmedicalrecordreview.com
(800) 670 2809
➢
The doctor will use the latest version of standardized guides to assign an impairment rating to the employee.
➢
The doctor makes a report of the medical findings and sends the official rating to the insurer. The employee also receives information regarding the IRE results and how it might affect benefits.
➢
The employee is allowed a specific period of time to appeal/challenge the IRE rating if he/she feels the rating is not correct.
The medical examiner performing the IRE must be especially cautious to assign the correct rating. Ideally, to assign a fair rating the following must be ensured. ➢
Review the patient’s medical history and medical records preferably with the support of professional medical review services. Using multiple sources of information will ensure objectivity and help avoid bias.
➢
It is important to ensure that the patient’s medical condition is stable and unlikely to change in the future even with appropriate treatment.
➢
The clinical information must be extracted from physical examination and medical records. To ensure consistency of this data, it can be compared with information from various sources. Any disparity identified must be resolved when possible.
➢
Whenever data is available, make use of medically accepted and scientifically procured data based on the patient’s normal functioning.
Given the importance of IRE rating, the physician should assign a rating derived from thorough and well-thought out observations. For a fair and just impairment rating, the patient’s medical documentation must be complete and reliable, and this also makes the process of medical records review very significant. The AMA Guides recommend that if the medical evidence is not sufficient to verify that an impairment of a certain intensity exists, then the physician should modify the impairment rating accordingly. In this case, the physician should describe the modification and explain the reason.
www.mosmedicalrecordreview.com
(800) 670 2809