What You Should Know About Handling Workers’ Compensation Claims

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A Glossary Of Relevant Terms For Workers’ Compensation Cases

Applicant. An applicant is an injured worker who applies for workers’ compensation benefits.

Applicant attorney. The applicant attorney helps the injured worker obtain appropriate care as well as a reasonable permanent disability rating, therefore compensation. Obviously it is in the applicant attorney’s interest to receive the highest disability award possible since the attorneys get paid a percentage of the disability award.

Defense attorney. Defense attorneys are interested in issues such as causation, apportionment and reasonable periods of temporary or total disability for which the employer and insurance company pays the injured worker. They are also interested in the final disability ratable award.

Claim adjustor. The adjustor works with the insurance company and their responsibility is to monitor the treatment that is being given to injured workers and either approve or send request for treatment to utilization review.

Utilization review (UR). This is a system whereby physicians review requests from the treating physician for treatment. Treatment in the State of California, per SB899 in 2005, has relied upon the American College of Occupational and Environmental Medicine, Second Edition, Practice Guidelines. These occupational practice guidelines from ACOEM are used by the California Workers’ Compensation System for evidenced-based treatment guidelines. Currently in California, there is a podiatry representative on the committee that is writing and reviewing the guidelines.

   Understandably, these guidelines are imperfect and in the field of podiatry, I find them especially lacking. Nonetheless, they are what we have to live with until the Department of Workers’ Compensation medical department comes up with specific guidelines for different professions.

Causation. Causation means that for an injury to be accepted as an industrial injury, it must arise out of employment during the course of employment. If employment, or work related activity, contributes in some way to a worker’s injury or impairment, then causation is considered to be work related.

   An example is a patient with diabetes, who may not know he or she had diabetes, who steps on a nail, gets an infection and loses part of the foot from osteomyelitis. This is considered to be a work related injury even though the worker may have had an insensitive foot and poor resistance to infection which contributed to an amputation. That leads to the next term.

Apportionment. Apportionment is a method whereby the evaluating physician, when the patient is finally considered to be permanent and stationary, having reached maximum medical improvement for all practical purposes, does a final ratable report. It is expected that the evaluating physician will apportion a percentage of the final disability to those factors that may have contributed to the final disability. This cannot be speculation but must be based on reasonable medical probability.

   Apportionment is a very difficult subject and that is why only those who have studied the topic and taken many classes qualify to be a QME or AME. In many instances, there are obviously no non-industrial factors of apportionment. In other instances, there are questionable non-industrial factors that the evaluating physician must consider.

Disability. This term relates to the injured worker’s ability to do their work or compete on the open labor market.

Temporarily/partially disabled (TPD). This means that an injured worker could be doing some work but not the job they were previously doing. They need modified work restrictions.

Temporarily/totally disabled (TTD). This means that an injured worker cannot be doing any work at all.

Impairment. This term relates to activities of daily living. It does not specifically relate to the injured worker’s ability to do his or her job or compete on the open labor market. The AMA Fifth Edition Guides is based on impairment.

Panel QME. An injured worker may wish to have a qualified medical evaluation to settle issues of treatment, causation or other issues regarding an industrial injury or medical care. These injured workers are not represented by an attorney and are allowed to have a panel QME.

   There are podiatry panels that an injured worker can choose. That podiatrist must evaluate the injured worker in that geographical location in which the injured worker applies for a panel QME. The panel QME decides issues such as whether or not a request for additional treatment by the primary treating physician is appropriate, if a request for surgery is appropriate or whether they feel a patient has reached a permanent and stationary/maximal medical improvement status, or whether they need additional treatment before they reach this point.

   Other issues are often for the panel QME to resolve by the claim examiner, the injured worker or attorneys if they become involved after the panel QME is chosen. In order to be a panel QME, you must be qualified by the State of California and pass a test. There are certain amounts of continuing workers’ compensation continuing education workers’ compensation hours per year required to maintain the QME status.

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Author(s): 
Steven I. Subotnick DPM, DC

Becoming a qualified medical evaluator in workers’ compensation cases may be a significant referral generator for your practice. Accordingly, this author offers a closer look at his experience with these cases, reviews pertinent points in the evaluation of these patients and key steps you can take if you wish to start seeing these patients in your practice.

   Over the years, I have found that assessing and treating patients in workers’ compensation cases allow you to see some pathology you may not normally encounter in the normal day-to-day caseload of a podiatry practice. I have also found that being involved in these cases provides a good source of patient referrals and enables you to forge relationships with other physicians who are involved in the treatment of injured workers.

   I started assessing injured workers for workers’ compensation cases approximately 20 years ago. At first, I treated a few injured workers. Then I was asked to become an independent medical examiner (IME) and was sent patients to evaluate for disability. I eventually became a qualified medical evaluator (QME).

   The state of California decided it wanted to have a pool of QMEs to evaluate for disability as well as other issues in the treatment of injured workers. It therefore created a QME system approximately 15 years ago. In order to become a QME, you had to take a test and be qualified by California’s Department of Workers’ Compensation.

   Some QMEs become agreed medical evaluators, who represent the insurance company, employer and the injured worker. They are expected to follow the worker’s compensation laws of the state of California. Agreed medical evaluators have more responsibility and they also get paid 25 percent more for their medical-legal evaluations.

   When I began treating workers’ compensation patients, referrals came from occupational medicine centers as well as attorneys representing injured workers and attorneys representing insurance companies and the employer (see the sidebar “A Glossary Of Relevant Terms For Workers’ Compensation Cases”).

Understanding The AMA Guide To Workers’ Compensation

   California’s disability evaluation guidelines previously evaluated injured workers. Currently, the state uses the American Medical Association (AMA)’s Guide to the Evaluation of Permanent Impairment, Sixth Edition.

   There is a section in the AMA Guides on the lower extremity. Chapters 1 and 2, which are considered to be the most important chapters, instruct the evaluating physician on how to go about his or her duties. Essentially, the key with this system is determining the level of impairment as opposed to disability.

   Previously, physicians used the term “disability” as per the Guidelines for Work Capacity in order to evaluate patients’ ability to compete on the open job market. The AMA guides use “impairment” to determine whether there is permanent impairment.

   The AMA wrote the guide to permanent impairment. There is no podiatry input. There is input from the American Orthopedic Association but no specific input from the American Orthopedic Foot and Ankle Society.

   Regarding the American College of Occupational and Environmental Medicine (ACOEM) Second Edition Guidelines for Occupational Medicine, membership in ACOEM is primarily for occupational medicine doctors and physical medicine doctors. There is no membership category for podiatrists. Therefore, there has been no podiatry input on the foot and ankle section.

   Needless to say, the lack of podiatry input in both of these books that are the standards for treating and evaluating injured workers in California is a source of frustration for the podiatrist who does this type of work.

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