Nobody wants a workplace injury or other accident to happen. When these unfortunate events do happen, having lots of information and facts on hand can help all parties work through the sometimes complex legal and insurance systems.
In these cases, it can be especially important to figure out how much someone has been injured. Are they unable return to work because of their condition? Are they injured but able to return to some type of different, lighter work? The answer to these questions is crucial when it comes to Social Security Administration (SSA) disability benefits, workers’ compensation claims and other possible benefits. Unfortunately, this is one area where disagreements often arise. An injured person may claim she can’t return to her tasks, but an employer may claim an employee can still come in to work and doesn’t qualify for extended disability benefits.
Who’s right? An impairment rating evaluation can help answer this question.
What Happens After an Injury?
When an injury occurs and it leads to legal or insurance claims, there is sometimes a question of what has happened and what injury has been sustained. In these situations, a number of tests and evaluations may be ordered to determine what happened and how seriously the worker is affected by an injury. For example, an independent medical exam (IME) may be ordered. This evaluation by a third-party medical professional of the person who’s injured determines what happened and what the injury is. A Functional Capacity Evaluation (FCE) may be ordered to decide what work tasks someone may complete after their injury. Other tests and evaluations may be needed, too.
Tests and evaluations protect all parties after an injury and help everyone achieve a resolution. An attorney representing the injured party may claim the injury is very serious and the person who owns the property where the injury occurred may claim the injury was minor. A medical professional provides an unbiased view of the injury, which helps settle disputes about what happened and allows a legal or insurance claim to move forward.
What Is an Impairment?
One issue that often arises after an injury is the question of impairment. Impairment is a problem that affects the functioning of a part of the body and makes someone unable to use their body the same way they did before the accident or injury. It can include physical impairments or mental impairments caused by injury or illness. Impairments can be permanent or temporary, severe or mild.
Impairments – and the way they are evaluated – can affect a person’s ability to perform their work and can therefore have a big impact on benefits, compensation and Social Security claims.
When considering impairment, it’s important to keep two distinctions in mind:
1. Permanent vs. temporary impairment
2. Partial vs. total disability
Permanent impairment gives workers the ability to pursue longer and larger benefits. Permanent impairments are also subject to impairment ratings, which place the impairment on a scale and quantify the injury. Total disability situations can also result in more compensation for a longer period of time.
The terms disability and impairment are sometimes used interchangeably, but when it comes to benefits they mean very different things. Disability refers to limits and restrictions on a person’s ability to complete tasks, while impairment refers to the issue affecting the neurology or physical condition of the person.
It’s important to keep these terms in mind because sometimes the two are mutually exclusive. For example, someone who works as a postal employee may sustain a permanent back injury. The condition of his back is the impairment while his disability may refer to the inability to drive and to carry mail bags. Another person with the same impairment affecting her back might work at a desk job. She may not be considered disabled, because she can continue her work in the office. She might not qualify for the same long-term benefits as the postal worker because she is not prevented from working.
While most workers are honest about their injuries, insurance fraud and mislabeling are very real concerns for employers and insurers. Some workers exaggerate their injuries and may claim benefits that don’t rightfully belong to them, increasing insurance costs for employers and others. In other cases, it‘s difficult to quantify the level of pain or how much a worker has been affected by an injury.
This is where impairment ratings can make a world of difference.
What Is an Impairment Rating?
A medical impairment rating is completed by an independent professional in an appointment known as an Impairment Rating Evaluation (IRE). The rating gives a percentage number – between 0 and 100 – to the level of impairment, so the worker, employer and insurer can all understand how much the worker has been injured and how much the impairment will affect work. The results of the medical impairment rating determine how long a person might get benefits, how much compensation he might receive and whether he’s expected to return to work.
If the medical impairment rating shows a worker can return to work at a lower-paying and less stressful job, she is considered partially disabled. The rating can be used to apply for benefits to make up for the income loss. If a worker is unable to return to work, she may be considered totally disabled. A medical impairment rating can be used to help her secure benefits to pay for everyday expenses.
An IRE is performed after someone has received 104 weeks of benefits after an injury. The impairment must be considered permanent and the patient must have reached what is known as maximum medical improvement in order for an IRE to happen. At this point, a doctor may simply tell the patient he won’t improve more. The focus will turn to managing the condition. A permanent impairment is stable and unlikely to change for at least a year.
For example, if someone has suffered a serious brain injury at work, doctors will initially try to help the patient recover as much function as possible. After some time, though, doctors will decide the patient has reached maximum medical improvement. The patient, though, might still not be back to the same physical or neurological level he was before. He may still have mobility problems or trouble remembering, but the patient is stable and doctors don’t expect more improvement in the next 12 months. The impairment is, at least in part, permanent.
One of the more important things that will arise out of the IRE is determining the extent of the disability. Can the employee return to work and earn the same income, or does he need to take on a less demanding job because of the injury and take a pay cut? The answers to these questions are very important because they decide the benefits a patient may be eligible for. If an IRE determines that a worker has a rating of less than 50 percent, then the worker may be limited to benefits for no more than 500 weeks. If the rating is more than 50 percent, the employee may be able to continue getting benefits for as long as he’s needed.
Each state uses a slightly different impairment rating guide and a different system of compensation for injured workers, but the rating is the basis of every state’s disability and workers’ compensation benefits system.
When Are Medical Impairment Ratings Needed?
Any time a worker has been injured to the point where she has been getting benefits for 104 weeks, a medical impairment rating is needed. Without the rating, a worker might not be able to get all the benefits and compensation she may be entitled to. Without a rating, employers and insurers may have no way to verify just how much a worker is injured and whether the employee can return to the workplace.
Medical impairment ratings are needed as part of the long-term benefits claim process. They can also be used effectively in case of disputes. They can be used to determine the extent of a worker’s or claimant’s injury in cases where it’s in question. If you are concerned about fraud or if a dispute arises, a medical impairment rating can help resolve the issue.
One common problem that arises is that an employee does not see eye to eye with insurers or employers about the impairment rating. A worker may choose to dispute the findings of an impairment rating evaluation. He may allege, for example, that the IRE was performed incorrectly or that the physician conducting the evaluation was not qualified. In some cases, an employee is found to be partially disabled through medical impairment ratings and may be denied further benefits and the employee may appeal the decision, claiming that the doctor at the IRE submitted the wrong forms or made a mistake. Resolving this dispute may require additional medical impairment ratings to determine whether there is any merit to the claims.
If you need a medical impairment rating, it’s important to work with service providers who are capable of handling these sometimes complex evaluations. An employee can’t be ordered to get an IRE more than twice a year and there are many claims that can be used to dismiss IRE findings. For example, an IRE can only be administered to someone who is permanently disabled, which is defined as someone who is at maximum medical improvement, meaning their condition is not expected to improve in the next year. However, if the employer is scheduled for surgery or another medical procedure within the year, this can be used to claim that an IRE is premature or is not accurate.
To avoid these and other problems, consider contacting The IME Care Center if you need an IRE or medical impairment ratings. The professionals at The IME Care Center know how to make your impairment rating evaluation results compliant with current state laws and will conduct careful reviews of medical records to ensure that the ratings are accurate. If you need impairment ratings, contact The IME Care Center today to find out more about our services.
Workers Compensation and Medical Impairment Ratings: Understanding the Connection
Workers’ compensation is meant to protect both employers and employees in the event of workplace injuries. This insurance – paid for by the employer – is paid out to injured workers. If a medical impartment rating is more than 50 percent, the worker is considered to have a total disability, meaning he cannot return to work. In this situation, workers may keep claiming workers’ compensation benefits with no time limits.
If a medical impairment rating is less than 50 percent, the worker is said to have a partial disability, which may mean he or she is eligible to return to work in some capacity. However, a worker with a partial disability can still claim workers’ compensation – for up to nine and a half years (500 weeks), in Pennsylvania. Obviously, the types of benefits received depend on a workers’ compensation impairment rating scale, which can help everyone decide the extent to which an employee is hurt.
If a worker has a permanent, total disability, she will usually get disability payments for 104 weeks through workers’ compensation insurance. After this period of time, the insurer can ask for an IRE to evaluate whether the injury or impairment has changed. The doctor at the IRE will use the American Medical Association, Guides to the Evaluation of Permanent Impairment, Sixth Edition to determine the level and extent of the impairment.
Understanding the Impairment Rating Process
Whether trying to evaluate the level of a workers’ compensation permanent impairment or whether trying to determine whether a worker qualifies for further benefits, the impairment rating system is pretty straightforward. Employers and insurers must follow the workers compensation impairment rating guide for their state. The process is usually as follows:
1. The worker will receive a letter requesting attendance at an IRE. This will happen after the employee has been receiving benefits for 104 weeks.
2. The employee will make an appointment to get the IRE.
3. The worker will arrive at the IRE and be examined by a doctor. The physician will examine the patient and look at his or her medical records. Medical tests may be necessary as part of the IRE.
4. The doctor will use standardized guides to place the worker on the workers compensation impairment rating scale. This is usually a percentage. A worker with a 0 percent rating is expected to do any basic tasks with no problem and is considered to have no impairment. A worker with a rating of more than 50 percent is considered totally impaired and likely has problems performing basic everyday tasks. In order for the IRE to be considered valid, the physician administering the IRE must use the latest version of the Guides to the Evaluation of Permanent Impairment to determine the exact disability rating.
5. The doctor will create a report of the findings and send the official rating to the insurer. The worker will also be informed of the results of the IRE and how this might affect benefits.
6. The worker will be given a specific period of time to appeal or challenge the results of the IRE if she feels the rating is inaccurate.
Where Can I Turn for an Impairment Rating Evaluation?
If you need medical impairment rating services, contact The IME Care Center. We specialize in IMEs and IREs. Our team of professional medical consultants is at your disposal and our range of services is designed for busy organizations and professionals. We are localized in and proud to serve the entire Central Pennsylvania area, so if you need fast, reliable IREs in Camp Hill, Carlisle or surrounding Pennsylvania communities, contact The IME Care Center. Our certified health care professionals and board-certified physicians know how to meet the current impairment rating guide and how to conduct compliant impairment rating evaluations.