Get the skinny on these commonly used workers' comp terms, abbreviations and acronyms to help you eliminate confusions.Work comp is one of the acronym heavy types of insurance coverages. We've got IME, DOI, ROI. Read this expert guidance provided by our expert in a health system conference to know more.
So first reported injury is often referred to as ROI. In many cases, the state requires that an employer first reported the injury on a particular form. And particularly when it's an employee’s occupational injury or disease that results in incapacity from work of one day or more.
So it's again, a state regulation. Most states along with the federal work comp have a specific form that they want to have used for that first report of injury. We'll sometimes see denials as providers particularly of those that are seeing patients is a first line of treatment for an injury. Our expert mentioned in a billing healthcare event that walk-in clinics or urgent care or Occ Med will get a denial back saying the employer has not filed a first report of injury form.
The DOI is the date of injury. It's a date andsome people go, “Well, duh”. Well, it's the date of work related injury occurs for occupational injuries. The issue comes up is what happens when we have an occupational disease like repetitive trauma, carpal tunnel. We don’t have a data of injury. It's over accumulation over a period of time.
Often it is looked at if maybe when the patient’s symptoms first occurred when they have an incapacity of work due to the disease. So that's a little bit more of a gray target.
Also there are the issues of the date of injury if it's an unobserved injury. So a patient reports, “Oh, six weeks ago, I had a slip and fall at work. And now I have a backache.” That always raises questions as to that date of injury. When it has been unobserved there's no one else there to attest to it.
MMI, you'll hear that frequently. It's actually when that patient has reached that condition where they're healed from a compensable injury or occupational disease to the fullest extent that they're expected to heal.
In many of the cases, providers have an inability to make that patient whole again. For example, if a patient has a catastrophic injury and it would be impossible for a physician to make that patient whole or get them back to that pre-injury state, if they've had above knee amputation because of that injury.
We can't give them their leg back. And so, at some point where it is likely that the patient is not going to get any better, that's when we're starting to look at the determination of MMI. It's often one of the sources of litigation of the attorneys becoming involved. The patient may feel that they're not at MMI.
And some providers erroneously don’t understand the state regulations for treatment guidelines, et cetera and place the patient in too soon at MMI.
This is what's anatomically or physically wrong with the individual. It's often confused with disability. It's a means to assign a numerical rating for whatever type of bodily function has been lost. Often, it's specified as a percentage, either a percentage of a limb or it's calculated into a whole body percentage of impairment.
In contrast, disability is that's representing how that impairment is combined with the patient’s age, their educational background and et cetera. And looking at the factors for that employee’s ability to return to work.
So again, impairment is just one part of assigning overall disability. And so, different states use different disability healthcare guidelines or additions. And so, that's something to be aware of that if your providers being asked to calculate an impairment and a disability, we have a different additions that may be used.
And there are 14 states that use the 6th Edition of the AMA guideline such as Oklahoma, Tennessee and Pennsylvania. There are 13 states that use the 5th Edition such as Georgia, Iowa and Washington. There are eight states that use the 4th Edition. That's Texas, South Dakota and Maine. There's only one state that currently is used a revised 3rd Edition. That's here in Colorado.
There are some that have state specific. They don’t use the AMA healthcare guidelines. They actually have their own state. And for example, Florida, New York and Oregon. And we actually have six states that actually don’t specify in their rules or regs of any required edition to be used such as South Carolina, Virginia or some of those not specified states.
Looking at disability evaluation, we may have a provider. Our provider may see a patient for a disability evaluation and they are not a treating physician. They are actually consulting physician. That may be because the treating physician is not credentialed with the state, with that jurisdiction to perform disability evaluations.
Most states have different requirements for providers to perform these disability evaluations. They may have to take an exam. They may have to meet certain continuing education requirements, et cetera. And so, not all providers, is it legal within the jurisdiction of that work comp to perform that disability eval.
IMEs, Independent Medical Eval exams
This is typically requested by another party. It's either typically the respondent in the case. So it may be, you know, an insurance company. It may be the work comp commissioner so a division requested, suggested our expert in a medical billing conference. It may be an attorney requesting on behalf of the employee.
It's conducted by a physician and this is a key point, other than the claimant’s attending physician as per healthcare rules. So this is a physician that typically sees the patient, reviews records, looks at it and makes a determination.
In many cases, there are interrogatives or specific questions that are included in that IME usually addressing such things as causality. Is the patient at MMI? What were they looking at a percentage of impairment, et cetera.
Also, it's determining the verification that the actual entry is work related. The medical necessity of treatments, maybe we've got a treating physician that’s asking for authorization of a certain procedure and the payer is denying it. And so, we've got an IME to look at do we need to continue or have an authorization for those services.
It's typically requested when the patient or payer disagrees with an MMI. So they don’t agree that they're at MMI or additional an impairment rating. That's a very common time.
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