Posts Tagged ‘Independent Medical Review’

Disability Levels ~ How The Veterans Administration Evaluates Cases

Written by Maurice Abarr on . Posted in Veterans Disability

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The VA has awarded you a service connection for PTSD. Now, it will review the most current clinical evidence available to it so as to assess how the severity of your symptoms impairs you—including your ability to work and your degree of social function. A schedule is used with definitions and percentages that have been set by VA regulations. They have established Diagnostic Codes (DC) for a range of psychiatric (and medical) disorders. Provision is made for the degree of severity of related symptoms. From this, a corresponding disability percentage is assigned. Typically, the VA evaluates the level of psychiatric disability under common criteria, irrespective of your specific diagnosis. This includes PTSD. You can share this information with your psychiatrist and request a report or opinion letter describing your disability or impairment that you can submit to the VA.

It’s worth noting that even though the severity of your symptoms do not satisfy the diagnostic criteria for a 100% rating level, you may qualify under a different VA regulation that permits them to compensate you at the 100% level—insofar as the medical evidence demonstrates that you are unable to obtain or maintain gainful employment and that this is a consequence of your service-connected PTSD. This is called, a TDIU or IU. It stands for “total rating on the basis of individual un-employability due to service-connected disability.”

In ascending order, these are the definitions and percentages (rating levels) the VA uses for mental disorders:

0%: A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication.

10%: Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication.

30%: Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events).

50%: Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships.

70%: Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships.

100%: Total occupational and social impairment, due to such symptoms as: gross impairment in thought process or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name.

The Bottom Line: If all of this sounds a bit daunting, please don’t worry. My staff and I understand it. We’re uniquely qualified to guide you to a fair and equitable outcome that’s based on your unique circumstances. Feel free to contact us for a free case evaluation.

A Change In Perspective: Settlement Of Future Medical Benefits

Written by Maurice Abarr on . Posted in Workers Compensation

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As I have alluded to in previous blog articles, the process an injured worker in California must go through in order to access medical care has become a maze of tedious regulations and timelines. It seems that the employer and insurance carriers’ “due process” rights are being given a greater priority than simply providing medical care to injured workers.

Easily 20% of my time (and probably 35% of my staff’s time) is now spent dealing with Utilization Review(s) (UR) denying our clients access to medical care. Before 2013, we had to go to a Qualified Medical Evaluator (QME) from a Panel of three doctors issued by the Division of Workers’ Compensation Medical Unit in Oakland, California. That process would ordinarily take up to three months and then we might still need to go to a hearing which would take another one to two months. In a word, maddening.

In the latest “reform” of the Workers’ Compensation laws near the end of 2012, the Panel QME process was eliminated for deciding “medical necessity” disputes (i.e., Should the injured worker get the treatment his treating doctor prescribed or not?). Instead, a new process called Independent Medical Review (IMR) has been put in place. IMR is conducted by a company called Maximus, a large organization that has been doing reviews of medical-necessity disputes for the federal government and private health insurers for many years. The reality of this new process is:

  • The name of the doctor doing the review is not disclosed.
  • There is almost no opportunity to appeal an adverse IMR decision (which upheld the UR decision to deny the injured worker the care his doctor prescribed).
  • Even if you do appeal—and manage to prevail—all that happens is that your issue is put through the IMR process all over again with a different reviewing doctor.
  • The injured worker is “stuck” with that denial of medical care for 1 year, unless there has been a material change in circumstances.

It appears that at least 70% of the UR denials of medical treatment are being UPHELD by the IMR process. In my experience, the percentage is even higher.

For more than 30 years Workers’ Compensation practice, I have generally urged my clients to hold on to their rights for future medical care under the Workers’ Compensation system and not settle those rights (i.e., “sell their rights to future medical”). Because of this latest IMR process, my advice has evolved. There are still some clients with medical needs that have little likelihood of coverage through other means (e.g., Medicare). For them, I believe it’s prudent to retain their rights to future medical in Workers’ Compensation—despite the problems we see with the IMR process.

In general, my opinion now is: Settle the future medical. Get what you can out of the Workers’ Compensation carrier or claims administrator and look for alternative means for medical coverage outside of the Workers’ Compensation system. The Workers’ Compensation system, especially with respect to current and future medical care, has been reduced to a farce.

The only rational approach is to get out of the Workers’ Compensation system as quickly as possible. There is little, if any, advantage to remain in the system as currently constituted for your future medical care.


NOTICE:  Making a false or fraudulent Workers Compensation claim is a felony subject to up to 5 years in prison or a fine of up to $50,000 or double the value of the fraud, whichever is greater, or by both imprisonment and fine.


Written by Maurice Abarr on . Posted in Workers Compensation

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Senate Bill 863 [SB 863] was rushed through the legislative process in about 3 days during the end of August, 2012. In September, Governor Jerry Brown approved it. This new body of legislation will have impact (some negative, some positive) on all pending cases that have not been resolved by December 31, 2012. The new laws will likewise impact new cases with Date of Injury on or after January 1, 2013.

The Good News
Overall, the Permanent Disability for Date of Injury on or after 1-1-13 will increase. Looking at all possible effect upon the range of all cases, the average increase will be around 30%.

The So-So News
As of 1-1-13 (for cases with that date of injury or later) all disputes regarding Medical Treatment will be submitted to “independent” doctors to resolve promptly (i.e., within 30 days from date they receive dispute). This process will be called Independent Medical Review (IMR). We will not learn the identity of the doctor reviewing a particular dispute. We will have to wait and see exactly how “promptly” and FAIRLY these doctors resolve medical treatment issues. It could be a good thing…getting issues resolved much quicker than the current Panel QME process (which frequently takes 6 months or longer to be resolved). The IMR process will also apply to all cases as of 7-1-13.

The Bad News
Most claims for psychiatric, sleep or sexual-dysfunction disorders that source from a physical injury (i.e., your back is hurt, you have chronic pain, and you develop depression with the chronic pain), can no longer be compensated in Permanent Disability benefits. You can be treated for these symptoms—provided, however, that the IMR doctor (see above) approves it when the carrier refuses to provide the treatment.

Regulations implementing these new laws are currently in process. They are likely to tweak and clarify some of the new laws.


NOTICE:  Making a false or fraudulent Workers Compensation claim is a felony subject to up to 5 years in prison or a fine of up to $50,000 or double the value of the fraud, whichever is greater, or by both imprisonment and fine.

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