Erroneous Ratings Study: Part III

Saturday, March 11, 2006 | 0

by Chris Brigham, MD

In the prior article we discussed our national study of 2100 impairment rating reviews and presented our findings: 80% of all ratings reviewed were erroneous, with 89% of the erroneous ratings being elevated. In this article we will start to explore some of the causes of erroneous ratings.

There are many cases of erroneous ratings, including bias, differences in clinical and causation assessment, and misapplication of Guides criteria, either through lack of knowledge and skills in rating impairment or intent. The nature of the errors is such that most erroneous ratings will be higher, rather than lower. Most medical schools and residency training programs do not include instruction on the assessment of impairment, disability, or causation. Therefore many physicians lack an adequate ability to assess these and other medicolegal issues.

The principles of assessing impairment are provided in Chapters 1 and 2, however it appears that often physicians have not become familiar with the rules presented in these chapters, and rather focus their attention on chapters specific to the region they are rating. Chapter 2, Practical Application of the Guides, is a particularly important chapter, not only for rating physicians, but also for attorneys. This chapter specifies rules and standards for the impairment evaluation. It also provides superb content for an effective cross-examination of a physician who has performed an erroneous rating. Section 2.1 defines impairment evaluations, Section 2.2 discusses who performs impairment evaluations, Section 2.3 identifies the roles and responsibilities of the examiner, Section 2.4 explains when ratings are performed, Section 2.5 provides critical rules for the evaluation, and Section 2.6 outlines standards for reports.

Failure to follow the defined procedures will result in an erroneous report. Section 2.6 Preparing Reports provides detailed standards for reports. Failure to follow these standards will result in a questionable report and rating.

The rating physician must be "independent and unbiased". This can be challenging for any evaluator, however it is more likely to be problematic for the treating physician since there is an inherent patient advocacy role. (Barth RJ, Brigham CR, Who is in the better position to evaluate, the treating physician or an independent examiner?, Guides Newsletter, November - December 2005). The Guides state on page 18 "An impairment evaluation is a medical evaluation performed by a physician, using a standard method as outlined in the Guides to determine permanent impairment associated with a medical condition... The physician's role in performing an impairment evaluation is to provide an independent, unbiased assessment of the individual's medical condition, including its effect on function, and identify abilities and limitations to performing activities of daily living as listed in Table 1-2."

A skilled independent medical evaluator typically spends more time with a patient than a treating physician at a single visit, and therefore may obtain clinical information not known to the treating physician. It is probable that the treating physician will not consider alternative or new diagnoses at the time of rating. It is possible that the treating physician will causally relate problems to an injury if this appears advantageous to the patient and/or the physician.

For example, if a treating physician receives referrals from plaintiff counsel it is not unexpected that this physician will causally relate problems to the defined injury and may inflate a rating. A treating physician caring for a patient in a managed care situation may be more likely relate a problem to an injury if this provides an additional source of revenue. The treatment role may influence when the physician defines maximal medical improvement (MMI), i.e. at discharge from care the physician may be inclined to define the patient as ratable, even though it is probable that the patient is not yet at MMI. A treating physician may want to increase a rating, particularly if the impairment number does not appear to reflect a level of perceived disability.

Brigham Walker provides training for Claims Professionals, Attorneys, and Medical Professionals on apportionment, use of the AMA Guides, California's new PD Rating System, and all of the areas noted above.

Please contact Mindy Brigham for further information on training and resources. Call 619-299-7377 or mbrigham@brighamassociates.com.

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