Erroneous Ratings Data: Part I

Saturday, February 11, 2006 | 0

Brigham and Associates, Inc., has completed a national study of 2100 cases referred for rating review. This is a crucial study since the AMA Guides to the Evaluation of Permanent Impairment, Fifth Edition are widely used in workers' compensation, Longshore and Harbor Workers' Act, automobile casualty and personal injury cases to quantify permanent losses associated with injury or illness. The results are very significant: 80% of all ratings are erroneous, with 89% of the erroneous ratings being elevated.

This study involved the critique of 1445 cases and the assessment of impairment on the basis of file review of 655 cases. Of Fifth Edition whole person erroneous ratings (839 cases of 1037 cases critiqued), the rating by the original rating physician averaged 15.5% whole person permanent impairment and upon re- rating the corrected rating averaged 5.6% whole person permanent impairment. Impairment ratings must be based on objective data and assessed by skilled independent evaluators. Therefore, all impairment ratings must be critically reviewed.

In a seven part series we will provide you with a summary of the findings, present data regarding typical ratings and errors, discuss the causes for erroneous ratings, present "red flags" for detecting erroneous ratings and provide specific effective strategies to manage impairment evaluations.

The goal of our reviews is to determine if ratings are accurate and the probable impairment based on the available clinical information. If the original rating is judged to be incorrect by the expert reviewer and there is adequate clinical information to rate impairment, then the case is re-rated using the Guides criteria and the data provided. Each reviewing expert is a Certified Independent Medical Examiner by the American Board of Independent Medical Examiners, a Certified Impairment Rater, board- certified in occupational medicine by the American Board of Preventive Medicine, and has several years experience in clinical medicine and ratings. Therefore, typically the expert reviewer has considerable greater knowledge and skills in the use of the Guides than does the original rater. Each critique results in recording key data and preparing a written report. Although this is not a random sample, this large unique national database illustrates challenges encountered with ratings and provides unique insight to these cases.

As of December 15, 2005, 2100 cases were reviewed and entered into the database; 1445 (69%) of these were critiques of ratings that had been performed by another physician and 655 (31%) were independent ratings performed on the basis of medical records. The cases included 1103 cases reviewed in 2005, 602 in 2004 and 395 prior to 2004. Most of the cases involved the use of the Fifth Edition, this reflecting 1670 (80%) of all ratings reviewed or performed and 92% of the cases critiqued. The database was national and included workers' compensation, Longshore and Harbor Workers' Act, automobile casualty and personal injury cases. Cases from 44 different states were reviewed; 45% of the cases were from California (the Guides were adopted for use in workers' compensation cases in 2005 as a result of workers' compensation reform and enactment of California Senate Bill 899), 12% from Hawaii, 9% from Florida, and 37% from other states. Depending on type of case and jurisdiction the final ratings were expressed as a whole person or regional impairment.

The vast majority (98% of cases) were musculoskeletal impairment assessments, the most common being spine (36%), followed by upper extremity (31%), lower extremity (21%), and multiple musculoskeletal (12%). The most common region rated was the lumbar spine (17% of all cases).

Of the Fifth Edition cases critiqued 80% were found to be erroneous and of the Fourth Edition cases critiqued 79% were erroneous. Of the 567 California Fifth Edition cases critiqued in 2005, 78% were erroneous, and for non-California cases 84% were erroneous. Therefore the error rate seen in California with the introduction of the Guides is similar to that seen nationally; however 100% of the ratings reviewed in January-February 2005 were erroneous, this initially improved with error rates of 84% for March-April, 75% for May-June, and 73% for July-August, however then worsened with error rates increasing to 84% for September-October and to 87% for November-December. The error rate for Florida cases was a staggering 94%. The vast majority of Florida ratings were performed by treating physicians typically prior to the probable date of maximum medical improvement. Plaintiff-oriented physicians in Florida may be inclined to report permanent impairment; if no threshold injury is found, tortfeasors with personal injury protection coverage are immune from liability for most tort claims. (section 627.737(1), Fla. Stat. (1995))

The error rate was higher as the value of the original rating increased; for 1037 original ratings whole person Fifth Edition ratings critiqued, for ratings under 5% whole person the error rate was 57%, between 5% and 15% whole person the error rate increased to 86%, and between 16% and 25% whole person the error rate was 94%, and over 25% the error rate was 91%. Error rates for lower extremity ratings were less (72% incorrect) than for spine (81% incorrect) and upper extremity (80% incorrect).

In the next installment in this series we will present more of the results of this landmark study.

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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