The adjuster is the insurance representatives that supervises and approves your initial evaluation, diagnostic studies. Any duplicate testing must be approved by a pre-authorization company. The injured body part is the critical basis for an approved treatment or a denial. This goes back to the original injury documentation given and the symptoms reported that affect the various body parts.
Activity of Daily Living (ADL)
A person’s ability for self care, personal hygiene, eating, preparing food, communication, speaking writing, sustaining a posture, standing, sitting, caring for the home, personal finances, walking traveling, moving about, recreation, social and work activities.
Benefit Review Conference (BRC)
If a dispute for treatment occurs, the injured worker should contact first the adjuster to see if resolution can be obtained. If resolution is not reached, the injured worker should contact OIEC. TDI-DWC may schedule a BRC which is an informal attempt to obtain resolution regarding the disputed claim. Prior to going to the BRC, contact OIEC so you can have an Ombudsman represents you if you do not have an attorney.
The Maximum Benefit Amount is the maximum amount of weekly benefits an employee may receive. This maximum benefit amount may not exceed the state average weekly wage (SAWW). Below is a rough schedule of income benefits. If you are not satisfied with benefits received, you should contact DWC or OIEC.
A compensable injury is an injury occurring during the performance of your regular job duties that has been appropriately reported and documented. The first determination of compensability is designated by the insurance company adjuster and not DWC. If the injured worker is not satisfied with the decision of disputed compensability, they have the right to contact OIEC and discuss their concern. This will entail a conversation between OIEC, the adjuster , a possible Benefit Review Conference or a Contested Case Hearing.
Compensable body part
A compensable body part is the body part that the physician is allowed to treat as a result of the injured workers work related injury. The mechanism of injury reported will dictate which body part is approved for treatment since it must match the injury report. For example, back pain that occurred after you slammed your finger with a hammer, will not be treated because the back pain will be considered a coincidental problem not related to the mechanism of injury. This underlies the importance of immediately reporting and accurately documenting the original injury and symptoms experienced. The treating or consulting physicians cannot treat a body part that is not deemed compensable.
Contested Case Hearing (CCH)
A contested case hearing is a formal hearing held by TDI-DWC between the injured worker and the insurance carrier when the informal BRC has not been successful in resolving a dispute for treatment. Prior to attending the CCH, the injured worker should contact OIEC so that an Ombudsman will be assigned to represent the injured worker, if the injured worker does not have an attorney.
Case manager (CM)
A case manager is typically a registered nurse or has specialty training in medical, vocational or rehabilitation services and can be a Certified Case Manager (CCM), Certified Rehabilitation Counselor (CRC), Certified Disability Management Specialist (CDMS). The CM is hired by the employer or the insurance carrier to assure the injured worker is receiving timely accurate treatment that is appropriate for the injury sustained. The case manager is there to confirm the treatments rendered are appropriate for the injury and that the treatments are improving your condition and to communicate to all having a need to know basis, about your clinical status so as to move your progress along. The case manager acts as an intermediary between the adjuster and medical provider to get approval for your treatment, and facilitate the approval of consultants with specialty training that you might need for further treatment.
A consulting doctor is normally a specialist that your treating doctor requests an evaluation from. ROC is commonly asked by treating doctors to assist in treating and guiding the patient treatments because injuries most commonly involve the musculoskeletal system requiring an orthopedic surgeon with expertise in the upper extremity, lower extremity or spine.
Causation means that a physical, chemical or biologic factor contributed to the occurrence of a medical condition. Causation is looked at both medically and non-medically. Documenting causation or aggravation of symptoms will depend on what has been documented. Estimation of causation requires confirmation of exposure, its severity and the timelines involved.
Department of Assistive & Rehabilitative Services (DARS)
Established to assist all Texas with disabilities of all kinds including an injured worker who has reached maximum medical improvement and has a permanent disability. It is not necessary however, to wait to be referred to DARS if the treating doctor believes the injured worker will not likely return to the previous employment. The OIEC can assist in referring the injured worker to DARS and DARS has their own website.
A disability is the inability of the injured employee to perform certain functions, in this case, the job description the employee was involved in prior to an injury event. It must be differentiated between Temporary and Permanent Disability. The presence of a temporary disability determines whether or not the injured worker is entitled to receive Temporary Income Benefits (TIB) which is determined at the beginning of the injury claim. At Maximum Medical Improvement, the treating doctor will address whether the disability and work restrictions are permanent, which requires the objective demonstration of permanently altered anatomy preventing the worker from adequately performing personal, social or occupational demands. If a permanent disability after maximum medical treatment has been reached cannot be improved by assisted devices, then they are deemed permanently disabled in relation to job performance.
The law defines a permanent disability as the inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death or has lasted or can be expected to last for a continuous period not less than 12 months. To meet the definition of disability, an individual’s impairment or combination of impairments must be of such severity that he or she not only is unable to do the work previously done, but also cannot perform any other kind of substantial gainful work considering the individual’s age, education and work experience.
Designated Doctor Examination
Can is requested by the injured worker and or his representative, the insurance carrier or DWC to settle a dispute. If requested by the Insurance carrier, it must first be approved by DWC and scheduled by the DWC. The Designated Doctor is a licensed physician, authorized by TDI-DWC to render a second opinion and recommend a resolution of:
This type of review is usually mandated by the TDI-DWC to resolve questions about a compensable body part, appropriate care if it has lasted too long, maximal medical improvement and impairment rating accuracy. A Designated Doctors opinion is given presumptive weight regarding the MMI status and impairment rating.
The capacity of an individual to meet the demands of a job and the conditions of employment associated with that job as defined by an employer, with or without accommodations for a adaption.
Functional Capacity Evaluation (FCE):
An FCE is a measure of your capacity to accomplish specific tasks that may be required during the performance of a job. A qualified staff person documents your level of performance during the evaluation and a final report is elaborated with this information. The test takes four hours to perform. Effort during this test is also documented.
An individual is handicapped if he or she has an impairment that substantially limits one or more of life’s activities. A handicap exists when there is a barrier to accomplishing tasks or life activities and an accommodation which may include modification of the environment to overcome the deficit does not exist. A disabled individual is not necessarily handicapped if an accommodation to the environment or assisted device can help them accomplish a specific task. If an assisted device or environment is not able to be accommodated, the individual is both disabled and handicapped.
A potential source of danger.
Independent Medical Examination (IME)
An Independent Medical Examination is normally obtained by an injured workers attorney to provide an expert medical opinion regarding causality, mechanism of injury, disability, employability or functional capacity to name a few.
Impairment is the loss, loss of use, or derangement of any body part, system or function. It is called a permanent impairment when the medical condition is no longer changing, has become static, and will not change by more than 3% in one years time, with our without medical treatment.
Impairment Income Benefits (IIBS) and Impairment Rating:
When you are insured by a DWC insurance carrier, it is a number obtained when you have reached maximum medial improvement that allows you to be paid income benefits. The calculation is based on the patient’s level of function as measured in sensation, motion and when indicated strength and is performed according to rules and tables provided by the AMA guidelines. The results are expressed as a percentage of the total body affected and follow charts and tables based on clinical measurements. The exam is performed during your final exam and cannot be influenced by your doctor. The final number obtained from the impairment is then translated into a financial number that reimburses the patient approximately 3 weeks of temporary Income Benefits (TIBS) per percent of impairment based on Average Weekly wage (AWW) for the 13 weeks prior to the date of injury and at 70% of the AWW. These benefits are not included in earnings for the IRS and are different from the Temporary Income benefits received during your convalescence.
Letter of Clarification (LOC)
An LO C is a letter requested by the carrier or an injured worker’s attorney and is drafted by the Texas Department of Insurance, Division of Workers Compensation (TDI-DWC) and sent to a designated doctor requesting clarification on certain issues in a report the doctor submitted following the examination of an injured employee.
Letter of Medical Necessity (LMN)
When a denial for treatment is received from an adjuster, it is typically because the treatment does not fall under the compensable body part, the injury in question has not been accepted or a peer review doctor or IME doctor has not agreed with the recommended tests or treatment. The treating doctor or the consultant doctor will write a letter of medical necessity which attempts to further explain and support the request that was denied.
Liability for medical services
This is the sole responsibility of the carrier prior to final disposition of a claim to pay fair and reasonable charges for necessary medical services rendered to an injured worker. This is the responsibility of the injured worker if:
(A) After final disposition of a claim for services that are not related to the compensable injury; (B) for services not related to the compensable injury; and (C) for services rendered after the liability of the carrier has been terminated.
Maximum Medical Improvement:
There are two types of Maximum Medical Improvement:
Clinical Maximum Medical Improvement
Clinical MMI has been reached, when the patient has reached the optimal function achievable. This assumes that reasonable treatment has been provided and sufficient time has passed for all involved tissues to heal and further improvement is not likely to occur over approximately over a 12 week period in spite of appropriate non-operative and operative treatment provided. The conditions is thus stable and no more than 3% improvement over one year is expected to occur.
Mandatory Maximal Medical Improvement
Defines Maximum medical improvement occurring at 2 years (105 weeks) from the first time the worker has lost time from work.
Mechanism of Injury (MOI)-
The Mechanism of Injury (MOI) is a detailed explanation of how the injury occurred. It should specify the timing, the insulting force magnitude, force direction, and the position of the body during impact. It is also important to note immediate symptoms or changes observed. This information is important both in acute and chronic injuries.
Office of the injured worker Counsel (OIEC)
Is a state run agency that falls under DWC and represents and assists the injured worker through education, referrals to other agencies and in settling disputes by providing an Ombudsman.
The Ombudsman is a specially trained employee of the office of injured employee council created by TDI-DWC, who represents and assists free of charge, the injured employee when a dispute with an employerâ€™s insurance carrier occurs. The ombudsman can be contacted through the local DWC office or the central Austin office:
A peer review is a review of medical records to include: medical reports, diagnostic studies, medication history, mechanism of injury and compensability questions. A peer to peer is a verbal conversation between the peer review physician and the physician requesting a diagnostic study or medical procedure. The peer review’s intention is to obtain more information on your treatment to better understand why the request for such treatment is being made.
The likelihood or chance that an injury or illness was caused or aggravated by a particular factor is less than 50%.
The likelihood or chance that an injury or illness was caused or aggravated by a particular factor is more than 50%.
Required Medical Examination (RME)
The RME is requested by a carrier, DWC or a injured workers attorney to address if the medical care is reasonable and necessary unless a designated doctor appointment has been completed and then the RME doctor can address any part of the DD physician has addressed.
The percent probability that an adverse event will occur.
Social Security Disability
the social security administration (SSA) has national responsibility for the administration of the social security disability insurance program based on medical inability to perform gainful employment. Everyone who pays into the social security contributes to the social security Disability Trust Fund. The program provides cash benefits to disabled workers and their dependents who have contributed to the trust fund through the FICA tax on their earnings.
Supplemental Income Benefits (SIBS)
An injured worker is eligible for SIBS if he has received impairment equal to or greater than 15%. SIBS are not guaranteed and an injured worker must follow the Statute under Rule 130.102. The SIBS begin payment when payment from Impairment Rating ends (IIBS) and is given on a monthly basis. It is calculates as 80 percent of the difference between 80 percent of your average weekly wage (earned prior to your work-related injury) and your weekly wages (if you have any earnings or offered wages during this 13 week period) after the work-related injury. This form of assistance lasts for 401 weeks or 7.5 years. The injured worker is eligible to receive SIBS if they have demonstrated job searching if capable, have medical documentation why you cannot be employed, you demonstrate cooperation with DARS.
Symptoms an individual feels are described according to the type of symptom affecting the neurologic, vascular and musculoskeletal symptoms and can include pain, numbness, tingling, instability, locking, weakness, cold sensation, discoloration, or poor function. Symptoms are further characterized in severity based on the intensity and frequency the symptoms occur. Intensity is:
Temporary Income Benefits (TIBS)
The wages are accepted or denied by the insurance company/adjuster. If not approved, the injured worker has the right to contact DWC or an attorney.
A treating doctor is the doctor who is in charge of your medical treatment and work status determination. However, any physician involved in your care is required to submit a D73 work status form after you are evaluated by them. The injured worker must receive the DWC-073 form on the day of the exam and the employer and insurance carrier must receive it within 2 days. The treating doctor is responsible in obtaining consults, diagnostic studies, and therapy services, dictates your work status, designates when you have reached maximum medical improvement and obtains or orders an impairment rating at the end of your care.
Work Conditioning Program
The purpose of work conditioning is to restore a patient’s full duty capacity by evaluating the specific job description and then tailoring the rehabilitation program to address the flexibility, endurance, strength, and functional capacity for that specific job. Work conditioning is done four hours per day and typically for a four week period.
Work Hardening is a multi-disciplinary program that simulates specific work activities for the purpose of restoring physical, behavioral and vocational functions and has with it specific goals. Work hardening starts at four hours per day and ends with eight hours per day for a period of 8 weeks.
Work Type Categories