What is the Doctor’s Role

When it comes to performing impairment rating evaluations to determine maximum medical improvement (MMI) and impairment rating (IR), Doctors who are certified to perform impairment rating evaluations have different roles and restrictions and include:

• Treating Doctor Referred Doctor
• TDI-DWC Designated Doctor (State-appointed)
• Required Medical Evaluation Doctor

1.  Treating Doctor Referred Doctor

When a Treating Doctor requests an impairment rating evaluation, it must be performed by a doctor who is certified to perform impairment rating evaluations by the Texas Department of Insurance (TDI), Division of Workers Compensation (DWC). This certification requires specialized training and the doctor taking a rigorous test every two (2) years. This type of doctor is referred to as the Treating Doctor Referred Doctor. This doctor is required to request and review all of the available medical records, perform a complete examination and utilize the necessary guidelines to determine if and when a patient reaches maximum medical improvement (MMI) and a textbook, the AMA’s Guidelines to the Evaluation of Permanent Impairment, fourth edition, to see if the proper criteria applies to assign an impairment rating (IR).

A Treating Doctor Referred Doctor is only able to base these decisions on the accepted conditions (diagnosis) from the insurance carrier. Once all of the necessary records are received, the Treating Doctor Referred Doctor has 7 working days to complete the report and then copies of the report along with the TDI-DWC DWC-69 form, Required Medical Evaluation, are sent to the patient, the Treating Doctor, the insurance carrier and to TDI-DWC as well as to the patient’s representative, either an attorney or a representative from the Office of Injured Employee Council (OEIC). Once the patient receives the report, they should schedule an appointment with their Treating Doctor and representative to review the report.

Sometimes disputes arise in which conditions are accepted and this creates a dispute and disputes are typically addressed by a Designated Doctor or a Required Medical Evaluation Doctor.

2. TDI-DWC Designated Doctor

A TDI-DWC Designate Doctor is a state-appointment Designated Doctor who acts independently from th involved parties to a workers compensation claim. If you and your Treating Doctor disagree with a Designated Doctor’s report and findings, you are entitled to have an alternative impairment rating performed to dispute the Designated Doctor’s evaluation. This must be disputed within 90 days from the date that the patient, receive the Designated Doctor’s report. If you have not received this report within 2-3 weeks of the date of the evaluation, you need to contact the Designated Doctor and make sure that they send you a report and you should document all of this and the person(s) you spoke with about this issue. It is your responsibility to make sure that you have received all of the documentation and forms of your Designated Doctor evaluation.

A TDI-DWC Designated Doctor Evaluation (RME) is mandatory and the injured worker is required to attend the evaluation and if the injured worker does not attend without providing adequate notice in advance of the appointment, could have their medical and temporary income benefits suspended.

A Designated Doctor may be requested by the insurance carrier, the injured employee (through their representative), an order from TDI-DWC ,or be the TDI-DWC Insurance Commissioner in accordance with Labor Code §408.0041 and §408.1225.

Designated Doctors are asked to address an answer one or more specific issues including:

• Maximum Medical Improvement
• Impairment Rating
• Extent of Injury
• Return to Work
• Disability
• Return to work with SIBs (Supplemental Income Benefits)
• Other Issues

Maximum Medical Improvement

Maximum Medical Improvement (MMI) is a point where a patient’s condition(s) have improved to or reached a level where no further improvement is likely to occur, even with more treatment. For example, if a person were to lose their little finger, the patient is entitled to reasonable treatment for the injury but the finger is not going to grow back. After a reasonable degree of care has been provided and the patient’s clinical findings are not showing any additional improvement, then the condition reaches a point of their recovery termed MMI.

According to TDI-DWC, Maximum Medical Improvement (MMI) is defined as "the earlier of (a) the earliest date after which, based on reasonable medical probability, further material recovery from or lasting improvement to an injury can no longer be reasonably anticipated (aka, Clinical MMI); or (b) the expiration of 104 weeks from the date on which income benefits begin to accrue (aka Statutory MMI); or (c) the date determined as provided by Section 408.104."

Impairment Rating

The Texas Labor Code § 401.011(24) defines an “Impairment rating,” as “the percentage of permanent impairment of impairment of the whole body resulting from a compensable injury.” In addition, “The impairment estimate or rating is a simple number. It may be necessary to refer to the criteria and estimates in several chapters if the impairing condition involves several organ systems. In that case, each organ system impairment should be expressed as a whole-person impairment; then the whole- person impairments should be combined by means of the Combined Values Chart,” which is on page 322 of the Guides.

The Workers’ Compensation Act defines both “impairment” and “impairment rating.” Within the Act both terms are used. Further, these terms are not always used together. Texas Labor Code §401.011(23) defines “Impairment” is “any anatomic or functional abnormality or loss existing after maximum medical improvement that results from a compensable injury and is reasonably presumed to be permanent.”

The AMA’s Guidelines to the Evaluation of Permanent Impairment, fourth edition, define "permanent impairment" as one that has become static or stabilized during a period of time sufficient to allow optimal tissue repair, and one that is unlikely to change in spite of further medical or surgical therapy.” The Guides continue and stated that, “An impairment should not be considered “permanent” until the clinical findings, determined during a period of months, indicate that the medical condition is static and well stabilized.”

Once an injury, which may include one or more areas of the body, is determined to have an impairment, the injured site(s) an algometric process is used to determine what all of the injuries represent in term of the whole person. This means that the end result is a single number the represent the impact the injury(s) has on a person’s entire body and is expressed in a percent (%).

Extent of Injury

An extent of injury dispute involves a disagreement that the insurance has with the conditions, diagnoses or body parts that are claimed to be caused by, or naturally resulting from the accident or incident and describe the accident or incident that caused the claimed injury. This determination is complicated and the Designated Doctor must rely on the medical records, the injury description, the mechanism of the injury and other evidence-based medical information to make a decision of which conditions did or did not result from the patient’s work-related injury. This decision must be based on the evidence available. Sometimes it becomes difficulty to separate which injuries were present before the injury occurred (pre-existing or degenerative) and which injury(s) were the result of the injury. Complaints of pain and other symptoms are not evidence in the manner to justify a body part or condition resulted from the injury.

Return to Work

Sometimes a part to the claim would like to find out if an injured worker is eligible to return work and in what capacity. This is a return to work question. A patient may be back at work and working under restricted work duties and the requesting party, usually the insurance company, would like to know if the injured worker is able to return to their regular work duties at full-time duties. The Designated Doctor utilizes their examination and return to work guidelines (the Md Guidelines) as well as possibly additional testing to make this decision. Once the information is obtained, the Designated Doctor completes a TDI-DWC Work Status form, DWC-73, and includes with their report.

Return to Work with SIBs (Supplemental Income Benefits)

This is similar to a return to work question except that the Designated Doctor determines If the injured worker in able to work at any capacity and in the specific qualifying time frame or if is applicable to the 9th quarter (or a subsequent quarter) of supplemental income benefits?

Disability

This question concerns only issues about the ability of an injured worker to work as it related to the wages earned. The Designate Doctor is supposed to determine if the injured employee is unable to obtain and retain employment at wages equivalent to the pre-injury wage, as related to the work- related incident. The Designated Doctor will ask your current wage amount as well as the amount prior to the injury and determine if their employability has affected their wages. This is not a question that addresses an injured workers physical disability or dysfunction.

Other Issues

This question may address other issues or questions that an involved party would like to get addressed that is not covered in the above questions.

3. Post-Designated Doctor Required Medical Evaluation Doctor

A Post-Designated Doctor Require Medical Evaluation (RME) is an examination that is ordered by the TDI-DWC and authorizes the insurance to request a medical evaluation to resolve any questions or issues regarding the appropriateness of the health care services provided to an injured worker and to resolve ant issues pertaining to a Designated Doctor’s evaluation and determination regarding the injured worker’s injury as outlined in the Texas Administrative Code (TAC) and the Texas Labor Code (TLC). A Require Medical Evaluation (RME) is mandatory and the injured worker is required to attend the evaluation and if the injured worker does not attend without providing adequate notice in advance of the appointment, could have their medical and temporary income benefits suspended.