by Don Harrison
Dealing with workers’ compensation administrators (or claims adjusters or attorneys) can be as frustrating as trying to decode a teenager’s text messages — KWIM (know what I mean)? This week, we thought we’d provide you a cheat sheet to help you make sense of the workers’ comp world.
Definitions of workers compensation terminology
Average weekly wage (AWW). AWW is used to determine the employee’s rate of temporary total or partial disability or permanent total disability. It is usually determined by dividing the employee’s total wages for the previous year by 52.
Benefit review conference (BRC). Some states offer BRCs to help resolve issues and disputes resulting from on-the-job injuries. BRCs vary by state but typically involve an informal mediation conference administered by a neutral hearing officer or ombudsman. If a dispute is resolved at a BRC, an agreement may be written and signed by the injured employee and a representative of the employer (or the employer’s insurance carrier or third-party administrator).
Claims adjuster (CA).
Case manager (CM) or nurse case manager (NCM). CMs are sometimes assigned by third-party administrators or workers’ comp carriers to monitor and assist with the coordination of medical aspects of workers’ comp claims. CMs are generally nurses or social workers. Some are employees of the third-party administrator or workers’ comp carrier, while others are essentially independent contractors. On occasion, CMs attend medical appointments with workers’ comp claimants, particularly in cases involving serious injury.
Carpal tunnel syndrome (CTS). CTS is a nerve condition in the wrist and is frequently the subject of workers’ comp claims.
Date of injury (DOI) or date of accident (DOA).
Functional capacity evaluation (FCE). An FCE is a series of tests administered to a workers’ comp claimant by a physical therapist or other health care professional. They can be beneficial in determining an injured worker’s capabilities and restrictions. FCE evaluators can review job descriptions and make a determination regarding whether the injured employee is capable of performing certain jobs. After a claimant undergoes an FCE, the evaluator typically provides a detailed report on the results, including the claimant’s capabilities and restrictions.
Full duty (FD).
First report of injury (FROI). Following an on-the-job injury, employers are usually required to file an FROI with the state administrative agency that oversees workers’ comp.
Future medicals (future meds) Employers are typically responsible for payment of medical expenses associated with their employees’ on-the-job injuries. Medical benefits are often lifetime benefits (i.e., employers are generally on the hook for future meds for the injured employee’s lifetime as long as the medical expenses are related to the underlying job injury). In some states, the employee’s right to future meds can be terminated when the employee and employer agree to the terms and a judge or appropriate administrative authority approves the agreement.
Independent medical examination (IME). As the name suggests, an IME is an assessment of a person’s physical condition (i.e., an evaluation) made by an independent physician. Many states authorize the use of IMEs in the context of workers’ comp claims. An IME can be a valuable tool in your arsenal, particularly if you are suspicious about possible fraud or some other abuse of the workers’ comp system.
Impairment rating (IR). An IR (sometimes called a physical impairment rating) is a medical assessment of a claimant’s injury represented by a percentage value. A physician may assign an IR to the body as a whole or to a specific body part. The rating may then be used to calculate the workers’ comp benefits owed to a claimant. Impairment ratings are particularly important in determining permanent partial disability benefits.
Injured worker (IW) or injured employee (IE).
Light duty (LD).
Life expectancy (LE). LE is sometimes a factor in determining the value of benefits owed to an injured employee, particularly in claims for permanent total disability.
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Here’s where it gets technical
Maximum medical improvement (MMI). Generally, to resolve a workers’ comp claim, the claimant must reach MMI. Typically, MMI is assigned by a treating physician when an injured employee’s condition has stabilized to the point that no major change is expected in his medical condition, despite continuing medical treatment. After MMI is assigned, the payment of temporary workers’ comp benefits may be suspended.
Medicare set-aside agreement (MSA). MSAs sometimes come into play when a workers’ comp case is settled to include the closing of future meds and the claimant is a Medicare beneficiary or is expected to become one in the near future. As part of the settlement, money for projected medical expenses associated with the workers’ comp injury is “set aside” into a bank account. The set-aside funds are used solely to pay for medical expenses related to the injury that would otherwise be paid by the employer. MSAs are designed to ensure that the federal government doesn’t get saddled with medical expenses (via Medicare) that should be paid in accordance with state workers’ comp laws.
Permanent partial disability (PPD). When a worker has been assigned MMI and is capable of returning to gainful employment but has some loss of function or residual problems as a result of an on-the-job injury, he is entitled to PPD benefits. In short, PPD describes a disability that is less than total. PPD benefits are calculated in different ways in different states, often in accordance with statutorily prescribed formulas. PPD may vary depending on the body part that is injured.
Permanent total disability (PTD). PTD benefits are payable to employees who are never able to return to gainful employment. An employee who is determined to be permanently and totally disabled because of an on-the-job injury is entitled to PTD benefits. In many states, PTD benefits are payable for the life of the injured employee. The rate is typically two-thirds of the employee’s AWW.
Physical therapy (PT). PT is the treatment of a physical injury by use of therapeutic exercise. It can be a valuable tool in getting an injured employee back to work.
Retaliatory discharge (RD) or wrongful termination (WT). These terms are synonymous. Many states have laws in place to make sure you don’t terminate employees in retaliation for filing workers’ comp claims. An employee who believes his employer violated those laws may file a claim for RD or WT.
Return to work (RTW).
Third-party administrator (TPA). In the workers’ comp context, a TPA is an organization that processes claims on an employer’s behalf. A large company may be self- insured for workers’ comp claims but may outsource the administration of its claims to a TPA.
Temporary partial disability (TPD). When an employee returns to work following an on-the-job injury but hasn’t achieved MMI and is earning less than his preinjury AWW, he is entitled to TPD benefits. Typically, TPD benefits are payable at two- thirds of the difference between what the employee earned at the time of the injury and his current earnings. TPD is perhaps the least common type of workers’ comp benefit.
Temporary total disability (TTD). When an employee is injured on the job and can’t return to work, he is temporarily totally disabled and entitled to receive TTD benefits during his convalescence. TTD benefits are generally paid weekly at the rate of two-thirds of the employee’s AWW, subject to a maximum or minimum rate. For example, an employee who usually makes $600 per week would be entitled to receive $400 per week for the period that he is temporarily and totally disabled. TTD benefits may be discontinued after the claimant reaches MMI.
Utilization review (UR). Many states have procedures for UR. UR is the process used by employers or claims administrators to review whether treatment is medically necessary.
Vocational benefits (voc benefits). In many states, voc benefits are available to injured employees. If an injured employee can’t return to his regular job, he may be a candidate for vocational rehabilitation. In many states, the employer may be on the hook for expenses associated with vocational retraining of an injured employee.
Vocational expert (voc expert). Either party may obtain the services of a voc expert. Voc experts are often retained when an employee hasn’t returned to work following a job injury or has returned at a lower wage. A voc expert may opine about jobs that the injured employee is capable of performing within his medical restrictions. Often, they will prepare a report and provide a voc rating based on the injured employee’s loss of earning capacity. The voc rating may be used as (1) a tool to determine PPD benefits owed to an injured employee, (2) a settlement negotiation tactic, or (3) persuasive evidence to a fact-finder.
Workers’ compensation (WC). That one’s a “gimme.”
Workers’ compensation rate (WC rate). Also referred to as the “comp rate” or “work comp rate,” the WC rate is typically two-thirds of the employee’s AWW and is often used to calculate an injured employee’s temporary or permanent benefits.
We hope this list is helpful the next time you find yourself navigating through the world of workers’ comp.