We are here to help you with your every day questions with Texas Workers’ Compensation. Please see the newest updates below in what is happening with the DWC.
Lunch and Learns – First Come, First Served CEU Credits for All Adjusters
Want Some Credit? Come and Get It!
Here are more Lunch and Learns so you can get your credit early!
We are offering Lunch and Learns for 1-hour credits. See the list of classes being offered below; the first 25 adjusters to sign up will be in the course. Once you have registered, you will receive confirmation for the Webinar.
The Zoom link will be emailed the Monday before each Webinar.
September 23, 2022 from 12:00 P.M. to 1:00 P.M.: Marihuana. The Ethical Considerations (125609)
October 14, 2022 from 12:00 P.M. to 1:00 P.M.: Paying and Denying Medical Bills Webinar ( 125371 )
October 28, 2022 from 12:00 P.M. to 1:00 P.M.: Utilizing Texas Guidelines: AMA, ODG Treatment & MDA Webinar ( Pending )
Please note if you have taken the course listed below in the last two years, you will not be eligible for credit again per Texas Administrative Code 19.1010 (7)(c).
Don’t delay! Email us today at CE@downsstanford.com.
Compliance and Investigations Corner
After review of the Division’s Performance Based Audit (PBO) regarding initial payment of TIBs claims, it is important to note that lack of communication from the Employer with respect to a Claimant’s work status is NOT an exception to the requirement to pay or dispute TIBs within 15 days of receipt of notice of a claim.
Please contact us at Q&A if you have a specific question about which PLN to file or what language to use on a claim.
DWC Corner
Your monthly look at what is happening at the Division and how it impacts Carriers
As some of you may know, the Texas Labor Code requires the Commissioner to put together an agenda on a yearly basis for the Workers’ Compensation Research and Evaluation Group. This agenda typically provides a good look at what the DWC is planning on focusing on going forward. For 2023, the Research and Evaluation Group has proposed to provide an update of medical costs and utilization in the system, with a focus on the cost and utilization of office visits and physical medicine services. They also plan on looking at injured employee access to medical care, including an analysis of medical care provided through networks. The other major focus will be looking at return to work outcomes, especially in light of both initial and sustained return to work programs, as well as wage recovery rates.
The Division is also attempting to solve their ongoing Designated Doctor “problem” by looking at new rules covering things such as billing and the actual reports. As many of you are aware, the number of Designated Doctors in the state continues to decrease. As of August 31, 2022, the number of approved Designated Doctors in Texas is down to 257 (down from 366 less than two years ago), and of that amount, only 75 are MD’s or DO’s. A PowerPoint presentation by Joe McElrath on September 9, 2022, addressed Informal Rule Proposals for Texas Administrative Rules 133 and 134, with the stated goals to increase physician participation and decrease the administrative burden to participate in the Designated Doctor program. This includes such things as increasing fees for doctors examining injured employees with complex injuries, increasing payment for medical record review, and possibly updating fees on an annual basis for examinations. They are also looking at ways in which to decrease the complexity of the billing by reducing the number of billing modifiers, eliminating tiered reimbursement and other steps to entice doctors to come back to the system. The comment period for these potential changes closes on September 23, 2022, and hopefully we will see some substantive changes in the near future to help bring qualified doctors back into the system.
Finally, as we have previously noted, the DWC is in the process of moving from their offices on Metro Center Blvd. in East Austin, to a brand new State of Texas office building in downtown Austin near the Capital. The Austin Field Office will be moving to that location as well, but as of the posting of this newsletter, no definitive time for the Austin Field Office to move has been announced.
Helpful Thoughts When Handling a Judicial Review Case: 3 Part-Series
By now, it may have already happened, or it could be just around the corner. You are involved in a judicial review action, either as a Plaintiff or Defendant. The scene may be something similar to this: you walk into your office and see an urgent email or received some documents in the mail pertaining to a case that you handled several months ago and since you are not sure what the documents are, you forward them to your Attorney. Your Attorney explains you received an Original Petition for Judicial Review naming you (the Carrier) as Defendant. The time to act is fast and imminent. It may be your first judicial review action, or it may be your tenth; however, since deadlines are nearing, it is time for action.
1. “Toto, I’ve a feeling we’re not in Kansas anymore.” The Wizard of Oz (1939). There are vast differences between handling an administrative workers’ compensation case versus that of a judicial review action. One of the most stark differences is the rules of evidence apply in judicial review actions and are real. Whereas, in administrative actions, the rules of evidence do not strictly apply. Sec. 410.165 of the Texas Labor Code specifically states, “Conformity to legal rules of evidence is not necessary.” What does this mean? Some Administrative Law Judges take this to mean rules of evidence are not applicable at all. While others believe the rules of evidence should be applied sparingly, only in certain instances; but not in all scenarios. Compare this with Texas Labor Code Sec. 410.306 which states evidence shall be adduced in judicial review actions as in other civil trials.
The takeaway – if you receive a lawsuit, contact your Attorney.
2. “Show me the money!” Jerry Maguire (1996). Your Attorney should prepare you accordingly for the costs of litigation. The costs of handling an administrative case is vastly different from handling a litigation matter. Real discovery is allowed at trial. How much discovery is allowed or needed depends on the issues in your case. Depositions may be necessary. Plus, written discovery will be allowed. Court intervention may be needed if discovery disputes arise. Calculating what discovery will be needed in a judicial review action and calculating accordingly is a necessary component of budgeting for the lawsuit. Many adjusters are unaware that handling a judicial review action may be double, triple, or even quadruple (or more), the costs of handling an administrative case. Make sure your Attorney prepares you and lets you know from the outset that judicial review actions are much more costly than administrative cases. Properly budgeting a judicial review action is critical and will change depending on the issues litigated, exposure and liability of an adverse determination, and venue of the case. Proper budgeting may even be a factor in possible resolution of the case.
The takeaway – We have handled judicial review cases for many years and our involvement in JR cases has not only become more complicated due to the issues involved (i.e. death claim, extent of injury), but also the value of lifetime future medical expenses. As a result JR litigation is much more expensive to handle. Being involved in a litigation case may not necessarily be “cut and dried” like handling an administrative case. Realistic information regarding attorneys’ fees and litigation expenses leads to a better attorney/client relationship.
3. “What we’ve got here is failure to communicate.” Cool Hand Luke (1967). Or “E.T. phone home.” ET: The Extra-Terrestrial (1982).
Be prepared to be treated like an alien at trial because we will be speaking “WC Greek” to the judge or jury.
One of the biggest challenges we face in handling a judicial review case is a judge or jury will likely not understand the nuisances of a workers’ compensation case, and may have no idea what workers’ compensation is even about. Just think about the number of abbreviations or acronyms used in WC parlance (MMI, RME, DD, PIE, TIBS, SIBS, LIBS, DIBS, SIF, etc.). These terms are bandied about in administrative hearings without thought. But at a judicial review trial, the use of such terms may likely result in confusion and confoundment on the part of the judge or jurors.
In our experience, many jurors have prior experience with either civil or criminal jury trials. This normally cannot be said for workers’ compensation cases. Imagine you have a blank canvas and we need to paint a picture of a broader context of what a worker’s compensation case is and may be about. Throw out the “WC lingo” and prepare to educate the judge/jury. As such, a fair amount of the trial will be spent indoctrinating the judge and jury to the “WC world”. This may prove to be our ultimate challenge. In 1991, when the new (old) law came into effect it was a huge task to educate a judge or jury to the “new” workers’ compensation laws. Now, thirty years later, it still is difficult. Remember with the turnover in the judiciary in many regions, and the relatively small number of JR cases being litigated, workers’ compensation, now over thirty years old, is still not a familiar world. When speaking to a jury, the task can be monumental. We will be prepared to explain the “nuts and bolts” of the workers’ compensation system, even before we launch into the specific facts/issues of the case. We will need to explain what MMI, IR, CCH, BRC, AP, TIBS, IIBS, DIBS, etc., are in layman’s speak. This will take time at trial.
The takeaway– We take for granted certain terms/terminology, and knowledge of issues in the administrative arena. There, parties don’t have to explain what “MMI” or “TIBs”, etc., are. We don’t have to go into detail as to what a compensability dispute is or the deadlines inherent in the dispute (filing of PLN’s). We must to adhere to “the KISS” theory – Keep It Simple Stupid (as much as we can). Without the nuts and bolts of explaining the WC world and painting a broad overview of what workers’ compensation is really about, the jury may be “lost in space” when we are trying to persuade a jury to our side of the case. You will see it in the faces of the judge or jury whether they get it or not. We will be prepared to administer small doses of WC knowledge to our Judge or Jury with the goal that by the end of our case, the messages we sent are well received.
Please join us next month for the continuation of this series of handling Judicial Review Cases.
We would be happy to assist you with any questions regarding this or any other issues you may have. Please email us at Q&A.
ESTIMATING IMPAIRMENT RATINGS
The Claimant is reaching statutory MMI (104 weeks from the 8th day of disability) and you don’t have an impairment rating? You’ve requested one from the treating doctor to no avail, and the designated doctor’s exam is not scheduled for another month. How do you come up with a reasonable assessment to file your PLN-3(c) based on the 4th Edition of the AMA Guides for the lower extremity?
Some impairments for the lower extremity are based on range of motion, but other are better evaluated using diagnostic categories. If an injured worker has several impairments of the same lower extremity, such as the leg or the ankle and a toe, the whole-person estimates are combined using the Combined Value Charts. If both extremities are impaired, the impairment of each should be evaluated in terms of whole person and the two impairments are combined. Possible lower extremity impairment in whole person:
Possible impairment ratings for certain lower extremity Impairment Ratings:
Table 64
Pelvic fracture Whole Person Impairment
Undisplaced, nonarticular, healed, 0%
without neurologic deficit or other sign
Sacroiliac joint fracture 1% – 3%
Total hip replacement
Good result 15%
Fair result 20%
Poor result 30%
Femoral shaft fracture
Healed with 10º- 14º angulation or malrotation 10%
15º – 19º 18%
20º+ +1% per degree up to 25%
Knee
Patellar subluxation or dislocation 3%
Patellar fracture
Undisplaced, healed 3%
Articular surface displaced, > 3mm 5%
Displaced with nonunion 7%
Mesiscectomy, medial or lateral
Partial 1%
Total 3%
Mesiscectomy, medial and lateral
Partial 4%
Total 9%
Cruciate or collateral ligament laxity
Mild 3%
Moderate 7%
Severe 10%
Cruciate and collateral ligament laxity
Moderate 10%
Severe 15%
Total knee replacement
Good result 15%
Fair result 20%
Poor result 30%
RANGE OF MOTION
Hip Motion Impairments – Table 40
Motion Mild 2% Moderate 4% Severe 8%
Flexion Less than 100º Less than 80º Less than 50º
Extension 10º – 19º 20º – 29º 30º
(Flexion contracture) (Flexion contracture) (Flexion contracture)
Internal rotation 10º – 20º 0º – 9º
External rotation 20º – 30º 0º -19º
Abduction 15º – 25º 5º – 14º Less than 5º
Adduction 0º – 15º — —
Abduction 0º – 5º 6º – 10º 11º – 20º
*Contracture
*An abduction contracture of greater than 20º is a 15% whole person impairment.
Knee Impairments – Table 41
Motion Mild 4% Moderate 8% Severe 14%
Flexion Less than 110º Less than 80º Less than 60º
Flexion Contracture 5º – 9º 10º – 19º 20º+
(Deformity measured by femoral – tibial angle; 3º to 10 º valgus considered normal)
Varus 2º valgus – 0º 1º – 7º 8º – 12º varus
Valgus 10º – 12º 13º – 15º 16º – 20º
Ankle Motion Impairments – Table 42
Motion Mild 3% Moderate 6% Severe 12%
Plantar flexion capability 11º – 20º 1º – 10º None
Flexion contracture — 10º 20º
Extension 10º – 0º — —
(Neutral)
Hindfoot Impairments – Table 43
Motion Mild 1% Moderate and Severe 2%
Inversion 10º – 20º 0º – 9º
Eversion 0º – 10º —
Ankle and Hindfoot Deformity Impairments – Table 44
Position Mild 5% Moderate 10% Severe 20%
Varus 10º – 14º 15º – 24º 25º+
Valgus 10º – 20º — —
Toe Impairments – Table 45
Type of Impairment Mild 1% Moderate and Severe 2%
Great toe 15º – 30º Less than 15º
Metatarsophalangeal
Extension
Interphalangeal flexion Less than 20º —
Lesser toes Less than 10º —-
Metatarsophlangeal
Extension
*The maximum whole person impairment percent for impairments of 2 or more lesser toes of one foot is 2%.
If you need help estimating Impairment Ratings, please email us, and we can help you. If the matter is complex, then we can assist in requesting a Peer Review to help calculate the estimated Impairment Rating as well.
Need Help with Designated Doctors, Peer Reviews, or Required Medical Examinations? You’ve Come to the Right Place!
Please contact dd-rme@downsstanford.com, and our office will be happy to assist you.
Decisions, Decisions, and More Decisions
Current Cases that You Need to Know
• Tex. Mut. Ins. Co. v. Hofer Builders, Inc., __ S.W.3d __, 2022 Tex. App. LEXIS 6328 (Tex. App.—Austin Aug. 25, 2022, no pet. h.)
DECISION: Injured Worker resided in Florida when he received a call from a Texas employer to work on three projects, including one in Texas, travelled straight to Louisiana where he was injured, and never set foot in Texas throughout the hiring process. The court held the worker did not meet the significant contacts prong because his physical location was not in Texas when he was “hired or recruited.” The worker did not meet the principal location prong because he did not physically work at or from Texas even though he communicated with the Texas office to receive his assignments and provide reports, and he received payments from there.
WHAT THIS MEANS FOR YOU: Workers’ compensation insurance “is intended for the benefit of Texas’ employees and because industry in Texas should not have the burden of providing insurance for employees of other states. . . .”
If you have any general questions regarding Longshore or would like a seminar regarding Longshore Claims, please email Longshore@downsstanford.com.
You’ve got WC questions? We have answers. Send your questions to Q&A.
For Employer’s Liability, General Liability, Subro, and all other areas of law, email questions here.
Want some CE credit? Come and get it! Join us for Lunch and Learns every Friday. For information and registration, email CE Department.
Have questions about Designated Doctors, RMEs, or Peer Reviews or have records for a DD, RME, or Peer? Email our DD Department.
Do you have a hearing and need help or need to send records for an already set hearing? Please send all set notices and records to DWCHearings@Downsstanford.com.