How Does the Doctor Get Paid in Arizona Work Comp Claim?

One of the good things about Arizona workers/workmans compensation is that an injured worker has 100% coverage of all medical expenses related to his or her injury. Coverage of the injury can last for the entire lifetime of the injured worker.

The insurance carrier pays the medical providers directly based on a fee schedule set by the Industrial Commission of Arizona. A.R.S. 23-908 sets the maximum fee that a physician or pharmacy can charge for treatment or medications. Many times the insurance carrier negotiates a special lower rate with a provider and that may be the reason they want you to treat with a specific doctor.

For the most part, the Arizona Workers Compensation fee schedule pays substantially more than private insurance or Medicare, so many doctors are eager to treat injured workers. The fee schedule is set by taking the fee schedules of 7 other states and calculating the 75th percentile of what they pay for different medical treatments. Fees for durable medical equipment, nurse practitioners, physicians assistants, and orthopedic devices are not set in the fee schedule.

The industrial commission of Arizona reviews the fee schedule yearly rotating through the different types of treatment every four years. For more thorough information about the fee schedule, see the Industrial Commission website at http://www.ica.state.az.us/Director/DIR_FSFAQs2010.aspx

Chad T. Snow is an attorney who limits his practice to representation of injured workers before the Industrial Commission of Arizona and Social Security Administration. He and his associates at Snow, Carpio, and Weekley can be reached at (602) 532-0700 in Phoenix, or (520) 647-9000 in Tucson.

Waddel's Signs - Defense Doctors are the Real Fakers

One of the most common techniques that Defense IME doctors use to discredit injured workers is the use of "Waddell's Signs".  Doctors hired by the insurance carrier will say that an injured worker has positive Waddel's signs to show that they are exaggerating their symptoms or outright faking their injuries. 

The test is named after a physician researcher, Gordon Waddell, who originally intended it to be used as a technique to determine appropriate patients for back procedures such as discography.  It consists of several physical tests including axial compression (pushing down on the top of the head, which shouldn't cause low back pain), distracted straight leg raising, overreaction to stimulus, and complaints of pain in areas that shouldn't have pain from the injured body part. 

A little research, however, has given me ammunition to combat this technique.  First, my partner found an obscure reference in the AMA Guides to the Evaluation of Permanent Impairment that indicates that the use of Waddell's Signs is inappropriate in non-Anglo patients.  That counts out about 80% of my clients. 

Also, a quick Wikipedia search showed that numerous recent medical studies have criticized the use of Waddell's signs and show that they have been misused by the medical community.  For example, a 2004 study by Fishbain showed that In a 2004 review, Fishbain, et al. concluded, "there was little evidence for the claims of an association between Waddell signs and secondary gain and malingering. The preponderance of the evidence points to the opposite: no association".

I can't wait to spring those on the next sheisty defense IME doctor who's trying to paint my client out as a faker. 

Chad T. Snow is an attorney who has handled over 5,000 hearings at the industrial commission of Arizona for injured workers.  He has offices in Phoenix and Tucson, Arizona and handles exclusively Arizona workers compensation claims.  He can be reached through his firm's website, Snow, Carpio, and Weekley.

Where You Get Your MRI Matters (AZ Workers Comp)

I learned something new today - there is a huge difference in quality between MRI facilities.  I was at an Industrial Commission of Arizona hearing where one of my favorite doctors, Brad Sorosky, was testifying.  Dr. Sorosky has a great way of explaining things in ways that normal non-doctors can understand.  The carrier in this case had agreed to pay for an updated MRI since the previous one was of poor quality.  Knowing that carriers always try to send injured workers to the cheapest facility possible, I asked Dr. Sorosky if there was a difference in quality between one facility and another.  He said that there definitely was and gave a perfect analogy:  he explained that it is the difference between taking a picture on your cell phone and taking a picture with a high quality Nikon camera.  He recommended any facility that has 3T technology (whatever that is...) 

I don't know about you, but if I've suffered an on-the-job back injury and the decision whether or not to do surgery depends on an MRI, I want the picture taken with the highest quality diagnostic equipment available, not the one that's going to save the insurance carrier a couple hundred bucks. 

Remember that in Arizona workers comp, unless your Employer is self-insured, you have the right to direct your own medical care.  I personally think that that extends to where diagnostic studies are performed.  The carrier is required to pay for treatment under the Industrial Commission Fee Schedule.  You want the best care possible.  Always ask your doctor which facility they prefer for their diagnostic imaging and insist on getting the MRI, CT, EMG, or whatever at that facility. 

Chad T. Snow is an Arizona Workers (workmans) compensation attorney with offices in Phoenix and Tucson.  He has represented thousands of injured workers before the Industrial Commission and Court of Appeals.  He can be reached at his website, Snow, Carpio, and Weekley, or at (602) 532-0700 and (520) 647-9000. 

Reasonable Degree of Medical Probability

As a follow up on my last post, I, Chad Snow of Snow, Carpio, and Weekley, want to discuss the burden of proof that applicant's have in their hearings before the Industrial Commission of Arizona.  At the end of almost every hearing involving a medical witness at the ICA, the attorney performing the direct exam will ask a question like "do you hold the opinions you've given today to a reasonable degree of medical probability?"  All this means is that the doctor must feel that it is more likely than not that his opinions are correct.  In other words, is the doctor 51% or more sure that what he has testified to is correct.  For example, a doctor can never say with absolute certainty that a herniated disc on an MRI is without any doubt related to an industrial injury.  But he can say that, if the applicant never had low back pain before the injury, had a mechanism of injury that could cause a herniated disc, and has had low back and leg pain ever since in the appropriate distribution, that it is more likely than not related to the injury.  If a doctor testifies that something is a mere possibility as opposed to a probability, then the applicant has not met his or her burden. 

This is a lower burden than, for example, what many people are used to hearing in criminal cases:  beyond a reasonable doubt - which is with almost certainty.

Cross Examining the Defense Medical Expert in AZ Workers Comp Hearing

In law school, there is a famous video called "The Ten Commandments of Cross-Examination".  They are:

1. Be brief.
2. Short questions, plain words.
3. Always ask leading questions.
4. Don't ask a question to which you do not know the answer.
5. Listen to the witness' answers.
6. Don't quarrel with the witness.
7. Don't allow the witness to repeat his direct testimony.
8. Don't permit the witness to explain his answers.
9. Don't ask the "one question too many."
10. Save the ultimate point of your cross for summation

I had two hearings today which perfectly demonstrated these Commandments.  In the first, I was cross-examining Dr. McLean, who is a very well respected expert that I use on many of my own cases.  I knew that I wasn't going to change Dr. McLean's opinion, I just wanted him to agree with a few of the stronger points of my case.  I only asked him leading questions that I already knew the answer to.  I asked him to concede the points of my case that were the strongest.  This has a twofold purpose - if the doctor concedes, it adds credibility to your own medical witness, if he refuses to concede the obvious, it makes him look partisan and ridiculous.  Dr. McLean agreed with the few points that I brought up and I ended on that. 

In the second case, a less seasoned defense attorney was cross examining my medical expert.  Every question he asked was open ended, which only allowed my doctor further chance to explain himself and address any doubts that the ALJ might have had.  He also kept trying to push the same point which is futile - you are never going to convince a board certified fellowship trained orthopedic surgeon that he's been wrong all along.  Finally, he allowed my expert to go on and on explaining himself.  He made my case more than I did. 

Of course, there is always what I like to call "The Overholt Rule", named after a former ALJ at the Industrial Commission.  Judge Overholt taught me early on that "most of the time, the best cross examination is 'no questions Your Honor."  In other words, let your expert's opinion stand on its own, don't give the other expert any further chance to explain himself or defend his position.  Good advice. 

Chad T. Snow is an attorney who practices in the area of workers compensation in Arizona with offices in Phoenix and Tucson.  He can be reached at (602) 532-0700, (520) 647-9000, or through his firm's website at Snow, Carpio, and Weekley.

Endorsement of Endurance Rehab

If anyone has any kind of injury that requires physical therapy, I highly recommend Endurance Rehabilitation.  I was referred to Endurance by one of the Industrial Commission judges who had treated there, and I couldn't be more pleased with the treatment I've received.  Having gone through extensive rehabilitation for a previous knee injury on two occasions, I know that having the right physical therapist can make a huge difference in your outcome following surgery.  You can learn more about Endurance Rehab on their website at http://www.endurancerehab.com/ 

Although I haven't treated there personally, many of my clients have also spoken highly of Strength Training International or S.T.I. Physical Therapy.  I would recommend them as well. 

Chad T. Snow is an attorney with Snow, Carpio, and Weekely. He has offices in Phoenix and Tucson, Arizona who represents those injured on the job.  He can be reached at (602) 532-0700 or (520) 647-9000. 

What Are the AMA Guides in Arizona Workers Comp?

Determination of permanent disability in Arizona work injury claims is governed by a book published by the American Medical Association called The Guides to the Evaluation of Permanent Impairment.  The Guides have a section for each of the major body parts which give uniform rules for doctors to "rate" permanent impairments in injuries.  Although the rules are supposed to be uniform, they are often interpreted very differently by different doctors.  I recently had a case where one doctor found my client had a 28% impairment, another found he had a 42% and a third found a 61% - all looking at the same table!

Some doctors think that the Guides are perfect, and won't deviate from them at all.  Others say that they are what they say they are - only a "guide" to help in reaching a determination of how an injury has really affected the overall function of the body part. 

In cases of "scheduled" injuries, the doctor's rating under the Guides is the most important factor in determining how much compensation the injured worker will receive for his or her injury.  In unscheduled injuries, the actual percentage rating is unimportant, as long as the injured worker has at least a 1% permanent impairment. 

Chad T. Snow is a workers compensation attorney who has represented thousands of injured workers in Arizona.  He has offices in both Phoenix and Tucson.  He can be reached at (602) 532-0700, (520) 647-9000, or on his website at Snow, Carpio, and Weekley.

Doctors Aren't Always Right

I had a doctor testify in a hearing today who I normally respect but who had it all wrong in this case.  At issue was whether or not walking on crutches and placing all of one's weight on their non-injured foot can aggravate an underlying asymptomatic condition in their heel.  This doctor, who shall remain nameless, testified that it is impossible for someone to develop increased pain in the uninjured leg/foot from placing all their weight on it while recovering from surgery. 

I've never wanted to take the stand and testify worse than I did today.  I had surgery on my right knee three weeks ago and have been using crutches and placing all my weight on my left leg.  And guess what?  My left leg hurts worse than the one that had surgery!  It just goes to show that doctors can have their opinions - but they are just that - opinions.  I've had doctors in other cases testify that knee injuries shouldn't result in any restrictions on prolonged sitting.  Bullcrap.  I can only sit comfortably for about 30 minutes until my right leg falls asleep and I need to stand for a few minutes. 

Some other things I've learned to believe my clients more since my injury:

1.  Using crutches for long periods of time hurts your hands, wrists, and shoulders.
2.  It is hard to sleep after an injury like this, which makes you tired all day, and makes it hard to concentrate.
3.  It would be hard to survive if I wasn't able to work and had to wait to litigate my workers compensation claim. 
4.  Doctors make you wait in their waiting rooms much much much longer than lawyers. 

Chad T. Snow is an attorney who practices exclusively workers compensation and Social Security Disability in Phoenix and Tucson, Arizona.  He is the founder of Snow, Carpio, and Weekley, who can be reached at (602) 532-0700 or (520) 647-9000. 

Letting the Insurance Carrier Pick Your Doctor

I had a potential client call me yesterday and cancel our appointment to meet because he said "the insurance carrier told me they would help me find a specialist, so I don't need an attorney right now."  He didn't seem to understand that the insurance carrier might not have his best interest at heart.  He probably still believes in the Easter Bunny and Santa Claus as well.  I guarantee he'll be calling me sooner rather than later. 

I'm not one of those attorneys that spends all my time slamming insurance companies - they have a right to make money like any other business.  But make no mistake about it, they are for profit companies in the business of making money.  And they make money by keeping the cost of claims down, which means paying you as little as possible in compensation and keeping your medical costs to a minimum.  Their most effective tool at both of these is getting injured workers to treat with the carrier's preferred physicians. 

The treating physician controls everything in an Arizona workers compensation claim.  Every carrier has hand picked doctors in every specialty that they send a lot of business to and therefore are somewhat beholden to the carrier.  They provide a minimal amount of medical care and release the injured worker back to work oftentimes well before he or she is ready.  At the end of the case, they either give very low percentages of permanent disability or little or no work restrictions to minimize the amount of permanent compensation that the carrier has to pay the injured worker. 

THe only question now is whether that potential client will be calling me because the carrier's hand picked doctor closed his case out too soon, released him back to regular work even though he can't do it, won't provide him medications, or a host of other things that save the carrier money...

Chad T. Snow is an attorney and the founder of Snow, Carpio, Weekley in Phoenix and Tucson Arizona who specializes in workers compensation claims.  He has represented thousands of Arizona's injured workers.

What is "Supportive Care"? Arizona Work Comp

Sometimes I have clients who have permanent injuries and when they are told that their case has been "closed", they get a horrified look on their face as they wonder where they will continue to get medications and treatment that they may need for the rest of their lives.  Don't worry, I tell them.  You have been given "supportive care" benefits.  The easy definition of supportive care is that it is medical treatment that is pre-approved after an injured worker has been found medically stationary, the goal of which treatment is to help the injured worker maintain his or her level of function.  It is different from "active care" which is care that is designed to improve a workers condition.  It is when the treating doctors feel that all active care (improving the condition) has been exhausted that they usually find the injured worker "medically stationary", close the claim, and make recommendations for "supportive care", which is also sometimes called "supportive medical maintenance". 

If you are given supportive care in your Arizona Workers Compensation claim, make sure and use it.  It is usually only approved in two year increments.  If you don't use it, the doctor and carrier will assume you don't need it and will cancel it. 

Chad Snow is a workers compensation attorney with offices in Phoenix and Tucson, Arizona.  He can be reached at (602) 532-0700 or (520) 647-9000 or at his webpage of Snow, Carpio, and Weekley.

What is an Independent Medical Examination and Do I Have to Go?

One of the most effective tools that the insurance carrier has to control an Arizona workers compensation claim and terminate benefits is an "Independent Medical Examination".  Usually, there is nothing "Independent" about it.  In fact, we call them DME's or "Defense Medical Examination".  The doctor is a doctor who is chosen by the insurance carrier and is normally more than willing to give whatever opinion is best for the carrier.  There are rare exceptions - if your IME is scheduled with Terry McLean, M.D., Jeff Scott, Sanjay Patel, Peter Mitchell, Peter Campbell, and a handful of others, we have found them to be very independent doctors who give honest opinions.  However, the great majority of IME's are done by doctors who give opinions that are beneficial to the carrier. 

So the question becomes:  do I have to attend an IME?  The answer is usually yes.  An injured worker usually has to submit to an exam by a company doctor once after an injury "to ascertain the character and extent of the injury occasioned by the accident."  (ARS 23-908(e)).  After that initial visit, the injured worker is usually free to choose his or her own doctor.  However, the carrier is permitted to have an IME "from time to time" thereafter to check up on the condition of the worker.  An injured worker who refuses to attend an IME or obstructs it can have their benefits suspended.  "From time to time" usually means about once every six months in our experience. 

Bottom line:  if the carrier is sending you for an IME, it is probably to get your claim closed out in the manner that most benefits the insurance carrier.  You should call our experienced Arizona workers compensation attorneys at Snow, Carpio, and Weekley as soon as possible.

Can I Choose My Own Doctor in my Workers Compensation Case?

If you have an Arizona Workers' Compensation claim and you are treating with a doctor that the insurance company sent you to, you should know that in most cases you have the right to change doctors to a doctor who is independent of the insurance company.  That is a right that the insurance company will never tell you about!  The only employers who can direct the care of their injured workers are those that are "self-insured", such as Fry's, Safeway, and Wal-Mart, along with a few others. 

When most workers sustain an on the job injury in Arizona, they are sent by their employer to an industrial clinic such as Concentra, MBI, or Banner Occ Health.  Our experience is that these clinics usually give a minimal amount of medical care and then release the person back to regular work - even if you're not ready or need more treatment.  They often are more concerned with saving the insurance company money than providing the injured worker with quality medical care.  Arizona law requires the injured worker to submit to one exam with these clinics, but after that initial exam, you are free to choose your own doctor. 

As an attorney who practices exclusively workers compensation in Arizona, I almost always recommend that my clients change physicians immediately.  To change doctors, all that is required is the written permission of either the insurance carrier, attending physician, or the Industrial Commission of Arizona.  The easiest way is to complete a form "Request to Change Doctors".  That form can be accessed by clicking here:  http://www.ica.state.az.us/Claims/Claims_Request_to_Change_Doctors.aspx  The Industrial Commission of Arizona's claims division almost always approves these requests unless it appears that the change of doctors would be detrimental to the injured workers' health or recovery. 

You want to choose a doctor who specializes in the body part that you have injured.  At our firm, Snow, Carpio, and Weekley, we have a network of doctors in all specialties who work independent of the insurance company.  If you would like a referral to a doctor, please feel free to contact me anytime at chad@snowcarpio.com or visit our website!