Workers' Compensation Glossary

ESI - Epidural Steroid Injections: These are usually given for back injuries if there is no improvement with physical therapy.

FCE - Functional Capacity Evaluation: This test is often used following a long recovery period or surgery to see if the employee is able to return to the physical demands of his preinjury job. Not all employees require the test. It will depend on their progress and recovery as well as their job type. This is performed at a physical therapy or rehabilitation facility. The employee is instructed to perform various tasks, often in an attempt to simulate his normal job duties. The test is designed to determine if the employee is putting forth his best effort, and it is reported to the doctor.

Field Case Manager: A field nurse works for the insurance carrier and goes with the employee to his physician appointments and completes a report to the carrier. They are especially effective for employees who are hospitalized immediately following an injury, as they can provide a detailed summary of the injury and treatment plan. IME - Independent Medical Exam: A physician, usually chosen by the insurance carrier, who gives an impartial opinion based on a physical exam of the employee and all pertinent medical information. The carrier will usually ask the IME to answer specific medical questions that pertain to the employee, the specific injury and their particular job duties. The IME can provide an opinion as to whether the injury was a direct result of the alleged incident. He can address surgical requests, treatment requests and work status. He can also recommend a treatment plan that he feels would benefit the employee. Only in some states is the IME physician allowed to assume treatment of the employee.

MMI - Maximum Medical Improvement: This indicates that the employee is at a treatment plateau in the healing process. Once an employee reaches MMI, he is typically physically ready to return to work.

Official Disability Guidelines: Official Disability Guidelines are evidence based guidelines based on cases from the CDC, OSHA and actual WC claims. The guidelines are provided by the Work Loss Data Institute in California. These guidelines are used by nurses nationwide in the insurance industry to determine medical necessity of a requested test, procedure, surgery or certain treatment plans such as therapy.

PPD - Permanent Partial Disability: A benefit paid to the employee due to the complete or partial loss or loss of use of a part of the body, or partial loss of use of the body as a whole. “Loss of use” generally means that the employee is unable to use the specific body part postinjury as they did pre-injury. These benefits are paid only if the work-related injury results in some permanent loss. The benefit is paid at 60% of the gross average weekly wage, subject to certain limits.

PTD - Permanent Total Disability: A complete disability making the employee permanently unable to do any kind of work or the loss of use of both hands, both arms, both feet, both legs, both eyes or any two such body parts such as arm and leg.

Reserves: Claim reserving is the practice of establishing a timely and adequate estimate of the medical and indemnity costs of a claim. It is most often broken down into categories such as Indemnity (Lost Time/Permanency), Medical and Expense. These categories take into account the amount that is paid out and the amount of monies left in outstanding reserves.

Telephonic Nurse Case Manager: Many insurance carriers employ nurses who provide telephonic case management. They maintain contact with the provider, employee and in many instances the employer. They obtain current medical information and work status and work in conjunction with the adjuster.

TTD - Temporary Total Disability: Benefits that are paid to the employee who is losing time from work due to a work related injury. The employee is entitled to benefits until his return to work. There is usually a waiting period before benefits begin but this is determined by state. The benefit is 66.2/3% of the employee’s gross average weekly wage and this is based on their wages during the year before the injury and does not change with changes in the employee’s salary or the statewide average weekly wage.

UR - Utilization Review: Many carriers have instituted this as a way to determine whether a specific diagnostic test, therapy or surgery is medically necessary. The review is usually performed by a nurse. Utilization reviews are mandatory in some states, but not in Illinois – where a UR is left to the carrier’s discretion.

Vocational Rehabilitation: If the injury prevents the employee from returning to his preinjury position he may be entitled to vocational rehabilitation. The employee works with a counselor from a certified facility who provides vocational and occupational training in an attempt to return the employee to gainful employment based on his capabilities.

Work Hardening: This is a program of progressive, work-related activities (flexibility, strength, endurance, coordination and work-related function) to physically and psychologically recondition the employee in order to facilitate their return to full employment. It is normally requested by the treating physician and can vary in the amount of time that is needed. It usually begins at 4 hours per day then advances to 8 hours over the course of 4 weeks.

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