Achieving Maximum Medical improvement in a workers’ compensation claim may not be easy, but it is one of the most important goals in claims management.
Maximum medical improvement (MMI) is a term used frequently in workers’ compensation claims management. Often, your adjuster will explain that a case is not ready to settle because your employee has not “reached MMI.” What is MMI? From the employer’s viewpoint, achieving MMI is one of the most important goals in a workers’ compensation claim. MMI is the point at which treatment options have been exhausted and, generally speaking, temporary total disability payments can be terminated. MMI may also be referred to as “permanent and stationary.”
Case law varies in defining MMI
Case law in various states defines MMI in a variety of manners. In Ohio, for example, MMI is defined statutorily as “a treatment plateau.” In California, the Division of Workers’ Compensation defines MMI this way: “Your condition is well stabilized and unlikely to change substantially in the next year, with or without medical treatment. Once you reach MMI, a doctor can assess how much, if any, permanent disability resulted from your work injury.” Texas defines MMI statutorily as “the earliest date after which, based on reasonable medical probability, further material recovery from or lasting improvement to an injury can no longer reasonably be anticipated.” MMI will vary depending on the claim’s jurisdiction.
MMI – “As good as it gets”
The common thread of both case law and lengthy discussions attempting to define MMI is this – the employee is at a treatment plateau: his or her medical condition will probably not substantially improve. MMI then, might be described this way: “This person’s medical recovery is as good as it gets.”
Does MMI mean the employee can function at his or her pre-injury status? Not necessarily. Even if the employee has not reached his or her pre-injury status, however, the employee can achieve MMI. Some states such as Texas are very clear in stating that an employee’s recovery need not be equal to or better than the pre-injury state.
Defining MMI may be clearly defined in statute, but getting your doctors to declare an injured employee at MMI is not always straightforward. One way to determine if an employee is MMI is to send a nurse case manager with the employee to the medical provider. The nurse should ask this important question: “Is the employee’s recovery as good as he or she will get?” If the doctor says, “Yes,” then obtain a written opinion to that effect and begin the settlement process.
Lack of cooperation in treatment can be managed
What about the claimant who refuses to cooperate in his or her recovery? All reasonable treatment must have at least been offered to the employee. There are times when further diagnostic testing and evaluation are deemed medically reasonable and necessary. It may later be determined that no further treatment would benefit the claimant, or where further treatment is identified and the claimant refuses the treatment. In that intervening time until the employee refuses treatment, the claimant has, in many states, not reached MMI and the employer still owes benefits. Only when treatment is recommended and refused, or not undertaken within a reasonable time, has an injured worker reached MMI. For example, a consulting surgeon may recommend a back fusion; however, the employee declines surgery. In this case, the claimant has usually reached MMI and your claims administrator can begin to conclude the case.
Pressuring the employee for a quick decision on surgery may push the employee to obtain an operation he or she would otherwise refuse. If may be best to give an employee a few weeks to consider his or her decision to obtain further treatment rather than insist on an immediate answer, even if it means paying a little more in temporary disability.
Chronic pain and MMI
Many injured workers allege chronic pain. Chronic musculoskeletal disorders and diagnoses such as arthritis and fibromyalgia impact workplace injuries. In most cases, if the employee’s pain would be materially improved by participation in a pain clinic or pain program, the injured worker has not reached MMI. A patient with chronic conditions may require continuing treatment to maintain his or her recovery or to avert any further deterioration. However, if further treatment is directed solely to maintenance of the patient’s condition and there is no likelihood of further improvement, the patient is at MMI.
The most difficult situation is when the employee’s symptoms fluctuate dramatically. These employees will complain of “good days” and “bad days.” These types of symptoms are troublesome and often delay MMI; however, fluctuation alone is immaterial to a decision of MMI. When symptoms fluctuate, the time it takes to determine whether the patient is at MMI may increase. However, the underlying reasoning remains the same: if the patient has plateaued or the number of good days is growing, consider the patient MMI and begin the settlement process.
However, before deciding MMI has occurred because the employee has had no continuing substantial improvement, the adjuster must offer all “reasonable treatment.” Reasonable treatment does not include experimental procedures. Reasonable treatment usually means treatment that is based on evidence-based medicine guidelines such as the Official Disability Guidelines. With alternative treatments plentiful, employees may want try therapies with only anecdotal track records of success. Just because there are untried treatments available, this does not make them reasonable. Treatment options should be evaluated on a case-by-case basis. When addressing requests by employees for alternative treatments, solicit the treating physician’s opinion in states where employers can direct medical treatment.
MMI is an often subjective and always an important goal
Reaching MMI is subjective and often a time-consuming and sometimes frustrating process. A great deal of state-specific case law concerning the definition of MMI provides some guidance. If you are in doubt, your claims adjuster or legal counsel should assess the likelihood that your employee’s condition has stabilized to the point of MMI. If so, your adjuster or legal counsel should begin to immediately attempt to settle the claim.