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Explaining Maximum Medical Improvement to Your Clients

Author: Nancy Germond

The term “maximum medical improvement (MMI)" is a phrase adjusters use frequently when explaining to their insureds why a work-related claim remains open. “The employee has not reached MMI" is probably one of the most frequent phrases adjusters repeat to explain why an employee either cannot return to work or the adjuster cannot close the claim.

When your insureds don't understand the phrase, or still have questions, they may turn to you for your thoughts. If you understand MMI, you are in a strong position to help your insureds understand why a claim may appear stalled.

MMI is the key goal in any workers' compensation claim, particularly important in any claim where lost time from work occurs. While I'll provide a few textbook definitions of MMI, here is the key concept. MMI is that point when the employee's treatment options end, the adjusters can usually terminate disability payments and they can try to settle the claim. You may also hear it called “permanent and stationary." Further treatment will not improve the patient's medical status.

Definitions of Maximum Medical Improvement

Here are a few MMI definitions I've taken from various resources that I like.

IRMI – “Healing Plateau" – “…the point of maximum recovery from a work injury or illness after which the employee will no longer improve with further treatment." IRMI calls this a “synonym" for MMI.

Nolo – “MMI is the point when an injured worker's condition isn't expected to improve with more treatment, at least in the near future. Once a worker has reached MMI, the worker can be evaluated for permanent disability."

While various experts define MMI slightly differently, there is one critical component: The employee has plateaued in treatment, and his or her medical condition will not substantially improve, either with or without additional medical treatment. In simpler terms, “This worker's recovery is as good as it's probably going to get."

Now, MMI does not mean in all states, which write their own rules for administering workers' compensation claims, that the carrier can terminate future treatment. In many cases, the courts may award that employee some future treatment to continue to keep the employee at the new baseline.

For example, consider a person who is seriously injured and requires a three-level fusion. Fusions can cause future instability above and below the fusion. The court may agree with the treating physician that some future physical therapy or other treatment may help the employee adjust to the fusion. The adjuster and the state, along with the employee and his or her legal representative, hash out additional future treatments at final settlement conferences.

Some Other Thoughts on MMI

The adjuster is not the person to decide MMI. He or she will consult with the treating physician, or in many cases, ask that an impartial doctor evaluate the patient to help determine MMI. For MMI to occur, the adjuster must have offered reasonable medical care to the injured employee.

In some cases, the employee may decide not to treat further, and MMI may be imminent in those cases. For example, a doctor may recommend a surgery or procedure that the employee refuses. Or the employee may delay treatment to the point that the adjuster will ask the treating physician or the administrative law judge (ALJ) to declare that the employee is MMI.

With caseloads higher than we'd like to see in all lines of claims, some employees may still require treatment that the adjuster has not yet offered. Talking to the adjuster to determine what treatment may be outstanding can help your employer understand lags in treatment or delays in settlement and move the employee toward medical improvement.

The Million-Dollar Question to Achieve MMI

At times, your insured may believe the employee should be back to work and as good as new. If your employer suspects this, prompt your employer to ask the adjuster that million-dollar question: “Is this employee's medical status as good as it gets?" If the answer is yes, a doctor who can confirm this can help get the claim in front of an ALJ and settled.

Using solid nurse case management in trickier situations where the employee's symptoms fluctuate dramatically may help. Asking the adjuster to write to the treating physician to ask that physician's opinion on the following can also help. “Would any further reasonable treatment improve this employee's condition?" If the answer is no, the adjuster can usually begin the settlement process.

The Ultimate Goal of Workers' Compensation

We all want our employees to heal and return to work. No one wants to shortchange medical treatment to an injured employee. Treating injured employees until they reach MMI is the ultimate goal of any workers' compensation claim. However, when doubts about the length of time it takes for an employee to return to work, or outside information from coworkers or other sources determine the employee may be less than frank in his or her medical status, it is necessary for the adjuster to intervene.

A word of caution, however. You can open your agency to an errors & omissions claim if you become too involved in any type of claim. Ensure that if you do not have claims coordinators on staff who are very familiar with workers' compensation claims management, you avoid reviewing any medical information directly. Simply rely on discussions with your adjuster and communicate with human resources employees who handle the injury claims at your insured's location.

Federal laws protect medical information. However, under HIPAA Privacy Rules, there are certain carveouts for medical information in workers' compensation claims. In short, only those with a “need to know" should have access to an employee's medical information after a work-related injury. An experienced human resources person should gatekeep all medical information.


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