Erroneous Rating Causes

The goal of the Guides is to provide consistent ratings that accurately reflect the loss associated with a medical condition, and thereby, reduce the number of disputes over impairment ratings. There are many causes of erroneous ratings, including bias, differences in clinical and causation assessment, and misapplication of Guides criteria, either through a lack of knowledge and skills in rating impairment, time applied to the process, or willful intent.

The rating physician must be independent and unbiased. This can be challenging for any evaluator. However, it is not possible for the treating physician to be independent and unbiased because there is an inherent patient advocacy role. (Reference: Barth RJ, Brigham CR, Who is in the better position to evaluate, the treating physician or an independent examiner? The Guides Newsletter. September - October 2005; 55:8-11.) The Fifth Edition of the Guides states “The physician’s role in performing an impairment evaluation is to provide an independent, unbiased assessment of the individual’s medical condition, including its effect on function, and identify abilities and limitations to performing activities of daily living as listed in Table 1-2” (5th ed., 18).

One study revealed that almost half of physicians surveyed were willing to exaggerate clinical data to help a patient obtain disability certification. (Reference: Zinn W, Furutani N. Physician perspective on the ethical aspects of disability determination. J Gen Intern Med. 1996; 11:525-532.) Some physicians may feel that an impairment rating does not fully reflect the impact of impairment on the patient, resulting in a search for approaches that will increase the rating.

There are many potential rating errors that result from inaccurate clinical or causation analysis. These include inappropriate diagnosis, rating prior to maximal medical improvement, use of unreliable examination findings, inaccurate assessment of causation, and failure to apportion impairment to underlying etiology. Patient exaggeration of complaints is common. (Reference: Rainville J, Sobel JB, Hartigan C, et al. The effect of compensation involvement on the reporting of pain and disability by patients referred for rehabilitation of chronic low back pain. Spine. 1997; 22:2016-2024.) Incorrect clinical assessment based on these subjective complaints can result in the rating of impairment for a condition that is not present, has no objective findings, or that is unrelated to the alleged injury. A physician may choose to provide an inappropriate diagnostic label. Such mislabeling may have undesirable consequences, including creation of a false self-perception of illness, legitimizing medical intervention, and providing a basis for erroneous rating of impairment. (Reference: Brigham CR, Talmage JB, Ensalada L. The dangers of diagnosis. The Guides Newsletter. May/June 2000; 23:3,6.)

An erroneous rating will occur if the rating is based on clinical findings that are invalid. Findings must be reproducible if they are to serve as a basis for impairment rating. (Reference: Brigham CR. Consistency in measurement. The Guides Newsletter. July/August 2004;48:6-8,12.) Many clinical findings are not totally objective, i.e., independent of the examinee. For example, an impairment rating for loss of range of motion is based on findings of active motion, i.e., what the individual demonstrates. An individual may display less range of motion than his or her actual capability. Because an individual may demonstrate less than his or her capacity, but cannot demonstrate more than his or her capacity, inconsistent examination findings frequently will result in an improper assessment of greater impairment. Examiners vary in their clinical examination skills; therefore, there may be a lack of reliability in demonstrating clinical findings. Varying interpretations of electrodiagnostic and imaging studies may also alter the rating.

The Guides define standards for evaluation and consistency in approach. There are multiple potential sources of error in physical examination. The greatest source of error that occurs is examiner inexperience or lack of knowledge and specifically not adhering to the evaluation protocol set forth in the Guides. The protocol outlined in the Guides provides comprehensive examination criteria based on the condition being evaluated. However, error in assignment of impairment typically is a result of poor examination.

The Guides criteria must be applied appropriately and consistently. Common errors include rating based on unreliable data, rating of uninvolved regions, selecting the wrong method, and misapplying the criteria.