Nevada Workers' Compensation Law Blog : Nevada Workers' Compensation Lawyer & Attorney : Virginia Hunt Law Firm : Las Vegas Job Injuries & Worker Accidents

The FCE (functional capacity evaluation) often serves to let the physician off the hook on trying to please both his patient and the insurer on the issue of work release restrictions. The insurer may be pressuring the doctor to give a full duty work release, while the patient keeps telling his doctor that he does not think he will be able to go back to his pre-injury occupation or employer. When the doctor order a FCE before giving final work restrictions, then his job is easier because he can simply adopt the findings of the independent physical therapist who gives the FCE.

The FCE is a 2-3 hour test given at a physical therapy facility. Generally, the tests consist of lifting, walking on a treadmill, bending, carrying, and doing other physical movements that may or may not have anything to do with the physical activity you actually do at work. The FCE has validity criteria built into the various tests that can supposedly detect when the patient is not giving a full effort.

If you fail enough of the validity criteria and the test comes back invalid, then you run the considerable risk of your doctor no longer believing that you are incapable of returning to your old job.   Or, your doctor may tell you that his only option is to return you to work full duty when a FCE is invalid. That is not true, however. Your doctor may instead disregard the FCE results, and based on his own exams of you, may decide that you do have permanent work restrictions. Few doctors are unwilling to override an invalid FCE.

If your doctor gives you a full duty work release following your invalid FCE, then you can expect your benefit checks to stop immediately. Moreover, if you don’t try to go back to work full duty, your employer may terminate you.

The best way to handle this situation is to file an appeal when the insurer stops your benefit checks. Secondly, assuming you have some money left, you will want to pay a different physical therapist to redo your FCE. Expect to pay at least $600 up front for a repeat FCE. While this is a lot of money for an injured worker, it is essential to obtain a valid FCE showing that you should have work restrictions.  Otherwise, you will not be able to convince a hearing officer that your benefits should be reinstated and that your doctor should review the results of the second FCE. Some attorneys will advance the cost of a second FCE if the attorney agrees to take you as a client.  

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The March/April 2010 edition of the AMA Guides Newsletter reports that a review of over 6,000 cases, mostly from California, resulted in 80% of them questioned by expert rating reviewers.   For the very small number of Nevada cases reviewed for this study , the error rate was much less, with an average difference of 3% whole person impairment.  This study confirms what most attorneys who represent injured workers know about rating evaluations.  There is a tremendous difference in ratings by the various rating doctors authorized to perform ratings in Nevada, even though the rating doctors should theoretically reach the same numbers by following the methods in the Guides.

In discussing the causes of errors found in ratings done under the AMA Guides, 5th Edition, the newsletter authors state that it is more likely that an erroneous rating will be higher, rather than lower than is appropriate.  The greatest source of error is examiner inexperience or lack of knowledge.  Spine injuries are most likely to be rated incorrectly.  Errors were also found in ratings for shoulder injuries and carpal tunnel syndrome, while knee injury ratings were less likely to be wrong.

Because of the high incidence of error in rating evaluations, I always ask the adjuster to agree with me on which rating physician will do the initial rating evaluation.  Adjusters  want to avoid having to hire a defense attorney to litigate the PPD if the injured worker appeals from the PPD offer, and they want to close the claim as soon as possible. Adjusters will therefore often agree to use a rating physician who is well known and has a reputation for performing objective and accurate ratings.  However, if the adjuster does not agree to use a particular rating physician with the injured worker's attorney, the adjuster is obligated to use the rating doctor assigned by the Division of Industrial Relations from the rotating list of rating doctors. 

I sometimes see cases where the injured worker who is not represented by an attorney agrees with the adjuster to use one of the rating doctors on a short list sent by the adjuster.  It puzzles me that someone without any information about the doctors on that list would agree with the insurer to use one of the doctors suggested by the insurer instead of requiring that the insurer use the doctor assigned.  Invariably, the unknowing injured worker agrees to be rated by  a rating doctor that  I would never choose for my client.  The injured worker must then pay $650 up front for a second rating and appeal the offer based on the first rater's exam.  

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This is a real story about a real client.  We will protect his identity by calling him Joe, and by saying only  that he worked for a very large employer.  He hired me near the end of his claim, and after considering what  issues might still come up on his claim,  I agreed to discount my usual fee and represent him for a 20% contingency fee of any permanent partial disability award.

 When the  adjuster would not agree to use one of several rating physicians I suggested, a chiropractor was assigned from the rotating list maintained by DIR to conduct the impairment evaluation. I went with Joe to his rating evaluation, and it was apparent to me that the doctor had not  done very many rating evaluations.  The insurer offered Joe a 13% whole person impairment for his low back injury that included a surgery with a fusion at L5-S1 and ongoing neurological complaints in his legs.    The lump sum equivalent of that award for Joe, given his age and his average monthly wage, was $51,586.

I have advised Joe not to accept the offer, as I think that the AMA Guides call for at least a 20% impairment, and that the correct percentage may actually be over 25%.  I filed an appeal for Joe, and the insurer has agreed to do more diagnostic testing that will help determine whether he is entitled to a 25% PPD award instead of the 13% originally offered.

If the insurer offers a 25% award, the lump sum award will be approximately $99,200.  If that amount is offered, after payment of attorneys fees, Joe will net  about $79,360 for his PPD award.  You can do the math to determine whether it was worth it to Joe to hire an experienced workers' compensation attorney to help him on his claim.

According to DIR, in 2009, there were 6,616 rating evaluations done in Nevada.  DIR employees in the north and south are required to review only 10% of those rating reports for obvious errors or for questions that should be referred to  the panel of six rating doctorss.  It is anyone's guess as to the number of injured workers who should have received a higher PPD but didn't, because of errors by the rating doctors.  If you decide not to have legal representation during the time your claim is open for medical care, at least take advantage of experienced workers comp lawyers who are willing to review your PPD award for free.   

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Most people who call me about their Nevada workers' compensation claims tell me that they just want to get decent medical treatment and get on with their lives.  They usually say something about not pursuing a claim just to get money. They  emphasize that  they like their jobs, and they don't want their employers to think less of them because they have hired a lawyer to  get them medical care or  benefit checks after trying to deal with an insurance company that acts like they don't exist.  However, all injured workers should know a few things about money awards.  Here are a few facts about money and your workers' comp claim:

1. The amount of off work compensation benefits (TTD benefits)  depends on how much money you were earning 12 weeks before your injury, unless special circumstances apply.   

This is the basic rule used to calculate benefits, and there are special circumstances that may apply to you that will allow an increase in the average monthly wage figure used by the insurer to calculate your benefits.  There is also a maximum average monthly wage and maximum benefit that changes on July 1 of each year.  Right now, the maximum amount an injured worker can receive each month she is off work for an injury occurring after July 1, 2009 is $3,472.40.  As this average monthly wage figure is also used to calculate any permanent partial disability award at the end of your claim for any permanent injuries, you will want to make sure that the insurer is using the highest possible figure on your claim. For more information on how benefits are calculated, click here.

2. There is no pain and suffering awarded on a work injury claim.

Any money paid on a work injury claim is paid strictly in accordance with a set of laws and regulations governing workers' compensation claims in Nevada.  Money damages awarded by juries (or judges) for "pain and suffering", or lost of enjoyment of life, or loss of earning capacity, are related to personal injury lawsuits and not workers' compensation claims.  There are some circumstances that would allow an injured worker with a work injury claim to also file a personal injury lawsuit against the person or corporation responsible for the accident ,so long as the employer or co-employee is not sued.  In those circumstances, pain and suffering damages might also be awarded on the personal injury action.

3. Money awarded on work comp claims are for permanent injuries only.

You might have a terrible accident at work, causing you to be hospitalized for weeks, but if  you fully recover for your injuries, you  might not be entitled to a permanent partial disability award.  There are two types of money settlements typically involved in a Nevada workers' compensation claim involving serious injuries.  One is the permanent partial disability award that is determined by a rating doctor when the treating physician releases you from further care.   The rating doctor must apply the criteria in the AMA Guide to Evaluation of Permanent Impairment, 5th edition, to arrive at a whole person percentage of impairment.  That percentage is then inserted into a mathematical formula that also uses your average monthly wage, and your chronological age to arrive at a lump sum of money for your permanent impairment.  You must be familiar with the AMA Guides in order to know whether the percentage of impairment is correct and whether you should accept the offer by the insurer or file an appeal.

4.  Insurers sometimes close files without offering PPD awards when  awards should be given.

The insurer only schedules an impairment evaluation if the treating doctor states that it is likely that the patient has a ratable impairment.  The problem is that many surgeons do not know what a "ratable impairment" is under the AMA Guides, and these doctors think that there is no ratable impairment if the patient is able to return to work full duty.  I have seen many cases where injured workers were entitled to thousands of dollars on their claims for their injuries, and they never knew to question the insurer's closure of their claims without a rating evaluation.

5. Rating doctors make mistakes frequently, costing injured workers thousands of dollars.

Theoretically, several rating doctors should arrive at the same percentage of impairment if several doctors were to examine and rate an injured worker.  In reality,  the same injured worker can be rated by several rating doctors, and the percentages come out differently. That can make a huge difference in the amount of money offered by the insurer. Again, either you or your attorney should know how to apply the criteria in the AMA Guides so that you are offered the correct and highest percentage of impairment.  You also need to consider that it now costs $650 to obtain a second rating from the rotating list of rating doctors, and you don't want to spend that amount if the first percentage offered is correct.

6. A vocational rehabilitation lump sum buy out can be negotiable.

The second type of lump sum of money an injured worker can receive on his claim is a vocational rehabilitation lump sum buy-out.  If the injured worker has permanent work restrictions, and if the employer does not offer a permanent light duty job, he is entitled to vocational rehab benefits.  Those benefits usually consist of either a program of retraining, or a lump sum of money for the injured worker to go away and find a job or retraining on their own.  It used to be that the insurer could offer 1 cent for a lump sum buy-out  if it wanted to be particularly nasty. and the injured worker's only option was to accept a retraining program.  Now, the law requires the insurer to offer at least  40% of what the insurer would have to pay in monthly benefits if the injured worker had instead opted for a retraining program.  What many injured workers do not know is that insurers can sometimes be persuaded to offer more than the minimum lump sum.

7. You can't put a price on quality medical care.

The most important consideration in any work injury case is the quality of the medical care provided to the injured worker. Money is never a sufficient substitute for an injury that could have been treated by faster and better medical care.  Injured workers must treat with doctors on their particular insurer's provider list.  It is essential that the injured worker obtain information as to which of the doctors on that list show consistently  good surgical results, and which are fair to injured workers.

8. It may be difficult to predict how much money an injured worker will get for a PPD award at the outset of the claim.

When an injured worker comes for a consultation at the beginning of his claim, I may not be able to predict how much money will be awarded for a permanent partial disability award, because we don't know to what extent the injury will heal after more months of treatment.  All of the people I accept as clients want to get better.  ( People who impress me as only trying to obtain money are not clients I want. )  Some injuries, such as amputations, are easily ratable under the AMA Guides, and I can give the injured worker an estimate of what to expect.  Other injuries depend on loss of range of motion, or neurological testing, or a review of operative reports to determine an approximate percentage of impairment, and that is information that is usually unavailable at the beginning of a claim.

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I asked Family Law attorney Stacy Rocheleau of Rocheleau Law Group to write a guest blog post for me on workers' compensation benefits and divorce.  The Rocheleau Law Group handles divorce, child custody, and guardianship matters and offers a free legal guide.  Their website is at www.rocheleaulaw.com, and phone is (702) 914-0400.  This is what Attorney Rocheleau wrote:

Are you getting a divorce and wondering who will receive the income your spouse received from a work related injury? 

This question is often asked and the answer can be complex. Earnings by either party could be community property, so any income received from a work related injury would need to be decided by the court in a divorce. Who receives the income will depend upon how the award is classified.

There are at least four different ways that workers' compensation benefits can be classified:

Treatment as wages. If the payments are designed to replace lost earnings due to a work-related injury, the payments would be characterized as wages. Those payments received during marriage are marital property; those received before or after marriage are individual or separate property.

Treatment as personal injury award. A workers' compensation award could be classified as a personal injury award, on the basis that they are meant to compensate for physical injury rather than lost wages. In that case, the award would then be considered that spouse’s separate property.

Treatment as disability pay. In some instances, a wage replacement analysis will be used, but the workers' compensation payments would be treated or classified as disability pay. In that event, any compensation received during marriage is community property and compensation received after marriage is the injured worker's separate property.

Treatment according to when the right was acquired or earned. Even despite a situation where a workers’ compensation award will in part or in whole replace post‑divorce wages, the award is community property if the right was acquired or earned during the marriage. 

Further complicating the analysis is that work related injury benefits, or workers compensation benefits, can be awarded to an employee injured on the job either as a lump sum or in weekly installments.

In Nevada, workers compensation benefits are generally treated as a wage replacement and any payments received during the marriage would be considered community property, unless part of the award is specifically labeled as a personal injury award for disfigurement, pain, or suffering, and then that portion is considered separate property.

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One type of physician that injured workers commonly encounter is the physiatrist,  also known as a physical medicine and rehabilitation (PM & R) physician.   While the name  sounds similar to a psychiatrist,  a  physiatrist  treats physical injuries as opposed to mental or behavioral problems. A surgeon may refer her patient to a physiatrist after a surgery when additional physical therapy is recommended.  Or, a physician who sees an injured worker in a clinic setting for the first couple of visits may refer the patient to a physiatrist when it appears that the injury  may require  more care over several weeks or  months.  

Physical medicine and rehabilitation (PM&R), or physiatry  is a branch of medicine which aims to enhance and restore functional ability and quality of life to those with physical impairments or disabilities. Physiatrists must complete four years of medical school,  one year of internship and three years of residency.   Physiatrists specialize in restoring optimal function to people with injuries to the muscles, bones, tissues, and nervous system. 

A physiatrist who treats an injured worker usually coordinates the medical care if several specialty physicians are required to treat different injured body parts.  If surgery has already occurred, or no surgery is necessary, the physiatrist may order physical therapy or may prescribe medication while the patient recovers from his injuries. When the patient is stable and does not need more treatment, the physiatrist may then order a functional capacity evaluation (FCE) to assist him in determining the patent's permanent work restrictions.  Finally, the physiatrist tells the adjuster whether the injured worker should be rated for permanent impairment or not. 

 If you are not satisfied with the physiatrist that is currently treating you for your work injury, you may be entitled to change physicians. Click here to read more about changing physicians.

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Effective February 10, 2010, the cost of a permanent partial disability evaluation on a Nevada workers' compensation claim is $650.99 for one or  two body parts.  An injured worker who does not agree with the percentage of impairment found by the assigned rating doctor may obtain a second rating evaluation by paying this same fee for a second rating.   However, if the injured worker does not think an exam is necessary in order for a second rating doctor to conclude that the first rating doctor made an error, he may pay the assigned second doctor $324.85 for a records review and report.  Click here for the  form to request the name of a second rating doctor from the rotating list maintained by the Division of Industrial Relations.  Read my earlier blog post on how to contest PPD awards.

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I have included a graphic to clarify what happens when the treating doctor tells the injured worker that he is "stable and ratable".   I have divided injured workers who are stable and ratable into two groups, depending on whether the injured worker is released to go back to work full duty, or whether the injured worker has permanent work restrictions.

If the injured worker has permanent work restrictions, then he is assigned a vocational rehabilitation counselor if the employer does not offer a permanent light duty job within 30 days of receiving permanent work restrictions from the treating physician.  Vocational rehabilitation benefits are started also.  (They are payable every two weeks and are the same amount as the temporary total disability check the injured worker has been receiving while out of work.)  Even though the vocational rehabilitation counselor will not know how much retraining the injured worker will receive until after the permanent partial disability percentage is determined, the counselor will start meeting with the injured worker to discuss potential programs.  Alternatively, the injured worker may receive a vocational rehabilitation lump sum buy-out instead of participating in a vocational rehabilitation retraining program. How much the insurer will offer will depend on the percentage of impairment.

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This week I visited the Las  Vegas Professional Institute of Technology & Accounting (LV-PITA) to get a first-hand impression of the school's retraining programs, to pop in on a few classes, meet some instructors, and to meet director Laurie Clemens. I like to personally acquaint myself with the doctors, vocational counselors, nurse case managers, and even the adjusters who will be major players on my clients' claims.  LV-PITA was provisionally licensed last June and expects its permanent accreditation from the state after its first year in operation.  The school is located in the Fountain View Business Park at Decatur, near Rochelle. 

Programs offered include accounting, basic computer training, networking, various network technologies, PC repair, and software applications used by office management staff and computer software specialists.  Click on this link  for more information on on certification programs and course specifics.

Laurie Clemens is an attractive, vivacious blonde with who exudes positive energy.  I will give you her official bio later.   About half of her 170 enrolled students are injured workers participating in retraining  programs paid by industrial insurers.  The other students are mostly older individuals who are referred by various other state and federal agencies that provide funds for vocational retraining.  LV-PITA also generously provides free  computer and job search classes by appointment every other Tuesday for all unemployed Las Vegans. 

I was particularly impressed that LV-PITA was working on retraining programs suitable for Hispanics who need help learning in Spanish before using more difficult materials in English.  The school also teaches the visually impaired, and has experimented and found the best method to teach those individuals who require a one-handed key board.  One of my former clients with a  severe hand injury and permanent impairment was very satisfied with the quality of instruction he received from the school.

Laurie is a native Las Vegan with many ties to the business community.  Having those long-standing connections gives her a tremendous advantage when placing students in internships and when helping graduating students with job placement in these difficult economic times.  Stay tuned for more information about LV-PITA and other schools I intend to visit myself.

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Apparently,  the doctors who wrote the American Medical Association's Guides to the Evaluation of Disease and Injury Causation  don't know the answer to this week's question  either.  Dr. J. Mark Melhorn and Dr. William Ackerman, editors of the 2008 book designed to help workers' comp doctors answer medical causation questions, write that disability in the workplace is rampant in the United States.  These docs state in their Foreword that injured workers with poor genetic makeups and preexisting psychological problems share the blame for the work disability epidemic with plaintiffs' lawyers. They write, " The attorneys need to understand that by encouraging the worker to remain off work rather than getting back into the work place, they are actually doing damage to their client." 

I wholeheartedly agree that any Nevada attorney who encourages their client to remain off work unnecessarily is doing a great disservice to their client.  But are there any work comp attorneys in Nevada advising their clients to stay home longer than necessary?  I hope not, because there is no relationship between how long an injured worker is off work for his injury and his permanent partial disability award at the end of the claim.  

 There is no financial advantage to an injured worker in Nevada remaining  off work.  Most injured workers figure that out immediately.  If an injured worker is only getting two-thirds of his wages while he is off work, there is no financial gain to his staying at home.  Additionally,  the percentage of impairment and the final award at the end of the claim is not determined by how long an injured worker has been out of work. ( For more information on how awards are determined, see the articles in this blog on permanent partial disability awards.)

Unfortunately, some of the medical providers who treat  injured workers in Nevada do not understand that the vast majority of workers' compensation claimants are  hard-working people who want to return to work as quickly as possible.  If an injured worker is out of work for a lengthy period of time, that person will invariably lose money the longer they remain off work.   Any attorney who encourages his client to stay off work unnecessarily does not understand Nevada law.  It would be great if the doctors treating injured workers knew a few things about Nevada law also, so that they do not erroneously think that a  patient  who tells his doctor that he cannot physically return to work yet is profiting from the system. 

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Last week the Nevada Supreme Court unanimously decided that rating doctors evaluating injured workers with spinal injuries can add one to three additional percentage points to the permanent partial disability award if the rating doctor finds that the spinal injury has substantially impaired activities of daily living (ADL's). The Nevada Self-Insurers Association had filed a lawsuit naming the Nevada Attorney for Injured Workers and the Nevada Division of Industrial Relations, arguing that  a section of the American Medical Association Guides to the Evaluation of Permanent Impairment allowing for impairment of ADL's  violated Nevada law.  A district court judge agreed with the Self Insurers, and entered an order back in June 2008 that allowed insurers to withhold payment of that portion of an injured worker's award for ADL's until the Nevada Supreme Court decided the appeal.  Injured workers were then put in the unfair position of having to wait until the Nevada Supreme Court decided the case if they wanted to accept their award in a lump sum payment.  Most injured workers could not wait and ended up losing their percentage points for ADL's so that they could accept their permanent partial disability awards immediately.  

Click on this link to read the complete decision by the Nevada Supreme Court.  If you are an injured worker who chose to wait for the Nevada Supreme Court to decide this case and did not accept your PPD award in a lump sum, you should contact your adjuster if you do not receive a new PPD offer that includes the ADL's award within the next 30 days.  The Division of Industrial Relations has notified all third-party administrators that they are to comply with the Nevada Supreme Court's decision.   Click these links for more information on how permanent partial disability awards are calculated, or information on how to contest an award and get a second rating.

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The Health Care Quarterly report in the recent issue of "Las Vegas In Business" has some good news for injured workers deciding which retraining program is most likely to lead to actual employment in the future. Health care employment was up 2,300 jobs from last year according to a research analyst.  The health care industry is recession-resistant because these are crucial jobs and because the health care industry is funded by either insurance or government programs.  The industry  expects more jobs with the opening of the Cleveland Clinic Lou Ruvo Center for Brain Health. 

Health care employees generally earn above-average wages depending on their level of training.  While state budget cuts in Nevada are affecting health care jobs also, and no one knows how the health care industry will be affected with federal health care reform, these jobs are still a solid career choice.

There are several vocational schools in Las Vegas that offer health care job training.  Talk to your vocational rehab counselor, and your attorney, about which schools are reputable and which assist their students in job placement.  Make sure you visit several schools and sit in on a few classes before deciding which school and which retraining program is best for you.

 After you are enrolled in a retraining program,  immediately  start thinking ahead to when the retraining program will end.  Only 28 days of benefits are paid when the formal retraining program concludes, and if you are not successful in finding a job right away , you are left without any income.   That means that you need to begin job search efforts before the school portion of the program ends.  Click on this link where  I found some good suggestions for networking and using existing contacts for referrals to potential employers who may be hiring.

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I asked local bankruptcy attorney Sam Benevento to provide an answer to the question:

Will filing a bankruptcy affect your workers’ compensation claim? Here's Sam's answer:

To understand the answer to this question, it helps to understand the difference between a Chapter 7 and a Chapter 13 bankruptcy. Chapter 7 is a “straight” bankruptcy. Under Chapter 7 you attempt to discharge your debts without payment. You can protect (exempt) your principal assets in chapter 7 (like a residence, household goods, car, retirement account, and other things) but non-exempt assets can be seized by the Chapter 7 Bankruptcy Trustee to pay your debts. Chapter 13, on the other hand, is a reorganization under which you voluntarily make payments to your creditors through the Chapter 13 Bankruptcy Trustee and thereby repay a portion (or sometimes all) of your debts.

Workers’ compensation benefits are exempt under Nevada law. NRS 616C.250. This means that if you file a chapter 7 bankruptcy, the Bankruptcy Trustee will not be able to seize either your monthly benefit or your lump sum settlement. However, the benefits are counted as income to determine whether or not you are eligible to file a chapter 7 in the first place. Also, if the benefits are deposited into a bank account with other funds (i.e. commingled), they may be at risk of seizure. So be sure to keep any lump sum settlement completely separated from other funds.  

In Chapter 13, the Trustee does not seize assets under any circumstances, so your workers’ compensation benefits are always protected. However, benefits received both prior to and after filing the Chapter 13 may be used in calculating the amount of your bankruptcy payment.

You should also be aware that worker’s compensation benefits may be garnished directly by a child support creditor.

Sam Benevento has been practicing bankruptcy law in Nevada for over 20 years and exclusively represents Debtors (that is – people and small business that need to file for bankruptcy protection). If you think that you may need to file, call Sam at 702-433-2000 to schedule a free consultation.

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For many injured workers who are unable to return to their old jobs due a permanent injury, a formal program of retraining with a vocational rehabilitation counselor may not be an option, or may not be the best option.  Hispanic employees who have difficulty reading and writing English, for example, will not be able to participate in retraining programs, because almost all programs are taught in English.  Many  injured workers will have to come up with a way to market other skills they have, or will have to start their own businesses.

Nevada law prohibits an industrial insurer from funding self-employment efforts directly.  However, those injured workers who want to, or who must start a small business will at least receive a vocational rehabilitation lump sum buy-out that will help.  The amount of a vocational rehabilitation lump sum buy-out will vary, depending upon the PPD rating of the injured worker, and whether the insurer can be convinced to pay more than the minimum amount the insurer must offer.  See my article onlump sum buy-outs for more information.

Because a vocational rehab counselor is primarily involved in enrolling injured workers in formal retraining programs, the injured worker may not have much help in setting up his or her small business.  I have provided some useful links below for the injured worker who is just starting a small business:

- Checklist for starting a small business by theIRS

- Business name registration for sole proprietor in Clark County

- State business license

- Visit the Nevada Department of Taxation for more information on necessary licenses

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I sat down recently with seasoned vocational rehabilitation counselor Jeff Shea to discuss  how the depressed local job market  was affecting Nevada's injured workers who are referred for vocational rehabilitation services.  Jeff is no stranger to overcoming physical adversities himself, and an injured worker cannot complain that Jeff does not personally know how to deal with the extra challenges of a physical disability when reentering the workplace following a devastating injury. Jeff is from Philly, and that explains a lot about his no-nonsense, direct approach to advising injured workers. If you need your voc rehab counselor to sugar-coat the facts regarding today's local job market, Jeff is not the counselor for you.   However, if you do need to quickly know what the best schools are in town, and what the realistic job prospects are in the Las Vegas labor market, Jeff can be a valuable ally.

Vocational rehab counselors like Jeff Shea are independent contractors who are hired by adjusters.  There are voc rehab counselors who take pride in their work, who have integrity, and who are not scared off by insurers threatening  to take their business elsewhere whenever an adjuster disagrees with the voc rehab counselor.   I think Jeff  is one of those counselors, and I am impressed when he goes the extra mile on behalf of an injured worker he believes is really trying to make their retraining  program successful.   However, if an injured worker fails to show up for class repeatedly and has no reasonable excuse for poor class performance, don't expect  much sympathy from Jeff.  While I have questioned Jeff's very tough approach to counseling in the past, I think his approach has merit in today's difficult economy. 

When I expressed my concern for Hispanic clients who are unable to return to their former jobs and who are unable to participate in retraining classes taught only in English,  his response was, " They should have learned English by now. This is the USA."   I have a different view of the problem than that, but I also am at a loss as to how to provide retraining services to injured workers who cannot read and write English sufficiently to attend available retraining programs. 

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The State of Nevada, Division of Industrial Relations, has approved the Nevada Medical Fee Schedule effective February 1, 2010.  It provides that rating physicians are entitled to charge $650.99 for a rating evaluation that includes up to two accepted body parts.  The rating doctor may charge an additional $217.41 for each additional body part.  Injured workers who contest the initial rating evaluation obtained by the industrial insurer are required to adhere to this fee schedule when obtaining a second rating evaluation from a second rating doctor.  However, pursuant to NRS 616C.100,  a hearings or appeals officer may reimburse the injured worker the cost of the second evaluation if the hearings or appeals officer finds that the second rating should be used as the basis for the permanent partial disability award.

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The State of Nevada DIR announced that mileage reimbursements to injured workers traveling to and from medical care or for vocational rehabiliation purposes has been decreased from 55 cents a mile to 50 cents a mile, effective January 1, 2010. 

The regulations for mileage reimbursement of travel expenses are found at NAC616C.150.  The request for reimbursement should be on the DIR form D-26, which has the rules for reimbursement on the back side.  Please be sure to send in your reimbursement request form to your adjuster within 60 days of the date of your first trip on the form.  Many injured workers make the mistake of waiting until the end of their claim to send in requests for mileage reimbursement, and the adjuster is then only obligated to pay for the last 60 days of qualifying travel. 

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Q: What is FMLA?

A: FMLA is The Family and Medical Leave Act of 1993, a federal law that requires employers of 50 employees or more to grant up to 12 weeks of unpaid protected job leave to eligible employees for certain family and medical reasons.   There is a 12-month eligibility requirement, and only serious health conditions are covered. 29 U.S.C.A. Sections 2601, et.seq.

Q: Can my employer reduce my FMLA time while my treating physician takes me off work for my accepted  work-related injury or occupational illness?

A: Yes, your employer can require that you complete FMLA paperwork and can reduce the amount of FMLA time you have available even though you are off work under an accepted workers' compensation claim.

Q: If FMLA time is running during my work injury, can my employer terminate my job?

A: During FMLA time, your employer may not terminate your job. At the end of your FMLA time, or 12 weeks, if your employer does not have light duty work within your restrictions, and if your employer decides not to extend your unpaid leave of absence, your employer may decide to terminate your employment. Your workers’ compensation benefit checks would continue, however.  You would also be considered for vocational rehabilitation when you have permanent work restrictions if your employer is unable or unwilling to rehire you and offer you a permanent job within your permanent work restrictions.

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After every visit to a treating doctor, the injured worker should make sure that he or she leaves with a copy of  a physician progress report (PPR).  Most doctors who are on insurers' provider lists use the DIR- approved physician progress report form.  However, some doctors have forms on their own stationery that  have the same information, but in a different lay-out.  If the nurse or assistant checking you out after the doctor's visit does not offer you a copy of the PPR, please insist that they give you a copy before you leave.  Then read the PPR before you leave the doctor's office to make sure that the information is correct and that you understand what the doctor has written..  A copy of  this form will be sent to the adjuster handling your worker's compensation claim, and a copy is often sent to your employer.

The top portion of this form states in abbreviated medical terms what your injury and diagnosis is.   If you have injured more than what is stated in this section of the form, you should have a discussion with the doctor to make sure that he or she has examined and noted all body parts that were injured and that need treatment. 

The second section of the form is important when the doctor releases you from care.  In that section, the doctor checks boxes that state that  you are, or are not, ratable and may have suffered a permanent disability.  If the doctor checks "no" to those two boxes, the adjuster is not likely to schedule you for a permanent partial disability evaluation, which is necessary to receive a settlement for your injury.

The section entitled "Treatment plan" often tells you whether the doctor will be requesting approval for MRI's, more physical therapy, or a referral to a specialist.    Hopefully, your doctor's staff will then follow-up with the proper authorization request form so that the treatment plan is approved and put into motion.

The bottom third of the PPR is very important and tells the injured worker whether the doctor has taken you off work completely (totally temporarily disabled), or whether the doctor has given you work restrictions.    If the doctor gives you temporary work restrictions, it is your responsibility to give a copy of the PPR with these restrictions  to your employer and ask whether your employer has work available within these restrictions.    Keep in mind that a copy of this PPR goes to your adjuster, and if the employer tells the adjuster that light duty work is available,  the adjuster will not continue to pay bi-weekly  TTD benefits to you.

Read the PPR before you leave the doctor's office to make sure you know whether the doctor has released you to  full duty or with temporary work restrictions.  Often injured workers misunderstand what their doctors verbally tell them about returning to work.  You need to know what the doctor writes on the PPR, and if you disagree with what the doctor writes, you want to calmly and politely ask to speak to the doctor again to get a clarification before leaving the doctor's office.

Some doctors tell injured workers that they are prohibited by Nevada law from taking an injured off work completely.  That is false information.  The doctor has a legal obligation to provide care for his patients regardless of who is paying for his services.  Many doctors, however, feel pressure from adjusters and case managers to give work restrictions instead of taking injured workers off work completely for extended periods of time.   So long as the employer provides work within whatever restrictions the doctor gives on the PPR, the injured worker must show up for work, or take leave without pay if available, or use whatever sick leave is available.   The only other recourse the injured worker has is to request a change of physicians to a more caring doctor.

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Under Nevada workers' compensation law, the final settlement, called a  permanent partial disability award (PPD) is based on 3 factors: 1) the percentage of impairment found by a rating doctor, 2) the average monthly wage of the injured worker, and  3) the age of the injured worker when the award is calculated.  If the average monthly wage was calculated correctly on the claim, and the insurer has the correct age for the claimant,  the  percentage of impairment offered by the insurer is the only basis an injured worker has  for challenging the  amount of the PPD award.  Both the injured worker and the insurer can disagree with the percentage of impairment the rating doctor finds. However, injured workers  who file  appeals of their PPD awards, arguing only that the amount of money offered is too low, almost always lose their appeals. 

An injured worker must be able to show a specific error in how the rating doctor determined the percentage of impairment in order to win an appeal regarding  the amount of the PPD award.  Or, if the insurer is refusing to offer the PPD percentage recommended by the rating doctor, the injured worker needs to be able to argue why that percentage is correct.  A review of the PPD award by an experienced  Nevada workers'  compensation attorney is necessary to help an injured worker with a serious,permanent injury decide whether an appeal should be filed or not, and whether money should be spent getting a second rating report.   Many workers' compensation lawyers in Las Vegas will review a rating report for free as part of a free initial consultation.

Rating doctors must use a book called the AMA Guides to Evaluation of Permanent Impairment (currently the 5th edition) to determine the PPD percentage.  The Guides are complex.  Many rating physicians, especially new doctors added to the list,  make mistakes.  While the Division of Industrial Relations is supposed to check PPD reports,  it is really up to the injured worker  and her work comp lawyer to find any errors, and to then file an appeal and get a second rating within 70 days.   Injured workers frequently think that the rating doctor has made a math error in adding the percentages in the last section of the report.  An experienced work injury lawyer can explain to an injured worker that  the Guides have charts requiring  that numbers be combined rather than added to arrive at the right percentage.  

If the injured worker' decides to contest the PPD award, he must first file a timely appeal   on the request for hearing form provided with the PPD offer.  Next, his attorney obtains the name of a rating doctor from the rotating list from DIR.  The attorney then sends a complete copy of the client's medical records to the assigned rating doctor, schedules an appointment for the rating exam, and pre-pays the current fee for a rating.  The fee for a rating,  effective 2/1/09 through 1/31/10 is $630.80. ( When hiring a work comp attorney, an injured worker should ask whether the lawyer goes with his or her clients to rating evaluations.)  

If the second rating doctor finds a higher percentage of impairment, the report is sent to the insurer.  If the insurer won't pay the higher PPD, the hearing officer may, or may not, award the higher PPD when the appeal is heard.  There is no guarantee that the second rating doctor will find a greater percentage of impairment.  If the second rating is lower than the first, the injured worker simply withdraws the appeal, and accepts the amount that the insurer has previously offered.  The hearing officer may, or may not order the insurer to pay any higher percentage, and the hearing officer can order the insurer to reimburse the injured worker for the cost of the second rating.  Both the insurer and the injured worker have the right to appeal the hearings officer's decision to an appeals officer. 

A hearings officer or appeals officer may order a third rating with either a mutually agreeable rating doctor or the next assigned rating doctor from the rotating list.  An injured worker is usually prevented from receiving any portion of his PPD award in a lump sum if the amount of the PPD is appealed, so the injured worker  will want to make sure that he or she has been advised by an experienced Nevada workers' compensation attorney before deciding to litigate this issue.  Once the injured worker elects to receive a PPD award in a lump sum and is paid, there is nothing that can be done to correct any wrong percentages of impairment.  As it costs the injured worker nothing to have the PPD offer reviewed by a knowledgeable attorney in Nevada workers' compensation law, it would be unwise to accept an award without first knowing whether it is correct or not.

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When an injured worker's treating physician reports to the insurer that there may be a permanent impairment, the adjuster should schedule an impairment evaluation with a rating doctor. The impairment percentage determined by the rating doctor results in a monetary settlement known as a permanent partial disability award (PPD).  Rating doctors are chiropractors and physicians who have taken a test on how to determine permanent impairment using the criteria in the AMA Guides to Evaluation of Permanent Impairment (currently the 5th edition).  Those doctors' names are on a rotating list of rating doctors  maintained by the State of Nevada Division of Industrial Relations.

If the injured worker or his attorney do not agree with the adjuster on a particular rating doctor to do the exam, the adjuster must schedule the exam with the next doctor assigned from the rotating list.  A chiropractor may perform the rating exam if the injury is to the musculoskeletal system (spine, knees, shoulders, feet, hands, etc.).  If the injury is to internal organs or is very complex, only a medical doctor will be assigned.   Only qualified eye doctors rate vision impairment.  The rating doctor cannot be a doctor who has treated the injured worker or who has been asked to do a consultation.

The rating takes place at the doctor's office. The adjuster is responsible for sending all of the medical records before the exam.  However, it is not unusual for records to be missing.  Almost all rating doctors allow the injured worker's attorney to be present for the exam.  The insurer must pay for the initial rating, and the cost of a rating depends on the number of body parts injured.  Effective for 2/1/09 through 1/31/2010, the cost for up to two body parts is $630.80.

The AMA Guides give detailed instructions to the rating doctor on how to determine an impairment percentage for each body part.   Many injuries are rated by measuring how much motion is lost in the joint.  Some injuries are easy to rate, such as amputations. However, most injuries require multiple measurements and depend on the doctor's ability to apply the Guides correctly.  There are often significant differences in rating percentages depending on which doctor is doing the exam.

Not every injury requiring a surgery is ratable.  An injured worker's ability to return to work is not used to determine impairment. Pain is not ratable, but injuries to particular nerves can be rated.

The rating doctor sends his report to the insurer within 14 days of the exam.  The insurer must then make a written offer within 14 days of receiving the report.  The offer must be based on the percentage of impairment determined by the doctor, or the insurer must explain in writing why the insurer disagrees with the percentage.  Injured workers who disagree with the percentage given by the rating doctor, or with a lesser percentage offered by the insurer, may file an appeal and obtain a second rating from another rating doctor assigned from the rotating list. (For more information go to the blog "I Disagree with My PPD Rating".)

The PPD award is calculated by using the percentage of impairment given by the rating doctor, and the average monthly wage of the injured worker, and the injured workers age at the time of the award.  It is necessary to have the actuarial tables and the correct statutory formula to correctly calculate the award. (See DIR forms 9a and 9b).   Injured workers with the same percentages of impairment for the exact same injury will receive different PPD awards depending on how much money they were making at the time of their accidents, and how old they are.

An injured worker may accept a PPD award in a lump sum, or may elect to receive the award in installments until she is 70 years old.  Awards taken in a lump sum are reduced to present value. If the injured worker's impairment was greater than 25%, only the equivalent of a 25% PPD can be taken in a lump sum.  The percentage over 25% is paid in installments.

Although the PPD percentage is not based on an injured worker's ability to return to work, the percentage does govern the length of a retraining program that can be offered if the injured worker is entitled to vocational rehabilitation services.  (See blogs and articles on vocational rehabilitation for more information.)

Please note that this is only a summary of how permanent partial disability awards are determined in Nevada.  Pertinent statutes andregulations are:  NRS 616C.100, NRS 616C.490, NRS 616C.495,  NRS 616C.110, NAC 616C.1162, NAC 616C.103.  Many attorneys offer a free review of a PPD rating report for signs of obvious errors.

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Nevada law (NRS 616C.555), provides that the length of a retraining program that may be authorized is determined by the permanent partial disability impairment percentage (the PPD).   This law does not make a lot of sense in that a an injured worker may have a high PPD under the AMA Guides to Evaluation of Permanent Impairment, but may be capable of returning to work, particularly if the injured worker’s job was sedentary.   Similarly, an injured worker may rate a low PPD under the AMA Guides , but may not be capable of working unless he is retrained for a long time. Nonetheless, the length of a retraining program is limited by the PPD percentage, regardless of the actual needs of the injured worker.

Injured workers with PPD’s of 1% to 5% may be offered programs up to 9 months long.

Injured workers with PPD’s of 6 to 10% may have programs up to 12 months.

Injured workers with PPD’s of 11% or more may have programs up to 18 months.

Only severely injured workers, or those with exceptional circumstances may obtain programs that are longer under NRS 616C.560.  The law is worded in such a way as to allow insurers to offer less than the maximum allowable length of retraining if the insurer believes that the injured worker could be retrained to gainful employment in a shorter amount of time. A good vocational rehabilitation counselor will try to request the best program for the injured worker.  Realistically, it is very difficult to find suitable retraining programs for injured workers who were earning high wages at the time of their accidents because of the statutory restrictions on the length of retraining programs.

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Once a claim is accepted by the insurer or the third-party administrator handling the claim, if the injured worker is off work for more than five days in a row, or five days within a twenty-day time period, temporary total disability benefits (TTD) are paid.   In order to pay TTD benefits, the insurer must first get information from the employer on a wage verification form that asks the employer what the injured worker’s gross wages were in the 12 weeks before the date of the injury.  Any overtime wages the injured worker earned during  those 12 weeks are included.   This earnings history is then used to determine the average monthly wage.   An injured worker can request that the insurer use a one-year earnings history instead of a 12-week earnings history if that would result in a higher average monthly wage.

The TTD paid is then calculated at 66 2/3% of the average monthly wage. For example, if the injured worker’s average monthly wage is $3000, the TTD benefits would be $2000 if the injured worker were off work for one month.   There is a maximum average monthly wage set by the state each year.   Injured workers who earn more than the state maximum average monthly wage will have their benefits based on the maximum average monthly wage, and will therefore receive less than 66 2/3 of what they were really earning before their injury date.

Regulations address how an insurer is to determine the average monthly wage of injured workers who have not worked for 12 weeks before the date of their injury, or how to calculate average monthly wage of piece workers, or union employees, or other individuals with special circumstances.   These regulations also address when the insurer should exclude days from the calculation if the employee had a certified illness or absence from work so that the average monthly wage calculation is not unfairly too low.   Injured workers who were working for more than one employer at the time of their accident may have the wages of the second employer, called the concurrent employer, included in the average monthly wage calculation. However, it is up to the injured worker to notify the adjuster that there is a concurrent employer and to supply that wage information to the adjuster. 

It is very important that the average monthly wage determination is correct, and that it is as high as it should be for the injured worker. This average monthly wage figure is used to calculate benefits when the injured worker is off work due to the injury, and is also used to determine how much money the injured worker receives for a permanent partial disability award.   The average monthly wage established on the claim when it is closed will also be the average monthly wage used if the claim is ever reopened in the future.   Injured workers who request a free consultation with an attorney should always discuss with the attorney whether the average monthly wage calculation appears to be correct.

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 Work-related traumatic injuries to knees and shoulders are common. These are two of the most complex joints in the body.  If an injured worker is not getting better with physical therapy, reduced activity, and drugs to reduce inflammation, the initial treating physician may then order a MRI to better diagnose injury to the ligaments, tendons, and cartilage. The clinic physician  may also refer the patient to an orthopedic physician.  An injured worker may ask for a specific orthopedic physician on the insurer's provider list. 

Nevada workers in occupations that require extensive kneeling, heavy lifting, squatting and climbing are at risk of  meniscal tears to the knees.  (The menisci are pads of cartilage that act as cushions between the femur and tibia bones, and they help distribute body weight and minimize friction within the knee joint.)  Most meniscal repairs can be done at an out-patient surgical center with an instrument called an arthroscope that creates only small scars.   Recovery time is usually quick, and  if a partial meniscectomy is done, a 1% whole person permanent partial disability award is given.  If you have had a knee surgery on your accepted workers compensation claim and the insurer tries to close your claim without a rating evaluation, you should consult with an attorney right away.

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When an injured worker is terminated, and the reason for job termination, are important.  If an injured worker files a claim for an injury after he is fired or layed off, then the law presumes that the claim is not valid.  Recently, the Nevada Supreme Court interpreted NRS 616C.150(2) in Levinson v. Milko, 124 Nev. Adv. Op. 35 (2008), and stated that the injured worker must prove that the injury did not occur after the worker was terminated.

Until recently, it was difficult for injured workers to get temporary total disability benefits while recovering from injuries while they had temporary work restrictions if the employee was fired while working on temporary light duty.  The insurer would deny TTD benefits because the employer would have had light duty work available if the employee had not been fired for cause.   Hearings and appeals officers rarely questioned the reason the employer fired the injured worker.

A.B.281, Section 5 amends NRS 616C.232 to make it clear that only compensation for TTD may be denied.  S.B. 195, Section 4, additionally amends that statute, effective October 1, 2009, to require that only a discharge for gross misconduct will disqualify an injured worker from TTD benefits. 

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When an injured worker is taken off work by the treating doctor, the insurer pays the injured worker 66 2/3 of the injured worker's average monthly wage if it does not exceed the state's maximum average monthly wage for the year in which the accident occurred.  For injuries occurring after July 1, 2009, the maximum average monthly wage has been certified by Nevada's Dept. of ESD as $5,208.60 a month.   That means that an injured worker who is unable to work for a month can receive a maximum of $3,472.40 a month in benefits.  As benefits are usually paid every two weeks, and each day in a 14 day period is counted, the bi-weekly benefit check would be $1,603.88.  If the injured worker is earning less than the state maximum average monthly wage, the benefit is 66 2/3 of the actual gross wages earned.  Rate charts showing the maximum average monthly wage going back to fiscal year 1974 are at this link.

The period of earnings that are examined is usually a 12-week period immediately preceeding  the date of the injury.  However, an injured worker may request that the insurer use a one year earnings history, or the full period of employment if it is greater than 4 weeks, but less than a full year, if it would result in a higher average monthly wage calculation.  The regulations on how to fairly calculate an injured worker's average monthly wage begin at NAC 616C.420.  If an injured worker has an unusual employment arrangement, has more than one employer at the time of his accident, or thinks that the benefits paid by the insurer are less than 2/3 of his typical monthly gross income, a free consultation with an attorney would be wise.   The average monthly wage that is established by the insurer to calculate the amount of temporary total disability benefits is also used to calculate how much a final permanent partial disability award will be at the end of the claim.  It is one of the most important determinations the insurer makes on the claim.

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The 2009 legislative session was preoccupied with the economic crisis,  the state budget, and an unprecedented number of bills vetoed by the governor, the majority of which  were promptly reaffirmed by the state assembly and senate. Injured workers seeking reforms didn't stand much of a chance to make significant changes in this climate.   However, Assembly Bill 281 made some minor reforms to NRS 616C.090, the law allowing insurers to establish exclusive providers lists from which injured workers must choose a treating doctor. 

Section 3 to A.B. 281 clarifies that an injured worker may request an alternative choice of physician from the insurer's provider list without the insurer's approval , if the alternative choice is made within 90 days after the injury.   However, expect insurers whose initial denial of the claim is overturned to continue to argue that the injured worker has no right to choose an alternative treating physician after 90 days, even if it takes more than 90 days to get the claim accepted after a lengthy appeals process.

This bill also clarifies that an injured worker may request an alternative physician from the insurer's provider list after 90 days, and if the insurer denies this request, it must give a specific , written reason for denying the request .  In other words, the insurer can no longer deny the request simply because the request was made  90 days after the injury.  

I think the most helpful change to the law is the addition of a provision in section 3 that a written request for a change of physician that includes the name of the new physician (who is on the insurer's provider list), will be deemed granted if no action is taken on the request by the insurer within 10 days. Whether the insurer can subsequently issue a written denial with appeal rights under this amendment will undoubtedly be the subject of debate during  future appeals .

Two years ago, in Valdez v. Employers Insurance Company of Nevada, 123 Nev. Adv. Op. 21 (2007), the Nevada Supreme Court held that injured workers with accepted workers compensation claims have no substantive right to choose a treating physician, and can be required to treat with physicians contracted by the insurer or employer to provide care.    The court went on to state in that case that the Nevada legislature may retroactively change the manner in which an injured worker may select a physician, and may impose limits on that selection procedure.   The recent amendment to the law  on selection of an alternative physician takes a little bit of the sting out of the Valedez ruling. This amendment became effective July 1, 2009.

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Children, spouses, or other legal dependents of employees whose industrial injuries result in death or permanent total disability may be eligible for a scholarship with the College of Southern Nevada.  This scholarship was established by the Nevada Self Insurers Association.   For more information on how to apply for this scholarship, contact Jamille Watson (702) 651-5831 at the College of Southern Nevada Foundation, Sort Code WE32, 6375 West Charleston Blvd., Las Vegas, NV 89146-1164.

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If you reside in another state and were injured while working temporarily in Nevada, and you have a a Nevada claim, you may want to move back home to have family and friends around to help you while you still need medical care.  While it can be more difficult to obtain medical treatment and benefits when you are in another state, with some careful planning, it can be done.  Either you, or your attorney, should do the following :

1. Notify your adjuster in writing of your new address and phone number.

2. Before you move, find a doctor who is willing to treat you and who will accept what the Nevada fee schedule provides for payment for medical services.  Provide this link to the doctor so that the doctor's office has the Nevada fee schedule.

3. Request authorization from the adjuster for out-of-state care with the doctor you have chosen to treat you, and tell the adjuster that the doctor will accept the Nevada fee schedule.  Occasionally, the adjuster will have a network of doctors in other states, and you will have to choose a treating physician from that network.  While prior authorization is necessary under the regulations, it cannot be arbitrarily denied by the adjuster.

4. Have the doctor complete the same  physician progress report form the Nevada doctors use to let the adjuster know whether you have work restrictions or should be off work completely.  Be aware that if your employer had temporary light duty work available for you when you moved from Nevada, you will not be entitled to compensation benefits unless your doctor takes you off work completely.

5. If your doctor states that you may  have a permanent impairment when you are released from care,  the adjuster should pay you to return to Nevada to have a rating evaluation.  The adjuster should schedule the rating appointment  within 30 days of receiving your doctor's last report.

6.  If you run into problems and must file appeals on adverse letters from the adjuster, call the hearings division and request that you be allowed to participate in the hearing by telephone if you do not have an attorney representing you.

Managing out-of-state claims does take more planning and often  more effort with doctors who are not familiar with Nevada's workers compensation system.  However, out-of-state care may be very important to you if you are seriously injured and want to go home for care.  You do need to be aware that while medical care should not be comprised with your move back home, your entitlement to other benefits may be affected. 

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