Independent Medical Exams and Physician File Reviews
Table of Contents
I. POLICY PURPOSE
II. APPLICABILITY
III. DEFINITIONS
Abatement of Substantial Aggravation
Administrative Agent
Alternative Dispute Resolution (ADR)
Exam
Disability Evaluators Panel (DEP)
Extraordinary Unforeseen Circumstances
Extent of Disability (EOD)
Good Cause
In-state Exams
Independent Medical Exam (IME)
Maximum Medical Improvement (MMI)
Occupational Disease (OD)
Official Disability Guidelines (ODG)
Out-of-state Exams
Parties to a Claim
Percentage of Permanent Partial (%PP)
Compensation
Physician File Review (PFR)
Scheduled Loss Compensation (SL)
Statutory Occupational Disease
Temporary Total Compensation (TT)
IV. POLICY
A. Authority to Schedule
IMEs and Obtain PFRs
B. DEP Selection Criteria
for IMEs and PFRs
C. IME Scheduling
D. Attending an IME
E. IMEs Prior to Initial
Determination
F. EOD IMEs
G. SL IMEs
H. Alternative Dispute
Resolution (ADR) IMEs
I. Additional Allowance
(AA) IMEs
J. Abatement of
Substantial Aggravation IMEs
K. Claim Reactivation IMEs
L. IME Reports
M. Failure to Appear
N. Refusal to Submit to or
Obstruction of an IME
O. IW-Requested IMEs
P. Employer-Requested IMEs
Q. Employer-Scheduled IMEs
R. IME Costs
S. Obtaining a PFR
T. PFR Reports
U. Addendums
V. DEP Requirements
V. PROCEDURE
A. General Claim Note and
Documentation Requirements
B. Preparation for
Scheduling an IME or PFR
C. Multiple IMEs or PFRs
D. IME and PFR Not
Indicated
E. Selecting a DEP
Physician
F. Contacting the IW for
an IME
G. Creating an Exam Packet
H. Requesting an IME
I. Scheduling the IME
J. BWC IME Cancellations
K. Failure to Appear and
Requests to Cancel Without Rescheduling
L. Requests to Reschedule
an IME
M. Diagnostic Testing
N. Initial Determination
IMEs- Statutory Occupational Disease (OD)
O. Initial Determination
(Other Than Statutory OD) IMEs
P. AA IMEs- Physical,
Psychiatric, Reflex Sympathetic Dystrophy (RSD)/Complex Regional Pain Syndrome
(CRPS)
Q. EOD IMEs
R. SL IMEs
S. Claim Reactivation IMEs
T. ADR IMEs
U. Evaluation of
Substantial Aggravation IMEs
V. IME Reports
W. IC-Ordered IMEs
X. MSS Referral for PFR
and Decision
Y. Referral for PFR
Z. PFR Receipt
AA. Addendums
BB. Employer-Scheduled IMEs
The purpose of this policy is to ensure that BWC and managed
care organizations (MCOs) properly process and obtain independent medical
examinations (IMEs) or physician file reviews (PFRs) when required by statute
or when needed to support the claims management process.
This policy applies to BWC claims services staff and MCO
staff.
Abatement of
Substantial Aggravation: A determination that a condition
that was allowed for the substantial aggravation of a pre-existing condition
has reached a state such as would have existed had the injury not occurred;
and, therefore, compensation based on and medical treatment for the condition
is no longer payable.
Administrative
Agent: A business that contracts with individual disability
evaluator physicians to perform administrative aspects of an exam or file review,
such as scheduling appointments, preparing reports and billing.
Alternative
Dispute Resolution (ADR) Exam: An exam conducted as part of
processing a medical dispute between an employer of record (EOR), an injured
worker (IW), a provider and/or an MCO arising from the MCO’s decision regarding
a medical treatment reimbursement request. An IW or EOR shall exhaust the ADR
process prior to filing an appeal pursuant to R.C. 4123.511 regarding an MCO’s
decision on a medical treatment reimbursement request.
Disability
Evaluators Panel (DEP): A panel of physicians contracted by
BWC to perform IMEs and PFRs. The panel was established to provide quality, impartial
IMEs and PFRs. Physicians must provide objective, accurate IMEs and PFRs that
produce concise, timely and justifiable reports.
Extraordinary
Unforeseen Circumstances: The basis for which a determination
of good cause is made. Extraordinary unforeseen circumstances include, but are
not limited to:
- Death of an immediate family member;
- Hospitalizations or medical emergencies;
- Auto accidents;
- Notice of the exam was not received due to an incorrect
address;
- Proper notice of the exam was not provided to the injured
worker; or
- Weather emergencies.
Extent of
Disability (EOD): An evaluation of IW’s allowed condition(s)
in the claim regarding:
·
The IW’s ability to return to the former position of employment;
·
Restrictions which prevent the IW’s return to the former position
of employment;
·
The IW having reached maximum medical improvement (MMI);
·
The feasibility of a referral for vocational rehabilitation
services; and
·
The IW’s eligibility for continued temporary total compensation
(TT).
Good Cause: For purposes of this policy, a
failure to attend an exam for good cause is demonstrated by a showing of
extraordinary unforeseen circumstances, as defined above.
In-state
Exams: An IME that takes place in Ohio or in a bordering
state within a 50-mile radius from the Ohio state border.
Independent
Medical Exam (IME): An impartial evaluation conducted at the
request of BWC by a qualified medical specialist that results in an objective
evaluation and a comprehensive report that is used in managing the claim for
appropriate medical care, disability status and/or payment of compensation.
Maximum
Medical Improvement (MMI): A treatment plateau (static or
well-stabilized) at which no fundamental functional, physiological or
psychological change can be expected within reasonable medical probability in
spite of continuing medical or rehabilitative procedures. An injured worker may
need supportive treatment to maintain this level of function.
Occupational
Disease (OD): A disease contracted in the course of
employment, where the employment is shown to create a risk of contracting the
disease in greater degree and in a different manner from the general public.
The disease’s causes and the characteristics of its manifestation must
demonstrate a relationship to the work environment, or the condition of the
employment environment must be shown to result in a hazard which distinguishes
the employment in character from employment generally.
Out-of-state Exams: An IME that takes
place outside of a 50-mile radius from the Ohio state border, including IMEs that take place outside of the United
States.
Parties to a
Claim: IW, IW representative, employer, employer
representative and BWC.
Percentage
of Permanent Partial (%PP) Compensation: Also referred to as
a %PP and/or C-92 award. Compensation awarded for residual impairment, either
physical or psychological, resulting from an allowed injury or OD in state fund
or self-insured (SI) claims.
Physician
File Review (PFR): A DEP physician’s review of the medical
documentation in an IW’s file that results in a report BWC uses to assist with
claims management.
Scheduled Loss
Compensation (SL): An award pursuant to R.C. 4123.57(B) made
to an IW for the amputation of, or loss of use of, a body part or a facial
disfigurement.
Statutory
Occupational Disease: For purposes of this policy, a
scheduled occupational disease that requires an independent medical examination
prior to claim determination.
Temporary
Total Compensation (TT): Compensation paid to an IW who is
unable to return to the former position of employment on a temporary basis due
to the work-related injury or OD, and who has not been found to have reached
MMI.
A.
Authority to Schedule IMEs and Obtain PFRs
1. It is the
policy of BWC to:
a. Schedule
IMEs or obtain PFRs as required by law, or when the need is identified during
the management of a claim; and
b. Require
that IWs appear for BWC-scheduled IMEs.
2. Statutorily
Required IMEs
a. It is the
policy of BWC to schedule an IME as required by statute.
b. Statute
requires an IME to be scheduled in the following circumstances:
i. Prior
to the initial determination of a claim for a statutory OD;
ii. After
the first instance of 90 consecutive days of TT compensation (90-day exam) to
determine EOD;
iii. After 200
total weeks of TT compensation (200-week exam) to determine EOD; and
iv. For the initial
determination of %PP.
3. BWC
Discretion
a. Other than
for those required by statute, BWC shall use its discretion when determining
whether to schedule an IME or obtain a PFR.
b. BWC shall
consider factors that include, but are not limited to:
i. Has
there been sufficient contact with the treating physician to identify the
treatment plan for the IW and the IW’s compliance with the treatment plan or to
otherwise resolve the outstanding issue?
ii. Has
necessary medical evidence been requested and received?
iii. Is there
sufficient evidence in the claim to make a decision without an IME or PFR?
iv. Is the issue to
be resolved a medical issue and not a legal issue (e.g., not a coming or going
issue)?
v. Are
there outstanding issues that should be resolved prior to scheduling an IME or
obtaining a PFR (e.g., additional allowance or referral to vocational
rehabilitation pending)?
4. Multiple
IMEs
a. BWC shall
schedule multiple IMEs or obtain multiple PFRs when the allowed or requested
conditions require the expertise of multiple specialists.
b. BWC shall
make efforts to coordinate the scheduling of multiple IMEs to avoid conflicts
for the IW.
B.
DEP Selection Criteria for IMEs and PFRs
1. It is the
policy of BWC to ensure equitable distribution of IMEs to DEP physicians. Considerations
include, but are not limited to:
a. IW’s travel
distance to the IME facility;
b. DEP phyician’s
availability; or
c. DEP physician’s
speciality.
2. The
medical specialty of the DEP physician selected for an IME or PFR must be
appropriate for the allowed conditions in the claim or the issue presented for
consideration.
3. Conflicts
of Interest
a. BWC will
attempt to avoid conflicts of interest when selecting DEP physicians.
b. The DEP
physician must, as a condition of the DEP agreement:
i. Identify
any conflicts of interest; and
ii. Withdraw
from completing an IME or PFR when a conflict of interest exists or appears to
exist.
c. Possible
conflicts of interest include, but are not limited to, when the DEP physician:
i. Is
in the IW’s immediate family;
ii. Works
with a member of the IW’s immediate family in the DEP physician’s practice or
clinic;
iii. Is in the
immediate family of the IW’s treating physician or POR in the current claim;
iv. Previously
provided treatment to the IW as part of the current or another workers’
compensation claim;
v. Performed
an IME of the IW as part of the current or another workers’ compensation claim
for BWC, the IC, the EOR or the IW in the last 36 months;
vi. Completed a PFR
of the IW’s current or another workers’ compensation claim within the last 12
months for BWC, the IW or the EOR;
vii. Is in the same
practice or clinic with a provider described above;
viii. Has a personal, professional or
contractual relationship with the IW, the EOR, or their representatives;
ix. Has a personal,
professional, or contractual relationship with the MCO assigned to the current
claim (merely being on an MCO’s provider panel or network as a treating
physician does not in and of itself disqualify a DEP physician);
x. Is
the medical director for the MCO managing the current claim, or is a member of
the same practice or clinic with the medical director for the MCO managing the
current claim; or
xi. Has 5% or
greater financial interest in the MCO managing the current claim.
C.
IME Scheduling
1. BWC shall
select the physician to conduct an in-state IME. In-state IMEs are either scheduled:
a. Directly
with the examining physician; or
b. Through an
administrative agent, when the DEP physician uses one.
2. Out-of-state
IMEs are scheduled through an administrative agent contracted with BWC.
3. BWC shall
consider the geographic proximity between the IW’s residence and IME location.
a. The IME shall
be scheduled at a location that is closest to the IW’s home, taking into
consideration available times, specialty of physician needed, and possible
conflicts of interest.
b. The IW
shall be reimbursed for expenses when attending an IME that requires travel
outside a certain radius of the IW’s permanent or temporary residence, as
detailed in the Travel
Reimbursement policy and procedure.
4. BWC shall
provide the IW and examining DEP physician written notice at least 14 calendar days
in advance of the IME date.
D.
Attending an IME
1. The IW
must provide photo identification at the time of an exam.
2. The IW may
have the following parties present during an IME:
a. A relative;
b. Chaperone;
or
c. An
interpreter, as needed (see the Interpreter
and Translation Services policy for additional information).
3. BWC prohibits
the following from being present during an IME:
a. IW
representatives;
b. EORs;
c. EOR
representatives; or
d. MCO
representatives.
4. BWC
prohibits audio or video recordings in the exam room.
E.
IMEs Prior to Initial Determination
1. BWC shall
schedule an IME prior to making the initial decision in a claim as required by
statute or when BWC identifies the need for an IME.
a. An IME is
required before determining an OD claim for these conditions:
i. Berylliosis;
ii. Silicosis;
iii. Asbestosis;
iv. Coal miners’ pneumoconiosis;
v. Cardiovascular
or pulmonary disease for firefighters or police officers; or
vi. Any other OD of
the respiratory tract resulting from injurious exposure to dust.
b. Depending
on the situation, BWC may schedule an IME for:
i. Other
ODs;
ii. Forced
sexual conduct; or
iii. Other
initial determinations as identified by BWC.
c. It
is the policy of BWC to require the minimum evidence as described in IC
Resolution R15-1-01 prior to scheduling an IME for certain ODs. See the Occupational
Disease Claims policy and procedure for additional information.
2. Failure to
appear for an IME regarding the initial determination of a claim for reasons
other than good cause, may result in denial of the
claim.
F.
EOD IMEs
1. BWC shall
schedule EOD IMEs as required by statute or when BWC identifies the need for an
IME.
2. BWC shall
schedule a 90-day exam no later than 30 calendar days after the first 90 consecutive-day
period for which the IW is paid TT, unless the exam is waived by the employer
or BWC.
a. The
employer may waive the 90-day exam, either permanently or temporarily. If the
waiver is:
i. Temporary,
a date must be given for when the 90-day exam is necessary again.
ii. Permanent,
the 90-day exam shall no longer be necessary.
b. The waiver
may be verbal or in writing, using a Waiver
of Examination (MEDCO-6) or equivalent form.
c. If
the employer is out of business or fails to respond to BWC’s request to waive
the IME, BWC may waive the IME.
d. If the
employer objects to waiving the IME, BWC shall schedule the IME.
3. BWC shall
schedule an EOD IME immediately after the IW has received 200 weeks of TT.
4. BWC may
schedule an EOD IME at any time when:
a. TT is
on-going; or,
b. TT is requested
on the date the IME is scheduled.
5. If the IW
returns to work prior to the IME taking place, BWC shall cancel the IME.
6. Failure to
appear for an EOD IME for reasons other than good cause
may result in suspension of TT.
7. See the Temporary
Total Compensation policy and procedure for additional information.
G.
SL IMEs
1. BWC may
schedule an IME regarding requests for SL.
2. Failure to
appear for an IME regarding SL for reasons other than good
cause may result in the suspension of the request for SL.
3. See the Scheduled
Loss Compensation policy and procedure for more information.
H.
Alternative Dispute Resolution (ADR) IMEs
1. ADR IMEs
may be completed by a BWC-certified physician who is not on the DEP.
2. Failure to
appear for an ADR IME for reasons other than good cause
may result in the suspension of medical treatment in the claim.
3. See the Alternative
Dispute Resolution Exams policy and procedure for additional
information.
I.
Additional Allowance (AA) IMEs
1. BWC may
schedule an IME for the determination of additional conditions.
2. Failure to
appear for an AA IME for reasons other than good cause
may result in suspension of the request for the AA.
3. See the Additional
Allowance policy and procedure for additional information.
J.
Abatement of Substantial Aggravation IMEs
1. BWC may schedule
an IME to evaluate the status of a condition allowed for substantial
aggravation of a pre-existing condition to determine whether the condition:
a. Continues
to be payable; or
b. Has
abated.
2. Failure to
appear for a scheduled IME to evaluate a condition allowed for substantial
aggravation of a pre-existing condition for reasons other than good cause may result in suspension of the compensation
or treatment requested based on that condition.
3. See the Aggravation
and Substantial Aggravation of a Pre-Existing Condition policy and
procedure for additional information.
K.
Claim Reactivation IMEs
1. BWC may
schedule an IME regarding the reactivation of a claim.
2. Failure to
appear for a scheduled IME regarding the reactivation of a claim for reasons
other than good cause may result in a suspension of
the request for reactivation.
3. See the Claim
Reactivation policy and procedure for additional information.
L.
IME Reports
1. It is the
policy of BWC that completed IME reports:
a. Be
submitted within 10 calendar days of the IME, except in the case of:
i. ADR
IMEs, which must be submitted within five calendar days; and
ii. Out-of-state
IMEs, which must be submitted within 10 business days.
b. Not be
altered in any way, such as cross outs or white outs (see the Standard Claim
File Documentation and Altered Documents policy and procedure for further
guidance on altered documents);
c. Be typed,
dated and contain the DEP physician’s signature; and
d. Contain
the IW’s name and claim number on each page of the report.
2. BWC shall
provide a hard copy of all IME reports (with the exception of %PP reports) and
any addendums to any party to the claim upon request.
M.
Failure to Appear
1. When an IW
fails to appear for an IME, BWC shall evaluate if the reason the IW failed to appear
was for good cause.
2. Depending
upon the issue being adjudicated, failing to appear for an IME may result in
dismissal or denial of an application, or suspension of compensation or
benefits, as described above.
3. BWC shall
lift a suspension as the result of failure to appear for a BWC-scheduled IME
when:
a. The IW
appears for a rescheduled IME; or
b. The issue
that resulted in the BWC or MCO-scheduled IME is moot.
N.
Refusal to Submit to or Obstruction of an IME
1. BWC shall
conduct an investigation if an IW refuses to submit to or otherwise obstructs
an IME after appearing for the IME.
2. If it is
determined that the refusal to submit or obstruction was justified, the IME
will be rescheduled, and processing will continue.
3. If it is
determined that the refusal to submit or obstruction was not justified,
processing will continue as if the IW failed to appear for the IME.
O.
IW-Requested IMEs
1. If the IW
or the IW’s representative requests an IME to support allowance of a new
condition or an increase in %PP, the cost of this IME is the IW’s
responsibility.
2. BWC shall
refer requests to schedule IMEs on behalf of the IW to the IC.
P.
Employer-Requested IMEs
1. State-Fund
(SF) Claims
a. Requests
by the EOR in a SF claim for an IW to be scheduled for an IME must be made in
writing.
b. When an EOR
in a SF claim requests that an IW be scheduled for an IME, BWC shall retain the
discretion to decide whether the IME is appropriate.
i. BWC
shall schedule an IME if BWC determines it is pertinent to the management of
the claim and BWC has jurisdiction to make the decision related to the request;
or
ii. When
the IME request is related to issues outside of BWC’s jurisdiction or BWC does
not agree with the request, the request shall be referred to the IC.
2. SI Claims
a. BWC may,
at the written request of an EOR in a SI claim, schedule an IME with a BWC DEP
physician on behalf of the EOR.
b. The EOR in
a SI claim shall pay:
i. The
provider’s costs associated with the IME; and
ii. Expenses
and lost wages to the IW for attending the IME.
Q.
Employer-Scheduled IMEs
1. SF Claims
a. The EOR in
a SF claim may schedule an IW for an IME:
i. One
time;
ii. On
any issue asserted by the IW or the POR/treating physician; and
iii. By a
physician of the EOR’s choice;
b. The EOR
shall pay:
i. The
provider’s costs associated with the IME; and
ii. Expenses
and lost wages to the IW for attending the IME (lost wages shall be paid within
three weeks).
c. The EOR
shall provide to BWC, the IW, and the IW’s representative:
i. The
time and place of the IME;
ii. The
questions asked of the examining physician; and
iii. The
information provided to the examining physician.
d. The EOR
must file the doctor’s report with BWC immediately upon its receipt.
e. If, after
one employer-scheduled IME of the IW, the EOR asserts that another IME by a
physician of the employer’s choice for the same issue is essential in the
defense of the claim, the EOR may file a written request with BWC to require
that the IW attend another IME.
f. Treatment
by a company doctor constitutes an employer-scheduled IME.
2. SI Claims
a. Upon
notification that an EOR in a SI claim has paid 200 weeks of TT, BWC shall
schedule an EOD IME.
b. This IME
must be paid for by the EOR.
R.
IME Costs
1. Except for
statutory OD IMEs where the claim is subsequently denied, the cost for an IME
shall be charged to the claim.
2. For
statutory OD claims, where the claim is subsequently denied, the cost of the
IME shall be charged to the Surplus Fund for those employers who contribute to
the Surplus Fund.
S.
Obtaining a PFR
1. BWC
retains the right to obtain a PFR when necessary in the course of claims
management.
2. Reasons a
PFR may be obtained include, but are not limited to:
b. Identification
of the proper diagnosis for the initial determination of a claim;
c. Determination
of requests for the allowance of additional conditions;
d. Evaluation
of requests for claim reactivation, including appropriateness of medical
treatment;
e. Processing
requests for an increase in %PP;
f. Determining
the IW’s eligibility for a SL award;
g. Determining
if drugs requested or currently being reimbursed by BWC are reasonably related
or medically necessary and appropriate for the treatment of allowed conditions
in a claim; and
h. Determination
of a claim or an issue in a claim when an IME is not possible due to physical
limitations that prevent an IW from being examined, or the IW has died.
T.
PFR Reports
1. BWC requires
DEP physicians who complete PFRs to expressly accept all findings of the
POR/treating physician(s), but not necessarily their opinion about those
findings.
2. BWC shall
provide copies of PFR reports to all parties to the claim upon request.
U.
Addendums
1. Addendum
Requests
a. Only BWC
or the MCO may request an addendum to an IME or PFR.
b. The
initial addendum request may be made by telephone but must be followed up with
a written request.
c. The
request for an addendum must be sent to all parties to the claim.
2. DEP
Reimbursement for Addendums
a. No
additional payment will be made to the DEP physician when the addendum request
is a result of an error on the part of the DEP physician.
b. The DEP
physician may request additional payment if the addendum request:
i. Requires
the review of additional information; or
ii. Is
needed as a result of an error on the part of BWC (e.g., BWC did not ask the
correct questions).
V.
DEP Requirements
1. The DEP
physician must:
a. Include in
a narrative report an opinion based on the allowed conditions with references
to the medical relied upon; and
b. Respond to
all questions with supporting rationale.
2. BWC
prohibits the DEP physician from communicating with the parties to a claim, or
their representatives, regarding the examination or report.
3. DEP
physicians shall complete a Service Invoice (C-19) and submit it
directly to BWC’s Medical Billing and Adjustment (MB&A) unit.
i. If
a C-19 is received in a claims office, it is the policy of BWC to image the C-19
into the claim.
ii. Refer
to the Disability
Evaluators Panel Handbook and the BWC
Provider Billing and Reimbursement Manual for billing codes and
other additional information.
4. It is the
policy of BWC to refer all concerns or complaints regarding a DEP physician to BWC’s DEP Central Unit.
1. BWC staff
shall refer to the Standard
Claim File Documentation and Altered Documents policy and procedure for
claim note and documentation requirements; and
2. Shall
follow any other specific instructions for claim notes and documentation
included in this procedure.
1. Prior to
scheduling an IME or PFR, the CSS, MCS, or CA:
a. Shall
verify that the conditions listed in the claim accurately reflect the narrative
description of conditions as they appear on a BWC or IC order, or as appropriate
in SI bankrupt claims (see the ICD
Modifications policy and procedure for additional information); and
b. May refer
the claim for MSS review to determine whether an IME versus a PFR is warranted.
2. Upon
referral to the MSS, the CSS, MCS, or CA shall:
a. Enter a
note in the claims management system describing the reason for the referral;
and
b. Create a
case event for the MSS.
1. Claims
services staff shall schedule multiple IMEs or obtain multiple PFRs when necessary,
based on the allowed or requested conditions in the claim.
2. When
scheduling multiple IMEs, claims services staff shall:
a. Notify the
IW, either over the phone or in writing, that more than one IME will be
scheduled; and
b. Coordinate
the scheduling of the IMEs to avoid conflicts for the IW to attend the IMEs.
1. Claims
services staff shall not schedule an IME for EOD in a claim where the IW has
been found to be permanently and totally disabled (PTD) without evidence of new
and changed circumstances.
a. Claims
services staff must review the claim with a BWC attorney before considering an
EOD IME in a PTD claim.
b. IMEs may
be scheduled in PTD claims for other issues, such as AA or treatment.
2. Claims
services staff shall not schedule an IME or obtain a PFR:
a. When there
is sufficient evidence on file upon which to base a decision; or
b. Based
solely on a request made by another party to the claim.
3. Claims
services staff shall not refer a medical issue to the IC recommending that a
request be denied without an IME or PFR report that supports BWC’s position.
1. Claims
Services Staff and MCO Shared Responsibilities
a. Claims
services staff and the MCO shall ensure that any physician selected for an IME
or PFR be a BWC DEP physician; and
b. Consider
the following when selecting a physician for an IME or PFR:
i. The
physician must be a BWC-certified physician for Alternative Dispute Resolution
(ADR) IMEs scheduled by an MCO;
ii. Select
a physician with the same or a similar specialty as the treating physician whenever
possible (BWC staff may use the Medical Specialty Guide found on COR as a
resource); and
iii. Base DEP
physician selection on the services that the physician has agreed to provide.
2. Claims
Services Staff Responsibilities
a. Claims
services staff shall obtain and image in the claim the Medical
Servicing Providers Report that lists physicians who have previously billed
BWC for treatment or previous DEP IMEs or PFRs performed in the claim;
b. Identify
other physicians who have examined the IW or reviewed the IW’s claim but have
not billed BWC for the IME or PFR (e.g., IMEs in SI claims, IMEs obtained by
the employer or IW);
c. Not
select a DEP physician for whom conducting an IME or PFR would represent a
conflict of interest or the appearance of a conflict of interest, as described
in this policy; and
d. Not select
a DEP physician with whom claims services staff have a personal relationship.
F. Contacting
the IW for an IME
1. Prior to
scheduling an IME, the CSS shall attempt to contact the IW by telephone.
2. During the
contact, the CSS shall:
a. Explain to
the IW the reason for the IME;
b. Verify the
IW’s address;
c. Tell
the IW that it is necessary to bring a photo ID to the IME;
d. Explain to
the IW that failure to attend the IME may result in the dismissal or denial of
an application, or suspension of compensation or benefits (see the Failure to Appear and Requests to Cancel Without
Rescheduling section of this procedure for additional information); and
e. Obtain the
IW’s availability and explain that BWC will attempt to schedule within the
availability given, however if BWC is unable to do so, the IW must still attend
the IME.
3. If phone
contact is made, the CSS shall include the IW’s exam availability in the note
regarding the contact.
4. If phone
contact is not successful, the CSS shall:
a. Leave a detailed
message for the IW (when possible) and allow three calendar days for the IW to
respond with availability to attend the IME. The detailed message must include:
i. The
information outlined above;
ii. That
if BWC does not hear back from the IW, the IME will be scheduled at the next
available time; and
iii. That BWC
will send the IW a letter with the date and time of the IME.
b. Contact
the IW’s representative, if represented.
c. If
it is not possible to leave a detailed message or contact the IW’s
representative, attempt one additional phone contact on a different day.
5. If phone
contact as described in this section is not possible, or no response is
received to the messages left by the CSS, the CSS shall continue with
scheduling the IME.
1. Claims
services staff shall complete the exam packet within seven calendar days of the
date of receipt of the IME referral.
2. Claims services
staff shall create an exam packet prior to requesting an IME.
3. The exam
packet shall contain the documents as outlined in the IME Packet Content
document found on COR, under Operational Guidelines and Workflows, on the IME
policy page.
4. Claims
services staff shall rename the packet according to the indexing and renaming
guidelines as directed by Claims Operations.
1. The CSS
(or MSS for AA Physical or SL) shall:
a. Obtain and
image in the claim the Medical Servicing Providers Report that lists
physicians who have previously billed BWC for treatment or previous DEP IMEs or
PFRs performed in the claim.
b. Ensure the
report is within seven calendar days of the date of the IME referral.
2. The CSS
(or MSS for AA Physical or SL) shall select a new medical exam scheduling case
and create a case event for the exam scheduler to schedule an IME.
3. The exam
scheduling case shall include at least the following information:
a. Type of IME
requested;
b. IW
availability, if known;
c. Type
of physician required for the IME;
i. The
CSS shall include the specialty recommended by the MSS, when applicable.
ii. Two specialty
options should be provided; however, if only one type of specialist would be
appropriate, the reason for only providing one shall be included in the
additional information section (e.g., a psychiatrist is needed to evaluate
treatment that includes prescription medications for psychiatric conditions);
d. Physicians
who have examined the IW or performed a file review of the IW’s claim(s) who
are not listed on the Medical Servicing Providers Report;
e. Need for
an interpreter, if applicable; and
f. Additional
exam questions, if any.
g. A BWC
attorney must review and approve additional questions that are not already
programmed into the claims management system before the questions are added.
1. The exam
scheduler shall:
a. Prior to
scheduling the IME, review the claim notes regarding the IW’s exam availability
(see note titled “IW Availability”).
b. Schedule
the IME based on the IW’s availability when possible;
c.
Ensure equitable selection and distribution of IMEs to DEP physicians
based upon Claims Operations physician selection guidelines.
d. Consider
proximity to the IW’s home and select a DEP physician closest to the IW’s home
when possible (the exam scheduler may consider scheduling further from the IW’s
home if necessary, to obtain a timely IME and accommodate the IW’s availability);
e. Work with
BWC’s contracted administrative agent to schedule IMEs for IWs who live in
another state and are more than 50 miles from the Ohio border;
f. Work
with a DEP physician’s administrative agent to schedule an in-state IME when
the DEP physician has indicated that they use an administrative agent;
g. Complete
scheduling of the IME within five calendar days of receiving the request;
h. Schedule
the IME for a date that allows for at least 14-day notice to the IW (except
when there is a documented request from the IW that the IME be scheduled more
quickly);
i. Send
the appropriate IW Notice of Exam letter, using the letters found in the
claims management system.
i. If
the IW’s letter is returned by the post office due to an incorrect mailing
address, the CSS shall attempt to find a new address for the IW by the
following means:
a) Researching
on the internet; or
b) Contacting:
i) The
IW by phone;
ii) The
IW’s representative by phone;
iii) The MCO; or
iv) A treating
provider.
ii. If
contact with the IW or IW’s representative is made after the receipt of
returned mail, and the IW is:
a) Able
to attend the IME at the original scheduled time, the CSS shall:
i) Confirm
the appointment date, time, and location;
ii) Document
in notes that the IME information was provided by phone;
iii) Update the IW’s
address information in the claims management system; and
iv) Resend the
notice to the IW at the updated address.
b) Unable
to attend the IME at the original scheduled time, the CSS shall:
i) Notify
the exam scheduler to cancel the scheduled IME;
ii) Update
the IW’s address in the claims management system;
iii) Complete all
tasks associated with the original IME referral;
iv) Update exam
scheduling information in the claims management system to close out the
original IME referral; and
v) Create a
new medical exam scheduling case or transition the previously closed exam scheduling
case for the same issue and create case event.
iii. If it is
not possible to obtain new contact information for the IW, the CSS shall:
a) Notify the
exam scheduler to cancel the scheduled IME; and
b) Proceed
with processing the claim as if the IW failed to
appear.
j. Send
the DEP physician the Physician Notice of Exam letter, including the
appropriate exam reason and questions.
k. When
interpreter services must be scheduled, notify the CSS of the date and time of
the IME (see the Interpreter
and Translation Services policy and procedure for additional information).
2. Scheduling
Exceptions
a. When
scheduling an AA IME, claims services staff shall follow the Additional
Allowance policy and procedure.
b. When
scheduling an IME for a C-92 IME, claims services staff shall follow the
procedures outlined in the C92 Independent Medical Examinations (IMEs) and
Physician File Reviews (PFRs) policy and procedure.
3. See below
for more information regarding specific IME types.
1. If it is
necessary for BWC to cancel or reschedule an IW’s IME, the exam scheduler shall
make two attempts to contact the IW or IW’s representative by phone.
2. The exam
scheduler also shall send written notice of the cancelation and, if applicable,
the reschedule date.
K. Failure to
Appear and Requests to Cancel Without Rescheduling
1. The CSS
shall contact the IW’s representative immediately upon notice from the DEP
physician that the IW failed to appear for a BWC-scheduled IME. If the IW is
not represented, claims staff shall contact the IW directly.
2. If the
initial attempt to contact the IW’s representative or IW is not successful, the
CSS shall:
a. Attempt
one additional contact by phone;
b. If the IW
is not represented and there is not a valid phone number for the IW on file,
send a letter requesting that the IW call the CSS;
c. Allow
three business days for response to phone messages, or six business days for a
letter; and
d. Continue
with the failure to appear process if no response is received.
3. Determination
of Good Cause
a. When
speaking with the IW or IW’s representative, the CSS shall determine if the IW
failed to appear for or is requesting to cancel an appointment for good cause.
b. When
determining if the IW failed to appear or is requesting that an IME be
rescheduled for good cause, the CSS shall take into consideration BWC’s efforts
to schedule within the IW’s availability.
4. If it is
determined that good cause does exist, benefits shall continue, and the CSS
shall reschedule the IME as soon as possible.
a. Generally,
the CSS shall not require the IW to provide evidence to support the good cause
reason for failure to appear, canceling or rescheduling the IME.
b. The CSS
may require evidence (e.g., obituary, medical reports/bills) if the IW has a
history of failure to appear for, canceling or rescheduling this or other IMEs.
5. If it is
determined that good cause does not exist for the failure to appear, or the IW
requests that an IME be canceled and not rescheduled, claims staff shall staff
the claim with a supervisor. The supervisor shall:
a. Verify the
Contacting the IW for an IME section of this
procedure was followed when the IME was scheduled;
b. For EOD
examinations, ensure the completed Failure to Appear for an IME Checklist
found on COR is imaged to the claim file.
6. If the IW
contacts BWC and requests that an IME be cancelled and not rescheduled, the CSS
shall:
a. Explain to
the IW that failure to appear for a BWC-scheduled IME may result in dismissal
or suspension of an application and/or suspension or denial of benefits; and
b. Contact
the IW’s representative, if one exists, to provide notice that a BWC-scheduled
IME has been cancelled at the IW’s request.
7. If good
cause does not exist for the failure to appear, or the IW fails to appear
without notice, or if the IW requests that an IME be canceled and not
rescheduled, claims services staff shall proceed with processing as follows,
with supervisor approval:
a. EOD IME:
i. Suspend
TT compensation beginning with the next scheduled payment period (payment for
the current scheduled payment period should be permitted to pay);
ii. Send
the TT Suspension Letter found on the claims management system to the IW
and IW representative; and
iii. Suspend
any subsequent request for compensation other than for Lump Sum Settlement
(LSS).
iv. Medical benefits
are not suspended.
b. Statutory
OD IME: Deny the claim by sending an Initial Denial Order if unable
to reschedule or the IW fails to appear for the second scheduled IME.
c. Initial
determination IME other than statutory OD: Make an initial determination
based on evidence in the claim, which may include a PFR obtained in lieu of the
IME.
d. Evaluation
of substantial aggravation IME: Send the Suspension Letter to
suspend the compensation and/or medical benefits requested based on the
substantially aggravated condition.
e. ADR IME:
Send the Suspension Letter to suspend the request for treatment.
f. Other
requests: Send the Suspension Letter to suspend the request.
8. If the IW
appears for the re-scheduled IME, the CSS shall:
a. For EOD
IMEs:
i. Send
the TT Reinstatement Letter from the claims management system; and
ii. Pay TT
beginning the date the suspension began.
b. For all
other IMEs, continue processing the request and issue the appropriate decision.
c. Process
any other requests that were suspended because of the failure to appear
suspension.
9. If the
issue for which the IME was scheduled becomes moot (e.g., IW returns to work
after the IME date, withdraws request, or new medical evidence is received) the
CSS shall:
a. For EOD
IMEs, if the IW returns to work after the IME date and later requests a new
period of TT compensation, the suspension shall be lifted for the new period
and TT shall be considered.
i. The
period of TT suspended as a result of the failure to appear shall remain
suspended.
ii. If
the IW files a Motion
(C-86) requesting payment for the suspended period, the CSS shall refer the
request to the IC.
iii. If the IW
attends an EOD IME for the new period of TT, the CSS shall staff with a BWC
attorney to determine if payment should be considered for the previously
suspended period.
b. For other
IMEs, dismiss the application as appropriate or continue processing based on
newly received evidence.
10. If the IW withdraws a
request and subsequently refiles the same or a similar request, the CSS shall
consider scheduling an IME for the new request.
1. When
contacted by an IW to reschedule an IME (including where the IW has failed to
appear for a previously scheduled IME), the CSS shall:
a. Determine
the reason for the request to reschedule the IME;
b. Explain to
the IW the importance of attending a BWC-scheduled IME and the consequence of
not attending an IME;
c. Verify
or obtain the IW’s availability to attend the rescheduled IME and explain that
BWC will reschedule as soon as possible which may result in less than 14-day
notice of the IME;
d. Contact
the exam scheduler to cancel the scheduled IME if appropriate;
e. Create a
new exam scheduling case, or update the existing exam scheduling case;
f. Reschedule
the IME as soon as possible; and
g. If
applicable, suspend processing of the claim or application, or dismissal of an
application as described in this procedure.
2. The CSS
shall process the IW’s claim or application as follows:
a. EOD IME:
i. If
the reason for rescheduling is for good cause, the CSS
shall allow TT to continue; or
ii. If
the reason for rescheduling is not for good cause,
claims staff shall follow the failure to appear procedure above.
b. Statutory
OD IME:
i. Withhold
making a decision regarding the claim until the IW attends the rescheduled IME
or fails to attend the rescheduled IME.
ii. If
the IW fails to attend the second IME for reasons other than good cause, the CSS may deny the claim.
iii. The CSS
shall staff with a supervisor prior to denying the claim.
c. Initial
determination IME other than statutory OD:
i. If
the IME can be rescheduled within the 28-day decision timeframe, withhold
making a decision in the claim until the IW attends the IME; or
ii. If
the IME cannot be rescheduled within the 28-day decision timeframe, make the
initial determination based on evidence in the claim, which may include a PFR
obtained in lieu of the IME.
d. Evaluation
of substantial aggravation IME:
i. If
the reason for rescheduling is for good cause,
continue processing the claim; or
ii. If
the reason for rescheduling is not for good cause and
the IW fails to appear for the IME, send the Suspension Letter to
suspend the compensation and/or medical benefits requested based on the
substantially aggravated condition.
e. Other
requests, not including C-92 IMEs: Staff with supervisor to determine if
the request will be suspended or not until the IW attends the IME.
1. The DEP
physician must obtain prior approval for diagnostic testing that may be needed
to complete the evaluation of the IW.
2. The CSS shall
create a “MSS Referral” work item for a decision and follow-up with a phone
call or email to the MSS.
3. The MSS
shall:
a. Review the
Medical
Evidence for Diagnosis Determination (MEDD) policy and procedure or
other on-line resources to evaluate the appropriateness of diagnostic testing;
b. Notify the
DEP physician of BWC’s decision regarding diagnostic testing; and
c. Document
in notes the specific diagnostic testing requested, the decision regarding the
request, and the method used to provide notification of the decision to the DEP
physician.
1. The CSS
shall schedule an IME before determining an OD claim for the following
conditions:
a. Berylliosis;
b. Silicosis;
c. Asbestosis;
d. Coal
miner’s pneumoconiosis;
e. Firefighter
or police officer filing for cardiovascular or pulmonary disease; or
f. Any
other occupational disease of the respiratory tract resulting from injurious
exposure to dust.
2. Claims services
staff shall obtain the minimum evidence required to schedule a statutory OD IME
as described in IC Resolution No. R15-1-01.
a. The ODs
included are:
i. Silicosis;
ii. Asbestosis;
Coal miners’ pneumoconiosis; or
iii. Any other
OD of the respiratory tract resulting from injurious exposure to dust.
b. The
required minimum evidence necessary to schedule the IME is:
i. A
written interpretation of x-rays by a certified “B reader” or a high-resolution
computed tomography;
ii. Pulmonary
function studies and interpretation by a licensed physician; and
iii. An opinion
of causal relationship by a licensed physician.
3. Additional
evidence that can assist the DEP physician with IMEs for berylliosis,
cardiovascular, pulmonary (including asbestosis) or respiratory disease
incurred by firefighters or police officers includes:
a. Physician
of record report which provides an opinion on causality;
b. Detailed
work history that indicates toxic and/or chemical exposures (claims staff should
obtain information regarding all previous employment in order to determine the
employer of record);
c. Medical
history inclusive of:
i. Chief
complaint;
ii. History
of present complaint and illness;
iii. Past
medical history (childhood illnesses, accident, hospitalizations, allergies,
etc.);
iv. Family history;
v. Review
of systems;
vi. Pre-existing
conditions;
vii. Diagnostic tests
(i.e., toxicology tests, auditory exams, MRI or CT-scan);
viii. Smoking history;
ix. Prescription
medications;
x. Other
drugs, substance abuse, illicit drug use; and
xi. IW’s outside
interests or lifestyle that would indicate toxic/chemical exposures.
4. The CSS or
MSS may combine the following exam questions with the initial allowance
questions:
a. TT
eligibility;
b. SL; or
c. EOD,
in unusual circumstances and after staffing with a BWC attorney.
5. The CSS
shall issue an initial determination order within 28 calendar days from receipt
of the report from a statutorily required IME.
6. See the Occupational
Disease Claims policy and procedure for additional information.
1. The CSS
may obtain an IME for the initial determinations of claims other than those
required by statute.
a. The CSS
must obtain MSS review or staff with a supervisor before scheduling an IME for
initial determination.
b. Unless
otherwise approved by a supervisor, the CSS must obtain the IME and issue a
decision within BWC’s 28-day determination timeframe.
2. The CSS or
MSS may combine the following exam questions with the initial allowance
questions:
a. TT
eligibility;
b. SL; or
c. EOD,
in unusual circumstances and after staffing with a BWC attorney.
1. Responsible
Parties
a. The MSS
shall be responsible for taking action on AA Physical and RSD/CRPS IMEs; and
b. The CSS
shall be responsible for taking action on AA Psychiatric IMEs.
2. Depending
upon the issue, the CSS or MSS shall determine the need for and attempt to
obtain medical evidence according to the Medical
Evidence for Diagnosis Determination (MEDD) policy and procedure prior
to scheduling an IME for the allowance of additional conditions.
3. The CSS or
MSS shall add the condition to be examined to the claims management system
prior to scheduling an IME and request that the condition description be
modified if necessary.
4. The CSS or
MSS may combine the following exam questions with the AA questions:
a. Evaluation
of substantial aggravation;
b. Claim
reactivation;
c. TT
entitlement;
d. TT
entitlement after MMI; or
e. SL.
1. Prior to
scheduling an EOD IME, the CSS shall:
a. Verify
that a job description for the injury position is in the claim or request one
if necessary; and
b. Contact
the POR/treating physician prior to scheduling an IME to ask about the EOD,
which may be done by using the MMI Clarification Letter to Treating
Physician found on COR.
2. The CSS
shall create the “MSS Referral” work item. Upon receipt, the MSS shall:
a. Determine
whether an IME is appropriate;
b. Select the
appropriate physician specialty; and
c. Modify
the work item for QA.
i. For
90-day IMEs only, the CSS will create the 90-day exam scheduling case; and
ii. Create
the “MSS QA” work item.
3. The CSS
may schedule multiple EOD IMEs if warranted by the conditions in the claim
(e.g., claim is allowed for psychological and physical conditions).
4. The CSS
shall schedule an EOD IME for all conditions in the claim that the treating
physician(s) identifies are currently preventing a full duty release to the job
IW held on the date of injury.
5. If an IW
is being treated concurrently by two physicians, most often for psychological
and physical conditions, both treating physicians are required to complete and
submit a Physician’s
Report of Work Ability (MEDCO-14). If the physicians identify
physical and psychological conditions as preventing a full duty release to the
job the IW held on the date of injury, the CSS shall schedule EOD IMEs for both
the physical and psychological conditions.
6. If not
examining on all conditions, the CSS shall enter a note indicating the reason.
Reasons for not examining on all conditions include, but are not limited to:
a. The IW was
previously found MMI on some condition(s) in a claim and there has been no
additional treatment for the condition(s) found MMI;
b. There is a
condition allowed for substantial aggravation of a pre-existing condition which
is no longer payable; or
c. Other
times as advised by the local BWC attorney.
7. Prior to
scheduling, the CSS shall review any prior EOD IME report(s) for the conditions
being examined and document in notes if any recommendations for treatment were
made by the DEP physician and if those recommendations were acted upon or not.
8. The CSS
shall schedule an EOD IME at the time indicated by the examining physician in a
prior EOD IME if the IW is receiving TT compensation at the time, unless there
is a good reason, staffed with a supervisor and documented in notes, for not
scheduling an IME.
9. 90-Day
Exam
a. The CSS
shall schedule an EOD IME within 30 calendar days of the first payment of 90
consecutive days of TT compensation as required by the statute.
b. If the treating
physician provides a statement that the IW is MMI, a 90-day exam is not
scheduled.
c. The
EOR or BWC may waive the 90-day exam.
i. The
CSS shall evaluate the claim to determine if a waiver should be considered.
Issues to consider include:
a) Surgery is
scheduled or was recently performed;
b) Type of
surgery and mode of anesthesia;
c) Normal
recovery time for surgery;
d) Post-operative
passive physical therapy (PT) is being performed;
e) The IW
remains hospitalized for the allowed conditions;
f) Referral
for or active participation in a vocational rehabilitation plan is underway;
g) DMC’s
recommendation on potential success and IW’s compliance with vocational
rehabilitation plan;
h) Projected
discharge date from inpatient hospitalization and normal healing times;
i) Notes
from POR/treating physician documenting the IW’s progress in treatment plan; or
j) Other
medical factors that justify waiving an IME.
ii. The
CSS shall contact the employer of record if it is determined that a waiver is
advisable.
a) The
employer may agree to the waiver verbally by phone or in writing, using a MEDCO-6 or
equivalent form.
b) The waiver
information obtained must include:
i) The
name and title of the person requesting or agreeing to waive the IME;
ii) If
the waiver is temporary or permanent;
iii) The reason the
IME is waived; and
iv) When the claim
is to be reviewed again to consider rescheduling the IME if the waiver is
temporary.
c) If the
employer agrees to waive by phone, the CSS shall send the 90-Day Exam Agreement
to Waive letter found on COR to the employer and employer representative.
d) The waiver
may be permanent or temporary:
i) If
the waiver is permanent, the CSS shall update the exam scheduling information
in the claims management system and no 90-day exam will be conducted, but an
EOD IME may be scheduled when appropriate.
ii) If
the waiver is temporary, the CSS shall review the claim at the end of the
waiver period indicated and either recommend an extension of the waiver period
or schedule the 90-day exam.
e) The IMS
may waive the IME:
i) If
the employer fails to respond to the request to waive the IME; or
ii) If
the employer is out of business.
f) Upon
waiving the IME, the IMS shall determine a future date for the IME.
g) Upon
receipt of the 90-day exam, the CSS shall set a follow-up work item to review
for reexamination as recommended by the physician.
i) If
the IW is still receiving TT, the IW shall be referred for a new EOD IME.
ii) If
the IW returns to work or reaches MMI, the EOD IME is no longer necessary.
10. 200-Week Exam- The CSS shall
schedule an EOD IME after payment of 200 weeks total of TT compensation as
required by statute.
11. Other EOD IMEs- The CSS may
schedule an EOD IME whenever necessary for management of a period of disability
when the IW is receiving or has requested TT.
12. Psychiatric Conditions
a. Prior to
scheduling an EOD IME for psychiatric conditions, the CSS shall:
i. Send
an e-mail to the MCO case manager as notification that an EOD IME for a
psychological condition is being considered.
a) The
purpose of the email is to gather any input the MCO case manager may have
regarding pending IME.
b) The CSS
shall set a work item for MCO email response within two calendar days.
ii. Request
the following data reports and image them into claim file as MISC document
type:
a) Psych
Detailed and Summary Medical Bill History for Claim for the six months prior to
the allowance of the psychological condition to present, and
b) RX drug
review for the previous two years.
b. The MCO
shall:
i. Respond
to BWC CSS’s email regarding IME input within two business days.
ii. Enter
a thorough treatment compliance summary claim note within five business days
from the CSS’s initial email, to include:
a) The IW’s
compliance with current treatment regime;
b) The amount
of treatment provided and specific periods over which it was provided; and
c) Identification
of gaps in treatment and an explanation for such gaps, if known.
iii. The CSS
shall follow-up with the MCO case manager if there is no response after five calendar
days.
a) The CSS
shall staff with a supervisor if unable to obtain a response from the MCO.
b) Depending
on the result of the staffing, the CSS shall then:
i) Continue
to attempt to obtain a response from the MCO; or
ii) Move
forward with scheduling the IME.
iv. Provide
up-to-date treatment reports for psychological counseling and medication
management.
13. The CSS will create the AA
Psych exam scheduling case and the “MSS QA” work item at the same time.
14. The CSS or MSS may combine
the following exam questions with the EOD questions:
a. TT
entitlement (in limited circumstances);
b. AA;
c. Evaluation
of substantial aggravation of a pre-existing condition; or
d. SL.
15. See the Temporary
Total Compensation policy and procedure for information about
additional processing when the outcome of an EOD IME is a finding of MMI.
1. The CSS
shall grant a request for SL without scheduling an IME when sufficient medical
evidence is present in the file to support the award.
2. The CSS shall
refer requests for SL based on loss of use to the MSS for review to determine
if an IME is needed.
3. The CSS or
MSS may combine the following exam questions with SL exam questions:
a. Initial
determination;
b. TT
entitlement;
c. TT
entitlement after MMI;
d. AA;
e. EOD;
f. Claim
reactivation; or
g. Evaluation
of substantial aggravation of a pre-existing condition.
1. If an IME
is indicated for claim reactivation, the CSS must schedule the IME and obtain
the report so as to make the reactivation decision within 28 calendar days of
receipt of the request unless otherwise approved by a supervisor.
2. The CSS or
MSS may combine the following exam questions with claim reactivation exam
questions:
a. Initial
determination;
b. TT
entitlement;
c. TT
entitlement after MMI;
d. AA;
e. EOD; or
f. Evaluation
of substantial aggravation of a pre-existing condition.
- See the Alternative
Dispute Resolution Exams policy and procedure
for additional information
regarding ADR IMEs.
1. The CSS
shall schedule an IME to determine if a condition allowed for the substantial
aggravation of a pre-existing condition shall be abated only if the IW is
receiving or requesting medical treatment or compensation based on the
condition.
2. Employer
requests to abate a condition allowed for substantial aggravation shall be
referred to the IC without scheduling an IME.
1. The exam
scheduler shall review the claims management system for the receipt of the IME
report 10 calendar days after the IME date, or 14 calendar days for out of
state IME dates. If the IME report is not received within the 10 or 14
calendar days immediately following the IME, the exam scheduler shall:
a. Make three
attempts to follow-up with the DEP physician to request the report between:
i. 10
and 21 calendar days after the in-state IME; or,
ii. 14
and 21 calendar days after the out of state IME.
b. Document
all attempts to contact the DEP physician in claim notes; and
c. If
the IME report is not received after 21 calendar days, notify BWC’s DEP Central Unit.
2. Claims
services staff shall image the IME report into the claim upon receipt, even if
an addendum will be requested.
3. The MSS
shall complete a quality assurance review of all IME reports and enter a claim
note.
a. The
reviewer shall verify that:
i. IW
information is correct throughout the report (e.g., proper pronoun for the IW’s
gender and the correct IW’s name is used throughout the report);
ii. The
report is not altered in any way;
iii. The report
includes the DEP physician’s name and is typed and dated and
contains the DEP physician’s signature; and
iv. That the
narrative report:
a) Specifically
acknowledges the conditions allowed and disallowed in the claim;
b) Includes
an opinion based on allowed or, when appropriate, requested conditions;
c) References
medical evidence relied upon to answer questions;
d) Includes
responses to all questions, including rationale for the responses; and
e) Includes
the IW’s name and claim number on every page.
b. A
completed C-143
or C-143 PC
must be included with EOD IME reports.
c. Following
the quality assurance review, the MSS shall:
i. Enter
a note in the claims management system, summarizing the contents of the report;
and
ii. Complete
the “Medical Referral Completed” work item if an addendum is not requested.
d. The MSS or
IMS shall report quality assurance problems to BWC’s DEP Central Unit.
4. The CSS
shall review IME reports to determine the necessary action.
5. The CSS
will:
a. Provide a
hard copy of any IME report to a party to the claim, upon request;
b. Notify the
MCO case manager by email or phone that the IME report is imaged in the claim
and discuss treatment recommendations, if necessary; and
c. Send
IME reports to the IW’s physician of record (POR) or treating physician by
mail, fax, or email.
1. The CSS
shall schedule an IME immediately upon receipt of an Interlocutory Order from
the IC requesting that an IME be scheduled.
2. Claims
services staff shall follow the same procedures (e.g., contact for availability
selecting DEP physician) as are followed for scheduling a BWC IME.
3. Upon
receipt of the IME report, the CSS shall:
a. Complete a
notice of referral (NOR) to the IC to return the claim to the IC to be reset
for hearing; or
b. Continue
processing the claim as ordered by the IC.
4. See the Notice
of Referral to the Industrial Commission policy and procedure for
additional information on referrals to reset for hearing.
1. Prior to
obtaining a PFR for the allowance of additional conditions, the CSS or MCS shall
determine the need for and attempt to obtain medical evidence according to the
MEDD policy.
2. Except for
C-92 PFR referrals, if the CSS or MCS determines that a medical review is
necessary, the claim shall be referred to the MSS. For C-92 PFRs, refer to the C92
Independent Medical Examinations (IMEs) and Physician File Reviews (PFRs)
policy and procedures.
3. Upon
receipt of a referral, the MSS shall:
a. Make the
decision on whether a PFR is warranted, utilizing the criteria detailed in the
policy above;
b. Ensure
equitable selection and distribution of PFRs to DEP physicians based upon
Claims Operations guidelines;
c. Enter
a note in the claims management system noting their decision and detailing the
criteria used in making the decision; and
d. If the MSS
determines that a PFR:
i. Is
not warranted, the MSS shall complete the “Medical Referral Completed” work
item.
ii. Is
warranted, the MSS shall:
a) Obtain and
image in the claim the Medical Servicing Providers Report; and
b) Create a
medical file review case in the claims management system.
1. When
referring a claim for a PFR, the MSS shall complete a Physician Review
(MEDCO-21) form.
2. The MSS
shall then:
a. Email the
form to the selected DEP physician; and
b. Image the
form and a copy of the email (with MSS last name redacted) to the claim file.
1. The MSS
that requested the PFR shall review for a completed PFR within five calendar
days after the request was made.
a. If the PFR
is not received within the five calendar days immediately following the request
for the PFR, the MSS shall:
i. Make
up to two additional attempts to contact the DEP physician; and
ii. Document
all attempts to contact the DEP physician in claim notes.
b. If the PFR
is not received following these attempts, the MSS shall report this to BWC’s DEP Central Unit.
2. Upon
receipt of the DEP physician’s report, the MSS who made the referral shall complete
a quality assurance review of the report.
a. The
reviewer shall verify that:
i. IW
information is correct throughout the report (e.g., proper pronoun for the IW’s
gender and the correct IW’s name is used throughout the report);
ii. The
report is not altered in any way;
iii. The report
includes the DEP physician’s name and is dated; and
iv. That the
narrative report:
a) Specifically
acknowledges the conditions allowed and disallowed in the claim;
b) Includes
an opinion based on allowed or, when appropriate, requested conditions;
c) References
medical evidence relied upon to answer questions;
d) Includes
responses to all questions, including rationale for the responses; and
e) Includes
the IW’s name and claim number on every page.
b. The MSS or
IMS shall report quality assurance problems to BWC’s DEP
Central Unit.
3. Following
the quality assurance review, the MSS shall:
a. Enter a
note in the claims management system, summarizing the contents of the report;
b. Complete
the “Medical Referral Completed” work item if an addendum is not requested; and
c. Image
the report into the claim immediately, even if an addendum is requested.
4. If the MSS
determines that an addendum is needed, the MSS shall follow the process
detailed in the Addendums section of this
document.
5. Upon
receipt of the “Medical Referral Completed” work item from the MSS indicating
that the PFR report is complete, the CSS or MCS will proceed with processing the
claim using the documentation in the medical report.
6. The CSS or
MCS shall provide a copy of the PFR report to all parties to the claim upon
request.
1. Requests
a. The MSS
shall request an addendum when the report contains an error, does not address
all questions asked of the DEP physician, or additional information is needed.
b. If an
addendum is necessary because the DEP physician states the supporting medical
evidence is insufficient and mentions specific supporting medical evidence that
is needed, the MSS shall refer the issue back to the requestor to obtain the
missing information.
c. CSS,
MCS or CA shall:
i. Determine
if the evidence needed exists and is available by contacting the MCO to request;
ii. Obtain
the required evidence; and
iii. Refer to
the MSS to process the addendum.
iv. If the requested
evidence does not exist, document and continue processing the request.
d. When the
MSS requests an addendum, the MSS shall:
i. Summarize
the need for the addendum in a note in the claims management system;
ii. Send
an email to the DEP physician requesting the addendum and image the email to
the claim file; and
iii. Follow-up
with a written request for the addendum using “Ad Hoc” correspondence in the
claims management system, copying all parties to the claim.
e. The
physician has five business days from the date of the addendum request to
submit their report.
f. If
the addendum has not been received, the MSS shall follow up in six to eight calendar
days from the date of the addendum request.
2. Receipt
a. Upon
receipt of the addendum, the requesting MSS shall:
i. Complete
a quality assurance review of the addendum; and
ii. Enter
a note in the claims management system, summarizing the outcome of the review.
b. Upon
notice that the addendum has been received, the CSS, MCS, or CA:
i. Shall
send copies of the addendum to all parties to the claim, if requested; and
ii. May
wait to mail copies of the original report until the addendum is received.
1. Initial
Employer-Scheduled IMEs
a. The
employer may require that the IW be examined by a physician of the employer’s
choice one time on any issue asserted by the IW or their POR.
i. If,
without good cause, the IW refuses to submit to an IME
scheduled by the employer or refuses to release or execute a release for any
medical information, record, or report required to address an issue related to
his/her claim, the employer may file a C-86 requesting the IW’s claim
be suspended during the period of refusal.
ii. BWC
shall complete a NOR to the IC citing the C-86 filed by
the employer.
iii. The decision
to suspend the claim is within the jurisdiction of the IC.
b. See the Industrial
Commission Suspensions policy and procedure for additional information.
2. Subsequent
Employer-Scheduled IMEs
a. If a claim
is pending before the IC and the employer requests another IME, claims services
staff shall review the claim for recent IMEs.
i. As
it concerns authorization of TT, an IME performed within the past 30 calendar days
is regarded as “recent”.
ii. If
the question involves an AA alleging a causal relationship to the allowed
injury/occupational disease, an IME performed within the past 60 to 90 calendar
days may be regarded as “recent” (depending on the nature and type of the
condition and/or disability).
b. After
reviewing the claim, claims services staff shall determine whether the issue is
within BWC’s jurisdiction and immediately take appropriate action on the
request. If the issue:
i. Is
within BWC’s jurisdiction (e.g., TT, AA), claims services staff shall:
a) Issue a
subsequent order if the decision is to allow the additional IME; or
b) If BWC
determines that the request should be denied (e.g., IW recently examined by a
physician selected by the employer on same matter) for any reason, claims
services staff shall refer the request to the IC for further consideration.
ii. Is
not within BWC’s jurisdiction, BWC shall complete a NOR to the IC for
further consideration.