OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:

ALTERNATIVE DISPUTE RESOLUTION EXAMS

Policy #:

CP-01-02

Code/Rule Reference:

O.A.C. 4123-6-16, R.C. 4121.441, R.C. 4123.53; R.C. 4123.511

Effective Date:

01/14/2020

Approved:

Ann Shannon, Chief of Claims Policy & Support

Origin:

Claims Policy

Supersedes:

Policy and Procedure # CP-01-02, effective 04/24/14

History:

CP-01-02

New 04/24/14


 

Alternative Dispute Resolution Exams Table of Contents

 

I. POLICY PURPOSE

II. APPLICABILITY

III. DEFINITIONS

Alternative Dispute Resolution (ADR) exam

IV. POLICY

MCO Requested BWC ADR Exam

V. PROCEDURE

A.        Standard Claim File Documentation

B.        The MCO Process for ADR Exams

C.       Failure to Appear (FTA) for an ADR Exam

D.       Billing ADR Exams

 

 


 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure Alternative Dispute Resolution (ADR) exams are processed in accordance with O.A.C. 4123-6-16 and that the appropriate entities make timely decisions.

 

II. APPLICABILITY

 

This policy applies to the BWC claims services staff, the BWC Medical Services Division, the Disability Evaluators Panel (DEP) and to all Managed Care Organizations (MCO).

 

III. DEFINITIONS

 

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 a Managed Care Organization (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.

 

IV. POLICY

 

MCO Requested BWC ADR Exam: It is the policy of BWC to process an MCO request for a BWC ADR independent medical examination (IME) when:

A.     Medical treatment is disputed; and,

B.     The exam is necessary or appropriate.

 

V. PROCEDURE

 

A.     Standard Claim File Documentation

1.     BWC staff shall refer to the Standard Claim File Documentation and Altered Documents policy and procedure for claim note requirements; and

2.     Shall follow any other specific instructions for claim notes included in this procedure.

 

B.     The MCO Process for ADR Exams

1.     The MCO shall process medical disputes in accordance with the MCO Policy Reference Guide (MPRG), Chapter 5.

2.     Exam Scheduling Preparation – under the authority of BWC, the MCO shall:

a.     Contact the IW to ensure that he/she is aware of the obligation to attend the ADR IME. The MCO shall make three (3) attempts to contact the IW at different times and on different days and shall document each attempt in the claim notes.

b.     Determine times when the IW is available to attend the IME and make every reasonable effort to schedule the ADR IME during those times.

c.      Explain to the IW that benefits may be suspended for failing to appear, cancelling or requesting to reschedule the exam without good cause.

d.     Attempt to schedule the IW with an examiner who speaks the IWs language if one is available in the appropriate specialty and location.

i.       In the event interpreter services are required, the MCO will contact the IWs Workers Compensation Claims Specialist (CSS) to make arrangements for interpreter services;

ii.      BWC will pay for interpreter services for ADR IMEs as often as needed.

e.     Inform the examining physician an appointment must be made available within 7 calendar days of the exam request.

3.     The MCOs may enter into agreements with administrative agents to schedule, coordinate and bill ADR IMEs under the authority of BWC.

4.     Exam Packets

a.     The MCO shall create the exam packet and include all relevant information to the dispute.

b.     The MCO shall neither add questions nor combine questions from another scheduled IME for an ADR exam. An ADR exam is a stand-alone exam.  

5.     The MCO shall only refer an IW for an out-of-state exam with a BWC out-of-state IME vendor when the IW lives more than 50 miles from the Ohio border.

6.     IME Report and Addendum

a.     The evaluating physician is expected to ensure that the MCO receives the ADR report within five (5) calendar days of the evaluation.

b.     The MCO shall be responsible for reviewing the report to ensure it:

                                               i.          Meets the basic requirements of an ADR IME as set forth in Chapter 5 of the MPRG;

                                              ii.          Contains a medically reasonable, evidence-based decision; and

                                             iii.          Meets the following additional Quality Assurance (QA) requirements:

a)     IW information is correctly identified [i.e., name, claim number, DOI and claim allowance(s)].

b)     Report is not altered in any substantive way.

c.      If the MCO determines that an addendum is necessary based on the QA requirements above:

                                                i.           The MCO will forward the appropriate questions directly to the examining provider;

                                               ii.           The amended report must be returned to the MCO within two (2) calendar days of the request.

7.     The MCO’s time frame for completing the ADR process is tolled while the ADR IME and the report are pending.

8.     The MCO shall:

a.     Submit its recommended ADR decision to BWC electronically within seven (7) calendar days after receipt of the IME report if an addendum is not required;  

b.     Submit its recommended ADR decision to BWC electronically within one (1) business day of the receipt of an acceptable addendum if an addendum is required;

c.      The order shall be published under the authority of BWC within two (2) calendar days after receipt of the MCO recommendation.

d.      Additional information on BWC Orders may be found in the Orders, Waivers, Appeals and Hearings policy.

9.     BWC and MCO staff shall refer to the Independent Medical Examinations policy and procedure for additional information and shall follow any other specific instructions included in this procedure.

10.  The MCO shall process travel reimbursement requests for ADR exams according to the BWC Travel Reimbursement policy and procedure.

 

C.    Failure to Appear (FTA) for an ADR Exam

1.     Pursuant to the Independent Medical Examinations policy:

a.      The MCO shall determine if the IW failed to appear, cancelled or requested to reschedule an ADR exam with good cause. An investigation is conducted to establish unforeseen extraordinary circumstances.

b.      If the MCO determines the IW failed to appear with good cause, the MCO shall reschedule the exam.

                                               i.          The MCO will update the status of the medical exam scheduling case in which the IW did not attend and close the case.

                                              ii.          A new medical exam scheduling case is created by the MCO when a new exam is scheduled

                                             iii.          If the exam is rescheduled and the IW attends, the MCO shall QA the report, as outlined in section V.B.7 above.

                                            iv.          The MCO shall write notes and shall update the medical exam scheduling case with the exam report receipt date and the appropriate ADR exam outcome status.

c.      If the MCO has determined the IW did not have good cause, the MCO shall update the status of the medical exam scheduling case with the appropriate ADR exam outcome and shall notify BWC claims services staff.

d.      Before suspending benefits, BWC claims services staff shall review the MCO determination regarding good cause and claims services staff shall determine if the IW had unforeseen circumstances that warrant good cause.

                                               i.          Claims services staff shall notify the MCO to reschedule the exam if claims services staff determines the IW failed to appear with good cause.

                                              ii.          Claims services staff shall staff all FTAs without good cause with the supervisor.

                                             iii.          Claims services staff shall suspend medical benefits only with supervisor approval.

                                            iv.          The supervisor may contact the IW or the IW’s authorized representative to discuss the reason for the FTA.

                                              v.          Claims services staff shall document all the facts, actions and reasons in claims management notes.

                                            vi.          Claims services staff shall send suspension letters to the IW with copies to all parties.

                                           vii.          Claims services staff shall email the BWC Medical Billing & Adjustments Supervisors mailbox to place the claim ‘On Review’ to stop bill payment of all medical benefits except for medications and emergency or life-sustaining treatment and authorization of treatment. The email shall:

a)     Have the subject: “Medical Suspended in Claim,” and

b)     Give the specific date of suspension.

                                          viii.          Claims services staff shall email the MCO to cease processing of all C-9s and ADR appeals except for those pertaining to emergency or life-sustaining treatment.

                                            ix.          If the IW contacts claim services staff and commits to attend an exam, claims services staff shall contact the MCO to reschedule the exam, but the medical benefits remain suspended until the IW appears.

                                              x.          After the IW appears for the examination and the physician sends the ADR report to the MCO, the medical exam scheduling case shall be updated with the appropriate exam status.

                                            xi.          Claims services staff shall immediately reinstate the IW’s benefits by:

a)     Sending the “ADR Reinstatement Letter” to the IW and copying all parties;

b)     Emailing the MCO and the BWC Medical Billing & Adjustments Supervisors mailbox so bills are no longer denied;

c)     Once notified, Medical Billing and Adjustments (MB&A) shall take the claim off REVIEW in Cambridge.

2.     The MCO shall then:

a.     Review all treatment authorization requests in its possession, as outlined by the C-9 authorization guidelines, as providers need not re-submit C-9s to the MCO that the provider submitted during the suspension of benefits.

b.     Notify the treating provider(s) that the authorization of treatment suspension is lifted, and C-9 authorization requests shall be considered and processed.

c.      Process pended bills as providers need not re-submit bills that the provider submitted to the MCO during the suspension of benefits.

3.     BWC shall send an “Administrative Time and Letter” fee to DEP physicians when an IW fails to appear for an ADR exam.

 

D.    Billing ADR Exams

1.     ADR IME’s are to be billed:

a.     Through an EDI 837 transaction using procedure code Z1600.

b.     For an out-of-state ADR IME, staff shall use procedure code Z9600.

2.     An “administrative time and letter” fee may be billed for non-compliant IWs using:

a.     Procedure code Z1601;

b.     For out-of-state scheduled IMEs, staff shall use Z9601.

3.     Claims services staff shall coordinate with the MCO in providing the IW an Injured Worker Statement for Reimbursement of Travel Expense (C-60) form, when appropriate based on the Travel Reimbursement policy and procedure.