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Policy and Procedure Name:
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ALTERNATIVE DISPUTE RESOLUTION EXAMS
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Policy #:
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CP-01-02
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Code/Rule Reference:
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O.A.C. 4123-6-16, R.C. 4121.441, R.C. 4123.53; R.C.
4123.511
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Effective Date:
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01/14/2020
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Approved:
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Ann Shannon, Chief of Claims Policy & Support
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Origin:
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Claims Policy
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Supersedes:
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Policy and Procedure # CP-01-02, effective 04/24/14
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History:
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CP-01-02
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New 04/24/14
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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
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.
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).
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.
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.
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.
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.
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.
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.