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Policy
and Procedure Name:
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ALTERNATIVE
DISPUTE RESOLUTION (ADR) 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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Previous
versions of this policy are available upon request
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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 will refer to the Standard Claim
File Documentation and Altered Documents policy and procedure for claim
note requirements; and
2.
Must
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 (IMEs) and Physician File Reviews (PFRs) 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 (IMEs) and Physician File Reviews (PFRs)
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.