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Policy and Procedure Name:

Independent Medical Examinations (IMEs) and Physician File Reviews (PFRs)

Policy #:

CP-09-08.1

Code/Rule Reference:

R.C. 4121.43; R.C. 4123.511; R.C. 4123.53; R.C. 4123.54; R.C. 4123.56; R.C. 4123.57; R.C. 4123.651; R.C. 4123.68; OAC 4121-3-09: OAC 4121-3-12; OAC 4121-3-15; OAC 4123-3-09; OAC 4123-3-15; OAC 4123-3-15.1; OAC 4123-3-16; OAC 4123-3-32; OAC 4123-6-40; OAC 4123-15-03; OAC 4123-6-16; IC Resolution R15-1-01

Effective Date:

04/09/21

Approved:

Ann M. Shannon, Chief of Claims Policy and Support

Origin:

Claims Policy

Supersedes:

Policy # CP-09-08.1, effective 12/31/20

History:

Previous versions of this policy are available upon request


 

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

 

 


 

I. POLICY PURPOSE

 

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.

 

II. APPLICABILITY

 

This policy applies to BWC claims services staff and MCO staff.

 

III. DEFINITIONS

 

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.

 

IV. POLICY

 

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.

 

V. PROCEDURE

 

A.     General Claim Note and Documentation Requirements

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.

 

B.     Preparation for Scheduling an IME or PFR

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.

 

C.    Multiple IMEs or PFRs

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.

 

D.    IME and PFR Not Indicated

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.

 

E.     Selecting a DEP Physician

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.

 

G.    Creating an Exam Packet

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 Exam Packet Content document found on COR, under Tips and Tools, 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.

 

H.    Requesting an IME

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.

 

I.       Scheduling the IME

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.

 

J.      BWC IME Cancellations

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.

 

L.     Requests to Reschedule an IME

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.

 

M.    Diagnostic Testing

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.

 

N.    Initial Determination IMEs- Statutory Occupational Disease (OD)

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.

 

O.    Initial Determination (Other Than Statutory OD) IMEs

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.

 

P.     AA IMEs- Physical, Psychiatric, Reflex Sympathetic Dystrophy (RSD)/Complex Regional Pain Syndrome (CRPS)

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.

 

Q.    EOD IMEs

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.

 

R.    SL IMEs

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.

 

S.     Claim Reactivation IMEs

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.

 

T.     ADR IMEs

- See the Alternative Dispute Resolution Exams policy and procedure

for additional information regarding ADR IMEs.

 

U.    Evaluation of Substantial Aggravation 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.

 

V.     IME Reports

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.

 

W.   IC-Ordered IMEs

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.

 

X.     MSS Referral for PFR and Decision

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.

 

Y.     Referral for PFR

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.

 

Z.     PFR Receipt

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.

 

AA.Addendums

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.

 

BB.Employer-Scheduled IMEs

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.