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OhioBWC - Basics: (Policy library) - File

Policy Name:

Independent Medical Exams (IME) and Physician File Reviews (PFR)

Policy #:

CP-09-08

Code/Rule Reference:

R.C. 4121.43; R.C. 4123.511; R.C. 4123.53; R.C. 4123.56; R.C. 4123.57(A); R.C. 4123.651; R.C. 4123.68; OAC 4121-3-12; OAC 4121-3-15; OAC 4123-3-09; OAC 4123-3-15; OAC 4123-3-16; OAC 4123-3-32; OAC 4123-6-40; OAC 4123-15-03; IC Resolutions R03-1-02, R03-1-04, R96-1-01, and R15-1-01

Effective Date:

 

09/29/17

 

Approved:

Kevin R. Abrams, Chief Operating Officer

Origin:

Claims Policy

Supersedes:

All Injury Management policies, directives and memos regarding independent medical exams and physician file reviews that predate the effective date of this policy.

History:

Revised 09/29/17, New  02/04/16

Review date:

02/04/21

 

 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure that BWC or a managed care organization (MCO) obtains independent medical exams (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 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:  Based on Ohio Industrial Commission (IC) Resolution R03-1-04, 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).

 

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, which by its causes and the characteristics of its manifestation or the condition of the employment results in a hazard which distinguishes the employment in character from employment generally, and the employment creates a risk of contracting the disease in greater degree and in a different manner from the public in general.

 

Official Disability Guidelines (ODG):  A comprehensive international medical treatment and return to work guideline that provides evidence-based decision support to improve, as well as benchmark, outcomes in workers' compensation claims. 

 

Out-of-state Exams:  An IME that takes place outside of a 50-mile radius from the Ohio state border.

 

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 occupational disease (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 disease that is considered to be an OD and compensable as such when contracted by an employee in the course of the employment in which such employee was engaged and due to the nature of any process described in R.C. 4123.68 and for which an exam must be scheduled prior to determination of a claim. 

 

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.  GENERAL POLICY FOR INDEPENDENT MEDICAL EXAMS (IME) AND PHYSICIAN FILE REVIEWS (PFR)

A.    It is the policy of BWC to consider when selecting a DEP physician that the medical specialty of the selected physician must be appropriate for the allowed conditions in the claim and/or the issue presented for consideration.

B.    The DEP physician selected must have neither a conflict of interest nor the appearance of a conflict of interest.  Possible conflicts of interest include, but are not limited to, when the DEP physician:

1.    Is in the IW’s immediate family;

2.    Works with a member of the IW’s immediate family in the DEP physician’s practice or clinic;

3.    Is in the immediate family of the IW’s treating physician/physician of record in the current claim;

4.    Previously provided treatment to the IW as part of the current or another workers’ compensation claim;

5.    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;

6.    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;

7.    Is in the same practice or clinic with a provider described in 4, 5 or 6 above;

8.    Has a personal, professional, or contractual relationship with the MCO assigned to the current claim (however, merely being on an MCO’s provider panel or network as a treating physician does not in and of itself disqualify a DEP physician from performing IMEs or PFRs on IWs assigned to the MCO);

9.    Has a personal, professional or contractual relationship with the IW, the EOR, or their representatives;

10.  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

11.  Has 5% or greater financial interest in the MCO managing the current claim. 

C.   Although BWC will attempt to avoid a conflict of interest when selecting a DEP physician, the DEP physician must, as a condition of the DEP agreement, identify any conflict of interest and withdraw from completing an IME or PFR when one exists or appears to exist.

D.   It is the policy of BWC to require that the DEP physician:

1.    Include in a narrative report an opinion based on the allowed conditions with references to the medical relied upon; and

2.    Include answers to all questions with supporting rationale.

E.    It is the policy of BWC to refer all concerns or complaints regarding a DEP physician to BWC’s DEP Central unit.

F.    It is the policy of BWC that IME and PFR reports and addendums be imaged into the claim immediately upon receipt.

1.    The original report must be imaged without waiting for an addendum should one be needed.

2.    See Section V.K. below for additional information regarding addendums. 

 

V.   POLICY FOR INDEPENDENT MEDICAL EXAMS (IME)

A.    It is the policy of BWC to schedule IMEs as required by law or when the need is identified in the course of claims management, and require that an IW appear for BWC scheduled exams.

B.    It is the policy of BWC to provide the IW and examining DEP physician notice at least 14 days in advance of the exam date whenever possible. 

1.    Notice to the IW and DEP physician is provided in writing.

2.    If the exam must be scheduled with less than 14 days notice, BWC shall also call the IW to provide notice of the exam.

3.    BWC shall select the physician to conduct an in-state exam.  In-state exams are scheduled:

a.    Directly with the examining physician; or

b.    Through an administrative agent when the DEP physician selected by BWC has notified BWC that they use an administrative agent. 

4.    Out-of-state exams are scheduled through an administrative agent.

C.   It is the policy of BWC to consider the geographic proximity between the IW’s residence and IME location.

1.    The IME will be scheduled at the acceptable location that is closest to the IW’s home, taking into consideration available times, specialty of physician needed and possible conflicts of interest.

2.    The IW shall be reimbursed for expenses when attending an exam that requires travel outside of the IW’s permanent or temporary residence.

3.    Mileage is reimbursed for travel over 45 miles round trip. 

4.    See the Travel Reimbursement policy for additional information regarding requirements for travel reimbursement.

D.   It is the policy of BWC that the IW must provide photo identification at the time of an exam.

E.    It is the policy of BWC to prohibit IW representatives, EORs, EOR representatives or MCO representatives from being present during an IME.

1.    The IW may have a relative or chaperone present during an exam.

2.    An interpreter may be present for an exam.  See the Interpreter Services policy for additional information.  

F.    It is the policy of BWC to prohibit the IME or PFR physician from communicating with the parties to a claim or their representatives regarding the examination or report.

G.   It is the policy of BWC to prohibit audio or video recordings in the exam room.

H.   It is the policy of BWC to image all IME and PFR reports to the electronic file for review online by the parties to a claim. For C-92 reports, a copy of the report shall be mailed either separately or with the BWC Order. BWC will provide a hard-copy of all other IME reports, file reviews and any addendums upon request.

I.      When an IW fails to appear for an IME, it is the policy of BWC to evaluate if the reason the IW failed to appear was for good cause based on extraordinary unforeseen circumstances. See L through S of this section below for failure to appear information for each type of exam.

J.     It is the policy of BWC that IME reports:

1.    Be submitted within 10 calendar days of the exam, except in the case of an ADR exam;

2.    Be submitted within 5 calendar of the exam in the case of an ADR exam;

3.    Not be altered in any way, such as cross outs or white outs (see the Standard Claim File Documentation policy for further guidance on altered documents);

4.    Be dated and contain the DEP physician’s signature; and

5.    Contain the IW’s name and claim number on each page of the report.

K.    It is the policy of BWC that only BWC or the MCO may request an addendum to a DEP physician’s report and that such request be made in writing.

1.    The initial request may be made by telephone, but must be followed up with a written request.

2.    The request for an addendum must be copied to all parties to the claim. 

3.    The original report must be imaged in the claim without waiting for the addendum.

4.    The addendum must be imaged in the claim upon receipt.

L.    It is the policy of BWC to schedule exams prior to making the initial decision in a claim as required by statute or when BWC identifies the need for an exam.

1.    An exam:

a.    Is required before determining an OD claim for these conditions:

i.      Berylliosis;

ii.     Silicosis;

iii.    Asbestosis;

iv.   Coal miner’s 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.    May be scheduled, depending on the situation, for:

i.      Other ODs;

ii.     Forced sexual conduct; or

iii.    Other initial determinations as identified by BWC.

2.    It is the policy of BWC to require the minimum evidence as described in IC Resolution R15-1-01 “Modification of R96-1-01 and R03-1-02 related to medical evidence necessary to support a claim for an asbestos-related condition” for the following types of diseases:

a.    Silicosis;

b.    Asbestosis;

c.     Coal miners’ pneumoconiosis; or

d.    Any other occupational disease of the respiratory tract resulting from injurious exposure to dust

3.    Failure to appear for an exam regarding the initial determination of a claim for reasons other than good cause may result in denial of the claim.

4.    See the Initial Claim Determination and Occupational Disease Claims policies for additional information. 

M.   It is the policy of BWC to schedule EOD exams as required by statute or when BWC identifies the need for an exam.

1.    BWC shall schedule an EOD IME no later than 30 days after the first 90-consecutive-day period for which the IW is paid TT compensation, unless waived by the employer or BWC.

a.    The employer may waive the 90-day exam, either permanently or temporarily.

b.    If the waiver is temporary, a date must be given for when the exam should be considered again.

c.     The waiver may be in writing, using a Waiver of Examination (MEDCO-6) or equivalent form.

d.    If the employer is out of business or fails to respond to BWC’s request to waive the exam, BWC may waive the exam.

e.    If the employer objects to waiving the exam, BWC shall schedule the exam.

f.      Reasons to consider waiver of the exam include, but are not limited to:

i.      Surgery is scheduled or was recently performed;

ii.     Type of surgery and mode of anesthesia;

iii.    Normal recovery time for surgery based on ODG;

iv.   Post operative passive physical therapy is being performed;

v.     The IW remains hospitalized for the allowed conditions;

vi.   Referral for or active participation in a vocational rehabilitation plan is underway;

vii.  The disability management coordinator (DMC) provides a recommendation regarding the IW’s potential success or compliance with vocational rehabilitation plan services;

viii. Projected discharge date from inpatient hospitalization and normal healing times recommended in the ODG;

ix.   Notes from the physician of record (POR) or treating physician documenting IW’s progress in a treatment plan; or

x.     Other medical factors that justify waiving an exam.

2.    BWC shall schedule an EOD IME immediately after the IW has received 200 weeks of TT compensation. 

3.    BWC may schedule an EOD IME anytime:

a.    When TT is on-going; or

b.    When a request for a new period of TT has been received.

4.    The IW must be receiving or have requested TT on the date the exam is scheduled.

5.    If the IW returns to work prior to the exam taking place, BWC shall cancel the exam.

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 for additional information.

N.   Scheduled Loss: It is the policy of BWC to schedule an exam regarding requests for SL when BWC identifies the need for an exam.

1.    Failure to appear for an exam regarding SL may result in the suspension of the request for SL.

2.    See the Scheduled Loss Compensation policy for more information.

O.   Alternative Dispute Resolution (ADR)

1.    Failure to appear for an ADR exam for reasons other than good cause may result in the suspension of medical treatment in the claim.

2.    ADR exams may be completed by a BWC-certified physician who is not on the DEP.

3.    See the Alternative Dispute Resolution Exams policy for additional information.

P.    Initial Determination of %PP or an Increase in %PP: It is the policy of BWC to schedule exams for the initial determination of %PP as required by statute or for an increase in %PP when BWC identifies the need for an exam.

1.    The DEP physician selected is not required to maintain an active practice but must have additional training in the %PP process.

2.    The DEP physician must use the version of the “American Medical Association’s Guide to the Evaluation of Permanent Impairment” (AMA Guides) approved by BWC.

3.    Failure to respond to BWC’s attempt to schedule or failure to appear for a %PP exam without notice or explanation may result in dismissal of the C-92 application.

4.    See the Percentage of Permanent Partial Disability or Increase of Permanent Partial Disability Compensation policy for additional information.

Q.   Additional Conditions: It is the policy of BWC to schedule an exam for the determination of additional conditions when BWC identifies the need for an exam.

1.    Failure to appear for an additional allowance exam for reasons other than for good cause may result in suspension of the request for the additional allowance.

2.    See the Additional Allowance policy for additional information.

 

R.   Abatement of Substantial Aggravation: It is the policy of BWC to schedule an exam to evaluate the status of a condition allowed for substantial aggravation of a pre-existing condition to determine if the condition continues to be payable when BWC identifies the need for an exam.

1.    Failure to appear for a scheduled exam to evaluate a condition allowed for substantial aggravation of a pre-existing condition for reasons other than for good cause may result in suspension of the compensation or treatment requested based on that condition.

2.    See the Aggravation and Substantial Aggravation of a Pre-Existing Condition policy for additional information. 

S.    Claim Reactivation: It is the policy of BWC to schedule an exam regarding the reactivation of a claim when BWC identifies the need for an exam.

1.    Failure to appear for an exam scheduled regarding the reactivation of a claim for reasons other than good cause may result in a suspension of the request for reactivation.

2.    See the Claim Reactivation policy for additional information.

T.    It is the policy of BWC to conduct an investigation if an IW refuses to submit to or otherwise obstructs an exam after appearing for the exam.

1.    If it is determined that the refusal to submit or obstruction was justified, the exam will be rescheduled and processing will continue.

2.    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 exam. 

U.   It is the policy of BWC to lift a suspension as the result of failure to appear for a BWC-scheduled exam when:

1.    The IW appears for a rescheduled exam; or

2.    The issue that resulted in the BWC-scheduled exam is moot.

V.    Employer-scheduled Exams in SF Claims

1.    The EOR in a SF claim may schedule an IW for an exam by a physician of the EOR’s choice one time on any issue asserted by the IW or the POR/treating physician.

2.    The EOR is responsible for the cost of the employer-scheduled exam.  

3.    The EOR shall provide the IW with a proper form to be completed by the IW for reimbursement of expenses, including travel, related to attending an employer-scheduled exam and shall pay the IW for such expenses immediately upon receipt of the completed form.

4.    If the IW is employed, the EOR shall pay the IW for any loss of wages arising from attending the exam within three weeks of the exam date.

5.    The employer shall inform BWC, the IW and the IW’s representative as to the time and place of the exam, the questions asked of the examining physician and the information provided to the examining physician. 

6.    Treatment by a company doctor constitutes an employer-scheduled exam.

7.    If, without good cause, the IW refuses to submit to an exam scheduled by the EOR or refuses to release or execute a release for any medical information, record or report required to address an issue related to the IW’s claim, the EOR may file a Motion (C-86) requesting the IW’s claim be suspended. 

a.    BWC shall refer requests to suspend a claim filed by the EOR to the IC.

b.    See the Industrial Commission Suspensions policy for additional information. 

8.    If, after one employer-scheduled exam, the EOR asserts that another exam 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 exam. 

a.    If the claim is pending before the IC and the question(s) sought to be clarified by such an exam is not within the jurisdiction of BWC (e.g., Permanent Total Disability [PTD] or a contested issue), BWC shall refer the request to the IC for further consideration.

b.    If the question sought to be clarified is within BWC’s jurisdiction (e.g., allowance of an additional condition not under appeal to the IC), BWC shall act immediately upon the request.

i.      BWC may determine that the request should be denied if the IW was recently examined by a doctor chosen by the employer or for other reasons.

a)    In cases of TT, a medical exam performed in the past 30 days shall be regarded as recent.

b)    In cases of additional allowances, a medical exam performed in the past 60 to 90 days may be regarded as recent.

ii.     BWC shall:

a)    Issue an order granting the request for an additional exam to be scheduled by the EOR; or,

b)    Refer the request to the IC if BWC’s decision is that the request should be denied.

9.    The EOR shall arrange for an exam within 15 days from the receipt of the order approving the exam and the exam shall take place not later than 30 days from the receipt of the approval.

10.  The EOR shall file the doctor’s report with BWC immediately upon its receipt.

W.  Employer-requested Exams

1.    BWC shall consider written requests from the EOR for BWC to schedule an IW exam.

2.    BWC shall schedule an exam 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

3.    BWC shall refer a request for an exam to the IC if it is related to issues outside of BWC’s jurisdiction or when BWC does not agree with the request.

4.    BWC may, at the request of a SI employer, schedule an exam with a BWC DEP physician on behalf of the SI employer.

a.    The SI employer shall pay the provider for the exam.

b.    The SI employer shall pay expenses and lost wages to the IW for such an exam.

 

VI.  POLICY FOR PHYSICIAN FILE REVIEWS (PFR)

A.    It is the policy of BWC to obtain a PFR when necessary in the course of claims management.  Reasons a PFR may be obtained include, but are not limited to:

1.    Identification of the proper diagnosis for the initial determination of a claim;

2.    Determination of requests for the allowance of additional conditions;

3.    Evaluation of requests for claim reactivation, including appropriateness of medical treatment;

4.    Processing requests for an increase in %PP;

5.    Determining the IW’s eligibility for a SL award;

6.    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

7.    Determination of a claim or an issue in a claim when an exam is not possible due to physical limitations that prevent an IW from being examined or the IW has died.

B.    It is the policy of BWC to require DEP physicians who complete PFRs to expressly accept all findings of the POR/treating physician(s), but not necessarily their opinion about those findings.

C.   It is the policy of BWC to provide copies of file review reports to parties to the claim when requested.

 

 

BWC staff may refer to the corresponding procedure for this policy entitled “Independent Medical Exams (IME) and Physician File Reviews (PFR)” for further guidance.


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