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 4121-3-9: 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; IC Resolutions R03-1-02, R03-1-04, R10-1-01, R96-1-01, and R15-1-01

Effective Date:

 

6/05/18

 

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 6/05/18, 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 R10-1-01, 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.


 

Procedure Name:

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

Procedure #:

CP-09-08.PR1

Policy # Reference:

CP-09-08

Effective Date:

06/05/18

Approved:

Kevin R. Abrams, Chief Operating Officer

Supersedes:

Procedure #CP-09-08.PR1, effective 09-29-17

History:

Revised 06/05/18, 09/29/17, 11/14/16, New 02/04/16

Review date:

02/04/21

 

 

I.     BWC staff shall refer to the Standard Claim File Documentation policy and procedure for claim-note requirements and shall follow any other specific instructions included in this procedure.

II.    Determining the Need for an Independent Medical Exam (IME) or Physician File Review (PFR)

A.    Claims staff shall schedule an IME in the following circumstances as required by statute (see Section V. below for additional information regarding these exam types):

1.    Prior to the initial determination of a claim for a statutory occupational disease (OD);

2.    After the first instance of 90 consecutive days of temporary total (TT) compensation (90-day exam) to determine extent of disability (EOD);

3.    After 200 total weeks of TT compensation (200-week exam) to determine EOD;

4.    Prior to issuing a decision when processing the initial Application for Determination of Percentage of Permanent Partial Disability or Increase of Permanent Partial Disability (C-92); and

5.    Prior to issuing a decision when processing a C-92 application for an increase in percentage of permanent partial impairment (%PP) when a PFR is not sufficient.   See the Percentage of Permanent Partial Impairment policy for additional information.

B.    When processing C-92 applications for an increase in %PP, claims staff shall obtain a PFR when an IME is not indicated.  See the Percentage of Permanent Partial Impairment policy for additional information.

C.   Claims staff may schedule an IME or obtain a PFR whenever needed to assist with management of a claim.  

D.   Claims staff shall not schedule an IME for EOD in a claim where the injured worker (IW) has been found to be permanently and totally disabled (PTD) without evidence of new and changed circumstances.

1.    Claims staff must review the claim with a BWC attorney before considering an EOD exam in a PTD claim.

2.    Exams may be scheduled in PTD claims for other issues, such as additional allowance or treatment.

E.    Claims staff shall consider the following when determining whether an IME will be scheduled or a PFR will be obtained, other than those required by statute (this list is not all inclusive):

1.    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?

2.    Has necessary medical evidence been requested and received?

3.    Is there sufficient evidence in the claim to make a decision without an IME or PFR?

4.    Is the issue to be resolved a medical issue and not a legal issue? (e.g., not a coming or going or voluntary abandonment issue)

5.    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)

6.    Is there sufficient evidence in the file such that a PFR will be adequate, thereby avoiding the need to schedule an exam? 

F.    Claims staff shall not schedule an IME or obtain a PFR when there is sufficient evidence on file upon which to base a decision.

G.   Claims staff shall not schedule an IME or obtain a PFR based solely on a request made by another party to the claim.  See Sections VIII. and IX. below.

H.   Claims staff shall not refer a medical issue to the Ohio Industrial Commission (IC) recommending that a request be denied without an IME or PFR report that supports BWC’s position. 

 

III.  General Procedures for IMEs and PFRs

A.    Claims staff and the Managed Care Organization (MCO) shall consider the following when selecting a physician for an IME or PFR:

1.    The physician must be on the BWC Disability Evaluators Panel (DEP) for an IME or PFR obtained by BWC.

2.    The physician must be a BWC-certified physician for Alternative Dispute Resolution (ADR) exams scheduled by a MCO.

3.    For exams other than those scheduled for C-92 processing, a physician with the same or a similar specialty as the treating physician shall be selected whenever possible.  (BWC staff may use the IME Medical Specialty Guide found on Claims Online Resources (COR) as a resource.)

4.    Claims staff shall select a DEP physician based on the services that physician has agreed to provide.  For example, for C-92 exams, claims staff shall select a DEP physician eligible to do C-92 exams or reviews.

5.    The physician shall be selected to avoid a conflict or the appearance of a conflict of interest.

a.    Claims staff shall obtain and image in the claim the “Medical Servicing Providers” report that lists physicians who have previously billed BWC for treatment or examination of the IW in any claim, or who have performed a PFR of any claim for the IW.

b.    Claims staff shall identify other physicians who have examined the IW or reviewed the IW’s claim but have not billed BWC for the exam or review [e.g., exams in self-insured (SI) claims, exams obtained by the employer and/or IW].

c.     Claims staff shall 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 the corresponding Independent Medical Exam (IME) and Physician File Review (PFR) policy.

d.    Claims staff shall not select a DEP physician with whom he or she has a personal relationship.

B.    Claims staff shall schedule multiple IMEs or obtain multiple PFRs when necessary based on the allowed conditions in the claim.

1.    Claims staff shall notify the IW that more than one exam will be scheduled.

2.    Claims staff shall coordinate the scheduling of the exams to avoid conflicts for the IW to attend the exams.

C.   Prior to scheduling an IME or PFR claims staff 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 Code/Description Modifications policy and procedures for additional information.

1.    Claims staff shall enter a note regarding the review of the conditions in the claim.

2.    For subsequent IMEs or PFRs, only conditions added to the claim after the last review note must be verified. 

D.   Claims staff may refer the claim for a nurse review to determine whether an IME versus a PFR is warranted.  The claims service specialist (CSS) enters a note and creates an event for the medical services specialist (MSS). 

E.    Claims staff shall send all complaints regarding a DEP physician to the BWC DEP Central Unit email box.  

IV.  IME Procedures

A.    When scheduling an exam for an additional allowance, claims staff shall follow the Additional Allowance policy and procedures. 

B.    Contacting the IW

1.    Prior to scheduling an exam, the CSS or claims assistant (CA) shall contact the IW.  During that contact the CSS or CA shall:

a.    Explain to the IW the reason for the exam;

b.    Verify the IW’s address;

c.     Tell the IW that it is necessary to bring a photo ID to the exam;

d.    Explain to the IW that failure to attend the exam may result in the dismissal or suspension of an application and/or suspension or denial of benefits (see additional information regarding specific exam types under G of this section); and

e.    Obtain information regarding the IW’s availability to attend an exam (i.e., ask the IW what days/times the IW is not available to attend).

f.      Explain to the IW that we will attempt to schedule within the availability given, however if we are unable to do so the IW must still attend the exam. 

2.    For exams other than those for C-92 processing, contact with the IW shall be attempted by telephone.

a.    If phone contact is made, the CSS or CA shall include the IW’s exam availability in the note regarding the contact.

b.    If phone contact was not made, but it is possible to leave a detailed message, the CSS or CA shall allow 3 days for the IW to respond with availability to attend an exam. The detailed message must include:

i.      The information outlined in IV.B.1. above;

ii.     That that if we do not hear back from the IW, an exam 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 exam.

c.     If phone contact was not made and the IW is represented, the CSS or CA shall contact the IW representative even if it was possible to leave a detailed message for the IW.

d.    If phone contact was not made and it was not possible to leave a detailed message or contact the IW’s representative, one additional phone contact on a different day shall be attempted. 

e.    If phone contact as described in this section is not possible or no response is received to phone messages, the CSS or CA shall continue with scheduling the exam.

3.    For C-92 processing or C-92A when an IME is deemed necessary, the CSS or CA shall review to determine if exam availability is provided on the C-92 application or other correspondence, such as an attachment or email.

a.   If availability has been provided, the CSS or CA will immediately move forward with scheduling the exam.

b.   If availability has not been provided:

i.      the CSS or CA shall attempt to contact the IW one time by phone and leave a message, when possible.

ii.     If phone contact is attempted but is not successful, the CSS or CA shall send the “Percent PP Notice of Application to the IW” letter and set a 10-day follow-up task in the claims management system.

iii.    If the IW fails to respond within 10 days and is represented, the CSS or CA shall place a call to the representative.

a)    If availability is obtained during the call, the CSS or CA shall move forward with scheduling the exam.

b)    If the representative needs additional time, the CSS or CA shall extend the task by 4 days to allow the representative to respond.

iv.   If no response is received from either the IW or IW’s representative by the time the task expires:

a)    For applications filed on or after 9/29/17, the CSS or CA shall move forward with dismissing the application.

b)    For applications pending prior to 9/29/17, the CSS or CA shall move forward with scheduling the exam.

4.    If the IW’s letter is returned by the post office due to incorrect mailing address, the CSS or CA shall:

a.   attempt to find a new address for the IW by:

i.      Contacting the IW by phone; and/or

ii.     Contacting the IW’s representative by phone; and/or

iii.    Contacting the MCO; and/or

iv.   Contacting a treating provider; and/or

v.     Researching the Internet.

b.    If the new address is obtained, the CSS or CA shall send a new “Percent PP Notice of Application to the IW” letter from the claims management system to the IW and copy the IW’s representative.

c.     If it is not possible to obtain a new address for the IW and phone contact was unsuccessful:

i.      For applications filed on or after 9/29/17, the CSS or CA shall move forward with dismissing the application.

ii.     For applications pending prior to 9/29/17, the CSS or CA shall move forward with suspending the application.

C.   another state and are more than 50 miles from the Ohio Creating a physician exam packet

1.    Claims staff shall create an exam packet prior to requesting an IME.

2.    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.

3.    The packet and the contents of the packet shall be renamed according to the indexing and renaming guidelines as directed by Claims Operations. 

D.   Requesting an IME

1.    The CSS or CA shall select a new medical exam scheduling case and create a case event in order for the exam scheduler to schedule an IME.  

2.    The MSS shall provide the information necessary to schedule the exam in notes and create a referral task for the exam scheduler to schedule an IME.

3.    The exam scheduling case shall include at least the following information:

a.    Type of exam requested;

b.    IW availability, if known;

c.     Type of physician required for the exam;

i.      The CSS shall include the specialty recommended in the MSS note when applicable.

ii.     Two 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 report of servicing providers;

e.    Need for an interpreter, if applicable; and

f.      Additional exam questions, if any.

E.    Scheduling the exam.  The exam scheduler shall:

1.    Consider proximity to the IW’s home and select a DEP physician closest to the IW’s home when possible; 

2.    Schedule the exam based on the IW’s availability when possible;

3.    For C-92 exams, the exam scheduler may consider scheduling further into the future or farther away from the IW’s home if necessary to accommodate the IW’s availability.

4.    For EOD or exams required for processing an IW’s application, the exam scheduler may consider scheduling further from the IW’s home if necessary to obtain a timely exam and accommodate the IW’s availability. 

5.    If it is not possible to schedule the exam within the IW’s availability, one attempt to contact the IW by telephone to explain why we cannot accommodate his or her availability must be made and documented in notes. 

6.    Work with BWC’s administrative agent to schedule exams for IWs who live in border;

7.    Work with a DEP physician’s administrative agent to schedule an in-state exam when the DEP physician has indicated that they use an administrative agent;

a.    BWC must select the physician who is to complete the exam.

b.    The administrative agent may provide the date and time of the exam.

8.    Complete scheduling of the exam within the number of days of receiving the request as directed by claims operations;

9.    Schedule the exam for a date that allows for at least 14 days notice to the IW prior to the exam if possible;

a.    If it is necessary to schedule the exam with less than 14 days notice:

i.      The exam scheduler must notify the CSS or CA that an exam date has been selected which does not allow for at least 14 days notice to the IW.

ii.     The CSS or CA must contact the IW by phone to provide notice of the exam in addition to mailing the IW notice of exam.

iii.    If phone contact is not made and the IW does not appear for the exam, this will not be considered as a failure to appear.

b.    An exam may be scheduled in less than 14 days to avoid suspension for failure to appear if IW requests that the exam be scheduled more quickly.

10.  Send the appropriate IW notice of exam letter, using the IW notice of exam letters found on the claims management system.

a.    If the IW’s notice of exam letter is returned by the post office due to incorrect mailing address, claims staff shall attempt to find a new address for the IW by:

i.      Contacting the IW by phone; and/or

ii.     Contacting the IW’s representative by phone; and/or

iii.    Contacting the MCO; and/or

iv.   Contacting a treating provider; and/or

v.     Researching the Internet.

b.    If contact with the IW or IW’s representative is made after the receipt of returned mail and the exam information can be provided in time for the IW to attend the exam, claims staff shall:

i.      Document in notes that the exam information was provided by phone;

ii.     Update the IW’s address information in the claims processing system; and

iii.    Resend the notice of exam to the IW at the updated address.

c.     If contact is made with the IW or IW’s representative after the receipt of returned mail and there is not sufficient time to provide notice of the exam, claims staff shall:

i.      Cancel the scheduled exam;

ii.     Update the IW’s address in the claims processing system;

iii.    Complete all tasks associated with the original exam referral;

iv.   Update exam scheduling information in the claims management system to close out the original exam referral; and

v.     Create a new medical exam scheduling case and create case event.

d.    If it is not possible to obtain a new address for the IW, claims staff shall:

i.      Staff with the supervisor;

ii.     Cancel the scheduled exam; and

iii.    Proceed with processing the claim as if the IW failed to appear, as outlined in Section IV.G. of these procedures.

11.  Send the DEP physician the “Physician Notice for Independent Medical Exam letter using the appropriate exam reason and questions.

a.    The address that appears on the system generated physician notice of exam may not be the address which is appropriate for mailing correspondence.

b.    The exam scheduler may need to manually address an envelope to mail the physician notice of the exam.

12.  Notify the CSS of the date and time of the exam when interpreter services must be scheduled.  See the Interpreters policy and procedure for additional information. 

13.  See Section V. below for more information regarding specific exam types.

F.    BWC exam cancelations

1.    If it is necessary for BWC to cancel or reschedule an IW’s exam, the CSS or CA shall make repeated attempts to contact the IW and/or the IW’s representative by phone.

2.    If the first phone contact is unsuccessful, the CSS shall send written notice of the cancelation and, if appropriate, the reschedule date.

G.   Failure to Appear and Requests to Cancel Without Rescheduling

1.    Claims staff shall contact the IW’s representative immediately upon notice from the DEP physician that the IW failed to appear for a BWC-scheduled exam.  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 or CA 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 3 business days for response to phone messages, or 6 days for a letter; and

d.    Continue with the failure to appear process if no response is received. Proceed to section 8 below.

3.    For all exams with the exception of C-92, when speaking with the IW or IW’s representative, the CSS or CA shall determine if the IW failed to appear for or is requesting to cancel an appointment for good cause based on extraordinary, unforeseen circumstances, which include, but are not limited to: 

a.    Death of an immediate family member;

b.    Hospitalizations or medical emergencies;

c.     Auto accidents;

d.    Notice of the exam was not received due to an incorrect address;

e.    Proper notice of the exam was not provided to the IW; or

f.      Weather emergencies.

4.    When determining if the IW failed to appear or is requesting that an exam be rescheduled for good cause, the CSS or CA shall take into consideration BWC’s efforts to schedule within the IW’s availability.  This consideration shall include, but not be limited to:

a.    Was the IW notified that we were unable to schedule within his or her availability and why (e.g. we have no physicians with the specialty needed available within the IW’s availability)?

5.    Did the IW provide good reasons for the limited availability (e.g., the IW requested that the exam be scheduled later in the day due to the need to place a child on a bus in the morning or the IW was planning to be away?)

6.    If it is determined that good cause does exist, benefits shall continue and the CSS or CA shall reschedule the exam as soon as possible.

a.    Generally, claims staff shall not require the IW to provide evidence to support the good cause reason for failure to appear, canceling or rescheduling the exam.

b.    Claims staff 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 exams.

7.    For C-92 exams, the CSS or CA shall attempt to contact the IW or IW’s representative if the IW fails to appear without notice or explanation for a C-92 exam.

a.    If the IW provides an explanation for missing the exam, the CSS or CA shall reschedule the exam as soon as possible.

b.    If the IW fails to respond or fails to provide an explanation, proceed to section 9.

8.    If the IW contacts BWC and requests that an exam be canceled and not rescheduled claims staff shall:

a.    Explain to the IW that failure to appear for a BWC-scheduled exam may result in dismissal or suspension of an application and/or suspension or denial of benefits as described in Section 8 below; and

b.    Contact the IW’s representative, if one exists, to provide notice that a BWC-scheduled exam has been canceled at the IW’s request.

9.    If it is determined that good cause does not exist for the failure to appear, or fails to appear without notice or explanation for a C-92 exam, or the IW requests that an exam be canceled and not rescheduled, claims staff shall staff the claim with a supervisor.  The supervisor shall:

a.    Verify that Section IV.B. of this procedure was followed when the exam was scheduled;

b.    Complete the Failure to Appear for an IME Checklist found on COR; and

c.     Contact the IW representative, or IW if the IW does not have a representative, to discuss the suspension or denial of benefits as described in Section 10 below. 

10.  If good cause does not exist for the failure to appear, or fails to appear without notice or explanation for a C-92 exam, or if the IW requests that an exam be canceled and not rescheduled, claims staff shall proceed with processing as follows, with supervisor approval:

a.    EOD exam: Suspend TT compensation

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.

v.     See the Failure to Appear in PowerSuite job aid on COR for additional information.

b.    Statutory OD exam:  Deny the claim by sending an Initial Denial Order if unable to reschedule or the IW fails to appear for the second scheduled exam.

c.     Initial determination exam other than statutory OD:  Make an initial determination based on evidence in the claim, which may include a PFR obtained in lieu of the exam.

d.    C-92 exam

i.      If the IW fails to appear without notice or explanation for claims with applications filed on or after 9/29/17, dismiss the application by issuing a C-92 dismissal order; or,

ii.     If the IW fails to appear without notice or explanation, for claims with pending applications filed prior to 9/29/17, suspend the application by issuing a C-92 suspension order; or,

iii.    If the IW asks that the exam be canceled and not rescheduled, consider the application to have been withdrawn and dismiss the application by issuing a C-92 dismissal order.

a)    Claims staff shall make one attempt to contact the IW representative, if there is one, by telephone prior to dismissing the application.

b)    Claims staff shall document the conversation or attempt to contact the IW attorney in notes. 

e.    Evaluation of substantial aggravation exam:  Send suspension letter to suspend the compensation and/or medical benefits requested based on the substantially aggravated condition. 

f.      ADR Exams:  Send suspension letter to suspend the request for treatment.

g.    Other requests:  Send suspension letter to suspend the request.

11.  The CSS or CA must complete a new or re-open an exam scheduling case when an exam must be rescheduled. 

12.  If requested by the IW, claims staff shall reschedule the exam as soon as possible, except for initial allowance exams when determination of the claim must be made.

13.  If the IW appears for the re-scheduled exam, claims staff shall:

a.    EOD exams:

i.      Send the “TT Reinstatement Letter” from the claims management system; and

ii.     Pay TT beginning the date the suspension began.

b.    C-92 exams: Issue the appropriate Tentative Order (TO) based on the findings of the exam report.

c.     For all other exams:  Continue processing the request and issue the appropriate decision.

d.    Process any other requests that were suspended because of the failure to appear suspension. 

14.  If the issue for which the exam was scheduled becomes moot (e.g., IW returns to work after the exam date, withdraws request, or new medical evidence is received) claims staff shall:

a.    For EOD exams, if the IW returns to work after the exam 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 claims staff shall refer the request to the IC. 

iii.    If the IW attends an EOD exam for the new period of TT, claims staff shall staff with a BWC attorney to determine if payment should be considered for the previously suspended period. 

b.    For other exams, dismiss the application as appropriate or continue processing based on newly received evidence. 

15.  If the IW withdraws a request and subsequently refiles the same or a similar request, claims staff shall consider scheduling an exam for the new request.

H.   Requests to Reschedule an Exam

1.    When contacted by an IW to reschedule an exam (including where the IW has failed to appear for a previously scheduled exam), claims staff shall:

a.    Determine the reason for the request to reschedule the exam;

b.    Explain to the IW the importance of attending a BWC-scheduled exam and the consequence of not attending an exam;

c.     Verify or obtain the IW’s availability to attend the rescheduled exam (i.e., when is the IW not available to attend) and explain that we will reschedule as soon as possible which may result in less than 14 days notice of the exam;

d.    Contact the examining physician to cancel the scheduled exam if appropriate;

e.    Complete a new exam scheduling case;

f.      Reschedule the exam as soon as possible (which may be in less than 14 days if it is possible to provide notice to the IW in advance of the exam); and,

g.    If applicable, suspend processing of the claim or application, or dismissal of an application as described in Section 2 below.

2.    Claims staff shall process the IW’s claim or application as follows:

a.    EOD exam

i.      If the reason for rescheduling is for good cause, claims staff shall allow TT to continue; or,

ii.     If the reason for rescheduling is not for good cause, claims staff shall:

a)    Suspend TT compensation beginning with the next scheduled payment period (payment for the current scheduled payment period should be permitted to pay);

b)    Send the TT Suspension letter found on the claims management system to the IW and IW’s representative; and

c)    Suspend any subsequent request for compensation other than for Lump Sum Settlement (LSS).

d)    Medical benefits are not suspended.

e)    See the Failure to Appear in PowerSuite job aid on COR for additional information.

b.    Statutory OD exam:  Withhold making a decision regarding the claim until the IW attends the rescheduled exam or fails to attend the rescheduled exam.

i.      If the IW fails to attend the second exam for reasons other than good cause, the CSS may deny the claim.

ii.     The CSS shall staff with a supervisor prior to denying the claim.

c.     Initial determination exam other than statutory OD

i.      If the exam can be rescheduled within the 28-day decision timeframe, withhold making a decision in the claim until the IW attends the exam, or

ii.     If the exam 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 exam.

d.    C-92 exam

i.      Reschedule the exam without dismissing the application, if investigation determines an explanation exists.

ii.     For applications filed on or after 9/29/2017, dismiss the C-92 application if investigation for failure to appear reveals the IW fails to respond or fails to provide an explanation.

iii.    For pending applications filed prior to 9/29/2017, suspend the C-92 application if investigation for failure to appear reveals the IW fails to respond or fails to provide an explanation.

e.    Evaluation of substantial aggravation exam

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, send the suspension letter to suspend all activity in the claim. 

f.      Other requests:  Staff with supervisor to determine if the request will be suspended or not until the IW attends the exam. 

I.      The DEP physician must obtain prior approval for diagnostic testing that may be needed to complete the evaluation of the IW.  The CSS or MSS shall: 

1.    Review the Medical Evidence for Diagnosis Determination (MEDD) policy and procedures or other on-line resources to evaluate the appropriateness of diagnostic testing; 

2.    Notify the DEP physician of BWC’s decision regarding diagnostic testing; and

3.    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. 

J.     IME Reports

1.    Claims staff shall follow-up with the DEP physician if the IME report is not received within 14 days of the date of exam.

2.    Claims staff shall image the IME report into the claim upon receipt, even if an addendum will be requested.

3.    Evaluating the report:

a.    A MSS shall complete a quality assurance review of all IME reports, except those for C-92 applications.

b.    For C-92 IME reports:

i.      The MSS shall review a sample of the reports according to claims operations direction; and

ii.     The CSS or CA shall review C-92 reports not reviewed by the MSS. 

c.     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;

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 every page.

v.     A completed DEP Report of Work Ability (C-143) or DEP Report of Work Ability Cognitive/Psychological Conditions (C-143 PC) is included with EOD exam reports; and

vi.   C-92 exams were completed using the BWC approved edition of the AMA guides.

d.    The reviewer shall report quality assurance problems to the BWC DEP Central mailbox.

4.    Claims staff shall review exam reports to determine the necessary action.

5.    Claims staff shall notify all parties that an exam report is available for review online.

a.    For C-92 reports, a hard copy of the report shall be mailed either separately or with the BWC tentative order.

b.    For all other reports, claims staff will provide a hard copy of any exam report to a party to the claim, upon request.

c.     For exam reports other than C-92 reports, claims staff shall also:

i.      Notify the MCO by email or phone that the exam report is imaged in the claim; and

ii.     Send exam reports to the IW’s physician of record (POR)/treating physician.

d.    The physician’s copy of the report may be provided by mail, fax or email.

K.    Addendums

1.    The MSS shall request an addendum when the exam report contains an error, does not address all questions asked of the DEP physician, or additional information is needed. 

2.    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.

3.    The DEP physician may request additional payment if the addendum request requires the review of additional information or the addendum is needed as a result of an error on the part of BWC (e.g., BWC did not ask the correct questions).

4.    All requests for addendums must be made in writing, with copies mailed to the parties to the claim.

5.    The initial request for an addendum may be made by phone to the DEP physician, but this must be in addition to the written request.

6.    Claims staff shall send copies of the addendum as indicated in Section IV.J.4. above; claims staff may wait to mail copies of the original report to be included with the addendum.

L.    DEP Billing

1.    DEP physicians shall complete a Service Invoice (C-19) and mail it directly to BWC’s Medical Billing and Adjustment (MB&A) unit.

2.    Claims staff shall image C-19s received in the claims office into the claim; the claims management system will notify MB&A that the bill was received.

3.    Refer to the DEP Handbook and the Medical Billing and Reimbursement Manual for billing codes and other additional information. 

4.    Except for C-92 exams or statutory OD exams where the claim is subsequently denied, the cost for an exam is charged to the claim.

5.    For C-92 exams:

a.    The cost for exams in state-funded (SF) claims is charged to the Surplus Fund.

b.    The cost for exams in SI claims is charged to the SI Surplus Fund.

6.    For statutory OD claims, where the claim is subsequently denied, the cost of the exam is charged to the Surplus Fund.

M.   Claims staff shall reimburse the IW for travel expenses related to attending an IME as described in the Travel Reimbursement policy and procedures.

 

V.   Exam Specific Information

A.    Initial determination - Statutory OD

1.    Claims staff shall schedule an exam before determining an occupational disease 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.    In accordance with a Claims Operations Directive, for purposes of performance measurement, claims for mesothelioma are to be processed the same as statutory OD claims.

3.    Claims staff shall obtain the minimum evidence required to schedule a statutory OD exam as described in IC Resolution No. 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.

a.    The ODs included are:

i.      Silicosis;

ii.     Asbestosis;

iii.    Coal miners’ pneumoconiosis; or

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

b.    The required minimum evidence necessary to schedule the exam 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.

c.     If medical evidence of greater quality than the minimum is received (e.g. biopsy tissue analysis), BWC shall accept that in lieu of the minimum.

4.    Additional evidence that can assist the DEP physician with exams for berylliosis, cardiovascular, pulmonary (including asbestosis) or respiratory diseases 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, accidents, 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 CAT 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.

5.    Claims staff may combine the following exam questions with the initial allowance questions:

a.    TT eligibility; and/or

b.    Scheduled loss; and/or

c.     EOD, in unusual circumstances and after staffing with a BWC attorney.

6.    Claims staff shall issue an initial determination BWC Order within 28 days from receipt of the report from a statutorily required exam.

7.    See the Occupational Disease policy and procedures for additional information.

B.    Initial determination – other than statutory OD

1.    Claims staff may obtain an exam for the initial determination of claims other than those required by statute; however, unless otherwise approved by a supervisor, the exam must be obtained and a decision made within BWC’s 28-day determination timeframe.

2.    Claims staff shall obtain a nurse review or staff with a supervisor before scheduling an exam for initial determination.

3.    Claims staff may combine the following exam questions with the initial allowance questions:

a.    TT eligibility; and/or

b.    Scheduled loss; and/or

c.     EOD, in unusual circumstances and after staffing with a BWC attorney.

C.   Additional allowance – physical, psychiatric, RSD/CRPS

1.    Claims staff shall determine the need for and attempt to obtain medical evidence according to the MEDD policy and procedures prior to scheduling an exam for the allowance of additional conditions.

2.    Claims staff shall add the condition to be examined to the claims management system prior to scheduling an exam and request that the condition description be modified if necessary. 

3.    Claims staff may combine the following exam questions with the additional allowance questions:

a.    Evaluation of substantial aggravation; and/or

b.    Claim reactivation; and/or

c.     TT entitlement; and/or

d.    TT entitlement after MMI; and/or

e.    Scheduled loss

D.   EOD exams

1.    Prior to scheduling an EOD exam, claims staff shall verify that a job description for the injury position is in the claim, or shall request one if necessary.

2.    Claims staff shall contact the POR/treating physician prior to scheduling an exam to ask about EOD, which may be done by using the “MMI Clarification Letter to Treating Physician” found on COR.

3.    Claims staff may schedule multiple EOD exams if warranted by the conditions in the claim (e.g., claim is allowed for psychological and physical conditions).

4.    Claims staff shall schedule an EOD exam 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 the MEDCO-14.  If the physicians identify physical and psychological conditions as preventing a full duty release to the job IW held on the date of injury, claims staff shall schedule EOD exams for both the physical and psychological conditions.

6.    If not examining on all conditions, claims staff 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 an EOD exam, claims staff shall review any prior EOD exam 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 exam scheduler shall include a C-143 or C-143 PC with the physician notice of exam for all EOD exams.

9.    90-day exam:  Claims staff shall schedule an EOD exam within 30 days of the first payment of 90 consecutive days of TT compensation as required by statute.

a.    If the treating physician provides a statement that IW is MMI, a 90-day exam is not scheduled.  

b.    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 based on ODG;

d)    Post-operative passive 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 recommended in ODG;

i)      Notes from POR/treating physician documenting IW’s progress in treatment plan; or

j)      Other medical factors that justify waiving an exam.

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 Waiver of Examination (MEDCO-6) or equivalent form.

b)    The waiver information obtained must include:

i)      The name and title of person requesting or agreeing to waive the exam;

ii)     If the waiver is temporary or permanent;

iii)   The reason the exam is waived; and

iv)   When the claim is to be reviewed again to consider rescheduling the exam if the waiver is temporary.

c)    The waiver may be permanent or temporary:

i)      If the waiver is permanent, claims staff shall update the exam scheduling information in the claims management system and no 90-day exam will be conducted, but an EOD exam 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 recommends an extension of the waiver period or schedules the 90-day exam.

d)    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.

e)    If the employer objects or refuses to waive the exam or the waiver is not advisable, BWC shall move forward with scheduling of the exam and send the” Notice of 90-Day Exam” letter found on COR to all parties to the claim.

f)     The IMS may waive the exam:

i)      If the employer fails to respond to the request to waive the exam: or,

ii)     If the employer is out of business.

g)    Upon waiving the exam, the IMS shall determine a future date for the IW exam.

h)    Upon receipt of the 90-day exam, the CSS shall set a follow-up task 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 examination.

ii)     If the IW returns to work or reaches MMI, the EOD examination is no longer necessary.

10.    200-week exam:  Claims staff shall schedule an EOD exam after payment of 200 weeks total of TT compensation as required by statute.

11.    Other EOD exam:  Claims staff may schedule an EOD exam whenever necessary for management of a period of disability when the IW is receiving or has requested TT.

12.    Claims staff shall schedule an EOD exam at the time indicated by the examining physician in a prior EOD exam if the IW is receiving TT compensation at that time, unless there is a good reason, staffed with a supervisor and documented in notes, for not scheduling an exam.  

13.    Psychiatric Conditions:

a.    Prior to scheduling an EOD exam for psychiatric conditions, the CSS shall:

i.      Send an email to the MCO case manager as notification that an EOD exam for a psychological condition is being considered. 

a)    The purpose of email is to gather any input the MCO case manager may have regarding pending exam. 

b)    The CSS shall set a 601 diary for MCO email response within 2 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, and;  

b)    RX drug review.

iii.    Image the ODG/treatment guidelines into the claim file as MISC document type.

b.    The MCO shall:

i.      Respond to BWC CSS’s email regarding exam 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 days.

a)    The CSS shall staff with a supervisor if unable to obtain a response from the MCO.

b)    As a result of the staffing the supervisor or CSS shall continue to attempt to obtain a response from the MCO or will move forward with scheduling the exam. 

iv.   Provide up-to-date treatment reports for psychological counseling and medication management.

c.     Prior to scheduling an EOD exam for psychiatric conditions, the MSS shall review the following information to identify number of treatments, duration of treatment, changes in treatment plan, amount of medication prescribed, duration of medication, changes in medication and IW’s compliance with treatment and medication plans:

i.      The ODG treatment guidelines that have been imaged into the claim;

ii.     The treatment and pharmacy reports that have been imaged into the claim; and

iii.    The MCO treatment summary notes.

d.    The MSS may add questions to the EOD exam specific to the treatment and prescription information reviewed.

i.      The MSS may add the standard optional questions without staffing with a BWC attorney.

ii.     The MSS must coordinate with the MCO if questions regarding appropriateness of prescribed medications will be asked and must include the DUR questions with any additional questions related to prescription medications.

iii.    The MSS shall staff with a BWC attorney prior to adding any non-standard questions. 

e.    Upon receipt of the exam report:

i.      The MSS shall complete a quality assurance review of the report and enter a note in the claim.

ii.     The CSS shall review the report and contact the MCO case manager to provide notice that the exam report is available for review in the claim.

a)    If the DEP physician makes no recommendations regarding treatment or prescription medications, the CSS shall notify the MCO case manager that the exam report is available to review. 

b)    If the DEP physician makes any recommendations regarding treatment or medication, the CSS shall contact the MCO case manager by phone to discuss the treatment recommendations and possible action needed based on DUR questions, if asked.

14.    Claims staff may combine the following exam questions with the EOD questions:

a.    TT Entitlement (in limited circumstances); and/or

b.    Additional allowance; and/or

c.     Evaluation of substantial aggravation of a pre-existing condition; and/or

d.    Scheduled loss.

15.    See the Temporary Total Compensation policy and procedures for information about additional processing when the outcome of an EOD exam is a finding of MMI.

E.    Scheduled Loss Exam

1.    Claims staff shall grant a request for scheduled loss without scheduling an exam when sufficient medical evidence is present in the file to support the award.

2.    The CSS shall refer requests for scheduled loss based on loss of use to the MSS for review to determine if an exam is needed. 

3.   Claims staff may combine the following exam questions with SL exam questions:

a.    Initial determination; and/or

b.    TT entitlement; and/or

c.     TT entitlement after MMI; and/or

d.    Additional allowance; and/or

e.    Extent of disability; and/or

f.      Claim reactivation; and/or

g.    Evaluation of substantial aggravation of a pre-existing condition.

F.    Claim Reactivation Exam

1.    If an exam is indicated for claim reactivation, Claims staff must schedule the exam and obtain the report so as to make the reactivation decision within 28 days of receipt of the request unless otherwise approved by a supervisor.

2.    Claims staff may combine the following exam questions with claim reactivation exam questions:

a.    Initial determination; and/or

b.    TT entitlement; and/or

c.     TT entitlement after MMI; and/or

d.    Additional allowance; and/or

e.    Extent of disability; and/or

f.      Claim reactivation; and/or

g.    Evaluation of substantial aggravation of a pre-existing condition.

G.   ADR Exams – see the Alternative Dispute Resolution Exams policy and procedures for additional information regarding ADR exams.

H.   Evaluation of Substantial Aggravation Exams

1.    Claims staff 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.

I.      C-92 exams

1.    Claims staff shall schedule an exam for all initial C-92 applications.

2.    An exam shall be scheduled for C-92 applications for increase in %PP if a PFR is not sufficient.

3.    For SI claims, Claims staff shall verify that the allowed conditions in the claim have been updated based on information provided by the SI employer or employer representative on The Self-Insuring Notice and Request for Information for C-92/C-92A Application (C-256).

4.    Claims staff must provide the DEP physician with information regarding prior %PP awards for same claim or for same part of body in other claims.

5.    Claims staff shall include the additional question regarding IWs who are receiving wage replacement compensation at the time of the exam when appropriate.

6.    Claims staff shall include for review in the exam packet the “Medical Treatment Report C92&C92A” that outlines treatment for the first 12 months post injury and the 12 most recent months.

7.    Claims staff shall include the statement regarding newly allowed conditions which are being treated when appropriate. 

8.    Claims staff shall indicate that the IW is PTD when appropriate and limit the conditions to be considered to those approved by staffing with a BWC attorney. 

9.    Claims staff shall refer to the MSS for combined effects when multiple exams are scheduled and calculation of combined effects is needed.   

10.  No other exam questions may be added to the C-92 exam questions unless requested by a BWC attorney.

VI.  IC Ordered Exams

A.    Claims staff shall schedule an exam immediately upon receipt of an interlocutory order from the IC requesting that an exam be scheduled.

B.    Claims staff shall follow the same procedures (e.g., contact for availability, selecting DEP physician) as are followed for scheduling a BWC exam. 

C.   Upon receipt of the exam report, Claims staff shall complete a notice of referral to the IC to return the claim to the IC to be reset for hearing or continue processing as ordered by the IC. 

D.   See the Notice of Referral to the Industrial Commission policy and procedures for additional information on referrals to reset for hearing.

VII.        Employer Scheduled Exams

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 his/her physician of record.

1.    If, without good cause, an IW refuses to submit to an exam 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 Motion (C-86) requesting the IW’s claim be suspended during the period of refusal.

a.    BWC shall complete a “Notice of Referral to the IC” citing the C-86 filed by the employer.

b.    The decision to suspend the claim is within the jurisdiction of the IC.

2.    See the Industrial Commission Suspensions policy and procedures for additional information.

B.    If after one employer-scheduled medical examination of the IW the employer feels that another medical examination is necessary to defend the claim, the employer may file a written request with the BWC or IC. 

1.    If the employer requests an exam for an issue that is within BWC’s jurisdiction (i.e., TT, additional allowance, etc.), BWC must immediately act on the request. 

a.    BWC shall issue a subsequent order if the decision is to allow the additional exam. 

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, the matter is referred to the IC for further consideration. 

i.      As concerns authorization of TT, a medical exam performed within the past 30 days is regarded as “recent.”

ii.     If the question involves an additional allowance alleging a causal relationship to the allowed injury/occupational disease, an exam performed within the past 60 to 90 days may be regarded as “recent” (depending on the nature and type of the condition and/or disability).

2.    If the employer requests an exam for an issue that is within the IC’s jurisdiction (PTD, an issue under appeal to the IC), BWC shall complete a NOR to refer the issue to the IC.

C.   Claims staff shall schedule an EOD exam for a SI employer, to be paid for by the SI employer, if notification is received that the employer has paid 200 weeks of TT compensation. 

D.   Payment for employer-scheduled exams is the responsibility of the EOR.

VIII.       Employer Requested Exams

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

B.    BWC shall schedule an exam if BWC determines it is pertinent to the determination of the issue presented and BWC has jurisdiction to make the decision related to the request.

C.   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.

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

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

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

IX.  IW Requested Exams

A.    If the IW or his/her representative requests an exam to support allowance of a new condition or an increase in percentage of permanent partial disability, the cost of this exam is the IW’s responsibility.

B.    BWC shall refer requests to schedule exams on behalf of the IW to the IC.

X.   PFR Procedures

A.    The MSS shall enter a “Staffing Note” when a decision is made to obtain a PFR and creates a medical file review case.

B.    The MSS shall complete a Physician Review (Medco-21) form and email the form to the selected DEP physician, and image the form and a copy of the email (with MSS last name redacted) to the claim.

C.   Upon receipt of the physician’s report, the MSS who made the referral shall complete a quality review of the report and enter a “Staffing Note” to summarize the contents of the report.

1.    If the MSS determines that an addendum is needed, the MSS shall:

a.    Summarize the need for the addendum in a “Staffing Note”;

b.    Send an email to the reviewing physician requesting the addendum and image the email to the claim; and

c.     Follow-up with a written request for the addendum, copied to all parties to the claim.  

2.    The original report must be imaged in the claim immediately, even if an addendum is requested.

3.    Upon receipt of the addendum, the requesting MSS completes a quality review of the addendum and writes a “Staffing Note” to summarize the outcome of the review.

D.   The CSS or CA will proceed with processing based on the PFR when the Medical Referral Completed task is received from the MSS, indicating that the PFR report is complete.

E.    Claims staff shall determine the need for and attempt to obtain medical evidence according to the MEDD policy prior to obtaining a PFR for the allowance of additional conditions.

F.    Claims staff shall:

1.    Attach copies of PFR reports to TOs when relied upon to make a decision; or

2.    Provide a copy of the PFR report to parties to the claim if requested, such as NOR.