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OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:

Return to Work Data

Policy #:

CP-18-01

Code/Rule Reference:

None

Effective Date:

11/14/16

Approved:

Rick Percy, Chief of Operational Policy, Analytics & Compliance (Signature on File)

Origin:

Claims Policy

Supersedes:

Policy # CP-18-01, effective 12/23/13

History:

New 12/23/13

 

 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure that MCO and BWC staff appropriately verify, update and/or maintain return to work (RTW) data in the claims management system.

 

II. APPLICABILITY

 

This policy applies to MCO and Field Operations staff.

 

III. DEFINITIONS

 

Actual Return to Work: The confirmed date the injured worker (IW) returns to employment, with or without work restriction(s). This may include an IW that has returned to the workplace with restrictions, but is participating in a vocational rehabilitation plan such as:

·         Employer Incentive;

·         On-the Job Training;

·         Transitional Work; or

·         Gradual Return to Work.

 

Estimated Return to Work: The anticipated date the IW may be able to return to employment.

 

Last Date Worked: The last date the IW reported to work prior to taking time off due to the work-related injury or illness, regardless of the length of time the IW worked on that date.

 

Return to Work Data: Data that includes any combination of the dates related to return to work, last date worked, estimated return to work, released to return to work or actual return to work.

 

Released to Return to Work: The date the physician of record releases the IW to return to employment (with or without restrictions). This may include an IW that is released to return to work with restrictions, and is participating in a vocational rehabilitation service or program such as:

·         Job Search/Job Seeking Skills Training;

·         Job Retraining; or

·         Work Trial.

 

Start and Stop Dates: The beginning and end dates of a working period or a period of disability/off work.

 

Wage Replacement Compensation: Compensation intended to replace an IW’s earnings. This includes temporary total, living maintenance, living maintenance wage loss, wage loss (working and non-working), permanent total disability and salary continuation..

 

IV. POLICY

 

A.    It is the policy of BWC to rely primarily on the managed care organizations (MCO) to provide accurate return to work data.

 

B.    It is the policy of BWC to ensure that return to work data is identified, verified, properly updated and maintained in the claims management system.

 

VI.  PROCEDURE

 

A.    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.

 

B.    The MCO shall provide RTW data on medical only claims, which will systematically update in the claim management system.

 

C.   For lost time claims, Field Operations staff shall presume the reliability of RTW data provided by the MCO when accompanied by a detailed MCO note which contains the following information:

1.    The estimated or release to RTW date, and the verified actual (i.e., employee physically reports to work) return to work date;

2.    The name of the person who provided the RTW information;

3.    The date the MCO spoke to the person who provided the RTW information;

4.    Clarifying details, including when “other” is noted as a reason the IW has not returned to work, if needed; and

5.    Any other information relevant to the RTW data.

 

D.   If the MCO has not entered a note containing the above-listed information, or if for any other reason further verification is needed, Field Operations staff shall first contact the MCO, and then, only if necessary, the employer or employer representative, IW or IW representative, medical provider, rehabilitation provider or other reliable resource. Staff may also use documentation for verification, as appropriate.

 

E.    Estimated RTW and End of Period Stop Dates

1.      Field Operations staff shall enter the initial estimated RTW date in order to:

a.    Calculate days of work missed and determine if a claim is a medical only or lost time; and

b.    Pay any form of compensation.

2.      Field Operations staff shall reflect a subsequent estimated RTW date (even if there is a release to RTW date, or a no RTW reason pursuant to V.G) by entering a stop date (the day before an estimated RTW) on a period of disability. This occurs when:

a.    A future date is received on a MEDCO-14;

b.    When wage continuation information is received from the employer and there is no estimated date provided on the MEDCO-14 or other medical documentation.

 

F.    Actual RTW

1.      Field Operations staff shall enter an actual RTW date when:

a.  MCO staff has verified the IW has actually returned to employment; or,

b.    BWC staff has verified the IW has actually returned to employment.

2.    When entering actual RTW data, Field Operations staff shall ensure the following are documented in the claims management system:

a.  Whether the RTW was:

i.      Light/modified duty (i.e., with restrictions); or

ii.     Full duty (i.e. with no restrictions); and

b.    The RTW job being returned to was:

i.      Same job, same employer; or,

ii.     Different job, same employer; or

iii.    Same job, different employer; or

iv.   Different job, different employer.

 

G.   No RTW Information Provided

1.      Once the IW is no longer receiving wage replacement compensation and Field Operations staff obtains a specific reason why the IW will not be returning to work, Field Operations staff shall update the claims management system to reflect one of the following reasons:

a.  Termination;

b.  Resignation;

c.  Layoff;

d.  Social Security retirement;

e.  Voluntary workforce abandonment;

f.   Incarceration;

g.  School enrollment;

h.  Retirement;

i.    Social Security disability;

j.    Other.

2.      Field Operations staff shall use the “Other” option as a reason for IW not returning to work only when no other listed reason is accurate for the situation.

3.      If more than one reason applies, Field Operations staff shall provide the additional reasons in comments.

4.      Field Operations staff shall not delete the estimated RTW date even when one of the reasons listed in E.1 above, apply.

 

H.   Released to Return to Work

Field Operations staff shall enter the released to return to work date when provided. Field Operations staff shall recognize that a release to return to work does not necessarily indicate that the IW will be immediately returning to work or otherwise that the estimated RTW date must be altered.

 

I.      Field Operations staff shall ensure that all periods of lost time related to the allowed condition(s) are reflected in the claims management system with appropriately identified last date(s) worked and return to work date(s), including periods of lost time when the IW does not receive compensation. Field Operations staff shall ensure that compensation is not paid over periods of ineligibility. Field Operations staff shall not delete periods of lost time from the claims management system unless the periods are incorrect.

1.    Example 1: The IC has issued an order which states that temporary total disability (TT) is denied because the IW violated a written work rule and was fired, and thus the IW voluntarily abandoned the job. In this case, in the disability management window in the claims management system, the disability type selected is “off work-ineligible for compensation”, medical status is “not released”, work status is “no RTW” and the “reason” is “voluntary workforce abandonment.”

2.    Example 2: The IC has issued an order which states that TT is not payable because the IW lost time from work because of some reason other than the allowed conditions in the claim. In this case, in the disability management window in the claims management system, the disability type selected is “off work-ineligible for compensation”, medical status is “not released”, work status is “no RTW” and the “reason” is “no supporting medical documentation.”

3.      Example 3: The MCO approves surgery for an allowed condition, but the IW does not request compensation for that period of lost time. In this case, on the disability management window in the claims management system, the disability type selected is “off work-ineligible for compensation”, medical status is “not released”, work status is “no RTW” and the “reason” is “Other” and then enter comment indicating compensation not requested.

 

J.    Permanent Total Disability (PTD)

1.    If the IW is receiving non-statutory PTD, Field Operations staff shall remove any actual or estimated RTW date, which is after the most recent last date worked.

2.    If an IW is receiving statutory PTD compensation Field Operations staff may enter RTW data without affecting compensation related to the statutory PTD.  

 


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