OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:

Return to Work Data

Policy #:

CP-18-01

Code/Rule Reference:

None

Effective Date:

March 1, 2018

Approved:

Kevin R. Abrams, Chief Operating Officer

Origin:

Claims Policy

Supersedes:

Policy # CP-18-01, effective 11/14/16

History:

New 12/23/13; Rev.11/14/16

 

 

  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 claims services staff.

 

III.  DEFINITIONS

 

Actual Return to Work (ARTW): 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 (ERTW): The anticipated date the IW may be able to return to employment.

 

Last Date Worked (LDW): The last date the IW reported to work prior to taking time off, 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 (RRTW): 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.

 

V.  PROCEDURE

 

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

 

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

1.    The MCO shall determine the LDW, RRTW, ERTW, and ARTW dates based on documentation received and contained in the claim file or as provided by the employer, injured worker, provider or other reliable source.

a.    The MCO shall exercise due diligence in obtaining the ARTW date for all medical only claims.

b.    Before submitting an ERTW that results in seven (7) or fewer missed days for a particular disability period in a medical only claim, the MCO shall contact the provider to verify the provider intended the RTW to be an ERTW and not an RRTW, and shall document the contact in notes.

c.     The MCO shall not submit an RRTW date as an ERTW. RRTW dates will be captured on the Claims Maintenance>Claim Dates page in the claims management system.

 

C.   The MCO shall enter detailed claim notes reflecting all actions taken to gather RTW data. Every claim note shall include the following:

1.      If RTW data was obtained, what those dates are;

2.      The name and position of the person the MCO spoke to or the name and date of the document being relied on to determine the reported dates;

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

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 and supporting the RTW data.

 

D.   Lost Time Claims: For lost time claims, the MCO shall provide the RTW data to claims services staff via the Electronic Data Interchange (EDI) 148. Claims services staff shall presume the reliability of the data when accompanied by a detailed MCO note and enter the data into the claims management system.

 

E.    If the MCO has not entered a note containing adequate information, or if for any other reason further verification is needed, claims services staff shall first contact the MCO, and then, only if necessary, the employer or employer representative, IW or IW representative, medical provider, vocational rehabilitation provider or other reliable resource. Claims services staff may also use documentation in the claim file for verification, as appropriate.

 

F.    ERTW and End of Period Stop Dates

1.      Claims services staff shall enter the initial ERTW 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.      Claims services staff shall reflect a subsequent ERTW date (even if there is a RRTW date, or a no RTW reason) by entering a stop date (the day before an ERTW) on a period of disability. This occurs when:

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

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

 

G.   ARTW

1.      Claims services staff shall enter an ARTW 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 ARTW data, claims services staff shall ensure the following is documented in the claims management system:

c.   Whether the RTW was:

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

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

d.  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 claims services staff obtains a specific reason why the IW will not be returning to work, claims services 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.      Claims services staff shall use the “Other” option as a reason for an IW not returning to work only when no other listed reason is accurate for the situation.

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

4.      Claims services staff shall not delete the ERTW date even when one of the reasons listed above apply.

 

H.   RRTW

1.      Claims services staff shall enter the RRTW date on the Claims Maintenance>Claims Dates screen in the claims management system when provided.

2.      Claims services 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 ERTW date must be altered.

3.      Claims services staff shall not assume the RRTW date and the ERTW date are the same.

 

I.      Claims services 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.

1.    Claims services staff shall ensure that compensation is not paid over periods of ineligibility.

2.    Claims services staff shall not delete periods of lost time from the claims management system unless the periods are incorrect.

3.    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.”

4.    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.” In addition, if an end date was entered into the previous working period, the end date should be removed.

5.      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 a comment indicating compensation not requested, to prevent payment of compensation. A second row is created and is sent electronically to the MCO to reflect the correct status. The new row is largely identical, except the disability type is “off work”, medical status is “not released”, work status is “no RTW”, and the “reason” is “other.”

 

J.     Permanent Total Disability (PTD)

1.    If the IW is receiving non-statutory PTD, claims services staff shall remove any ARTW or ERTW date which is after the most recent last date worked.

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