OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:

C-92 Independent Medical Examinations (IMEs) and Physician File Reviews (PFRs)

Policy #:

CP-09-08.2

Code/Rule Reference:

R.C. 4123.57; OAC 4123-3-15; OAC 4123-3-15.1

Effective Date:

04/09/21

Approved:

Ann M. Shannon, Chief of Claims Policy and Support

Origin:

Claims Policy

Supersedes:

Policy # CP-09-08.2, effective 12/31/20

History:

New


 

C-92 Independent Medical Examinations (IMEs) and Physician File Reviews (PFRs) Table of Contents

 

I. POLICY PURPOSE

II. APPLICABILITY

III. DEFINITIONS

Administrative Agent

Disability Evaluators Panel (DEP)

In-state Exams

Independent Medical Exam (IME)

Out-of-state Exams

Parties to a Claim

Percentage of Permanent Partial (%PP) Compensation

Physician File Review (PFR)

IV. C-92 IME AND PFR POLICY

A.          C-92 IMEs and PFRs

B.          IME Costs

C.         DEP Requirements

V. C-92 IME AND PFR PROCEDURES

A.          Standard Claim Note and Documentation Requirements

B.          Creating an Exam Packet

C.         Requesting a C-92 IME

D.         Contacting the IW

E.          Scheduling the IME

F.          BWC IME Cancelations

G.         Failure to Appear and Requests to Cancel Without Rescheduling

H.         Requests to Reschedule an IME

I.           Requests for Diagnostic Testing by DEP

J.          Referral for PFR

K.          IME and PFR Reports

L.          Addendums

M.         DEP Billing

N.         Industrial Commission (IC) Ordered IMEs

 

 


 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure that BWC properly processes and obtains independent medical examinations (IMEs) or physician file reviews (PFRs) for Determination of or Increase in Percentage of Permanent Partial Disability (C-92) applications when required by statute or when needed to support the claims management process.

 

II. APPLICABILITY

 

This policy applies to BWC claims services staff.

 

III. DEFINITIONS

 

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.

 

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.

 

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.

 

Out-of-state Exams: An IME that takes place outside of a 50-mile radius from the Ohio state border, including IMEs that take place outside of the United States.

 

Parties to a Claim: IW, IW representative, employer, employer representative and BWC.

 

Percentage of Permanent Partial (%PP) Compensation: Also referred to as a %PP and/or C-92 award. Compensation awarded for residual impairment, either physical or psychological, resulting from an allowed injury or 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.

 

IV. C-92 IME AND PFR POLICY

 

A.     C-92 IMEs and PFRs

1.     BWC will schedule a C-92 IME for an IW to assist in determining:

a.     The initial percentage of permanent partial disability (%PP);

b.     The %PP for a newly allowed condition in the IW’s claim; or

c.      The amount of an increase in the %PP.

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

3.     For subsequent C-92 determinations, when an IME is not indicated, BWC may schedule a PFR when processing an increase in %PP.

4.     BWC shall mail copies of the C-92 IME or PFR reports along with the Tentative Order (TO) to all parties to the claim.

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

 

B.     IME Costs

1.     The cost for IMEs in state-funded (SF) claims is charged to the Surplus Fund, except for state agencies, which are charged directly for the cost of the IME.

2.     The cost for IMEs in self-insured (SI) claims is charged to the SI Surplus Fund.

 

C.    DEP Requirements

- The DEP physician must use the 5th Edition of the “American Medical Association’s Guide to the Evaluation of Permanent Impairment” (AMA Guides). In addition, Chapter 7 of the DEP Handbook contains important documents regarding impairment determination for mental health and pain, which do not follow the current approved AMA Guides.

 

V. C-92 IME AND PFR PROCEDURES

 

A.     Standard Claim Note and Documentation Requirements

1.     BWC staff shall refer to the Standard Claim File Documentation and Altered Documents policy and procedure for claim note and documentation requirements; and

2.     Shall follow any other specific instructions for claim notes and documentation included in this procedure.

 

B.     Creating an Exam Packet

1.     The C-92 CA or CSS shall complete the exam packet within seven calendar days of the date of receipt of the IME referral.

2.     The C-92 Claim Assistant (CA) or Claim Service Specialist (CSS) shall create an exam packet prior to requesting an IME.

3.     The IME packet shall contain the documents as outlined in the Exam Packet Content document found on COR under Tips and Tools on the Independent Medical Exam policy page.

4.     The packet and the contents of the packet shall be renamed according to the Indexing Guidelines and Renaming Guidelines found on COR under Tips and Tools on the Standard Claim File Documentation and Altered Documents policy page.

 

C.    Requesting a C-92 IME

1.     The C-92 CA or CSS shall:

a.     Image a current copy of the %PPD Worksheet/10 Year Check (C-123) in the claim; and

b.     Ensure the report is within seven calendar days of the date of the IME referral.

2.     The C-92 CA or CSS shall create a new medical exam scheduling case and create a case event so the exam scheduler can schedule the C-92 IME.

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

a.     Type of IME requested;

b.     IW availability. The C-92 CA or CSS shall review to determine if availability is provided on:

i.       The C-92 application; or

ii.      Other correspondence, such as an attachment or e-mail;

c.      Type of physician required for the IME, including the appropriate specialty when applicable;

d.     Physicians who have examined the IW or performed a file review of the IW’s claim(s) who are not listed as a servicing provider on the %PPD Worksheet/10 Year Check (C-123);

e.     Need for an interpreter, if applicable; and

f.       Additional exam questions, if any. If the C-92 CA or CSS believe additional exam questions are necessary, the C-92 CA or CSS must obtain approval to add the additional exam questions from a BWC attorney.

 

D.    Contacting the IW

1.     If availability has been provided, the exam scheduler will immediately move forward with scheduling the IME.

2.     If availability has not been provided:

a.     The exam scheduler shall attempt to contact the IW one time by phone and leave a message, when possible.

b.     If phone contact is attempted but is not successful, the exam scheduler shall send the Percent PP Notice of Application to the IW letter and set a 10-day follow-up work item in the claims management system.

c.      If the IW fails to respond within 10 calendar days and is represented, the exam scheduler shall place a call to the representative.

i.       If availability is obtained during the call, the exam scheduler shall move forward with scheduling the IME.

ii.      If the representative needs additional time, the exam scheduler shall extend the work item by 4 calendar days to allow the representative to respond.

d.     If no response is received from either the IW or IW’s representative by the time the work item expires:

i.       The exam scheduler shall:

a)     Complete all open events;

b)     Close the exam scheduling case; and

c)     Return the referral to the C-92 CA or CSS.

ii.      The C-92 CA or CSS shall move forward with dismissing the application.

3.     During contact with the IW, the exam scheduler shall:

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

b.     Verify the IW’s address;

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

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

e.     Explain to the IW that failure to attend the IME may result in the dismissal or suspension of the application; and

f.       Explain to the IW that BWC will attempt to schedule within the availability given, however if BWC is unable to do so the IW must still attend the IME.

 

E.     Scheduling the IME

1.     The exam scheduler shall:

a.     Ensure equitable selection and distribution of IMEs to DEP physicians based upon Claims Operations physician selection guidelines.

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

c.      Schedule the IME based on the IW’s availability, when possible.

i.       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.

ii.      If it is not possible to schedule the IME within the IW’s availability, the exam scheduler will document in the exam scheduling letter to the IW why it was not possible to accommodate the IW’s availability.

iii.     The exam scheduler will also document in claim notes.

d.     Work with BWC’s administrative agent to schedule IMEs for IWs who live in another state and are more than 50 miles from the Ohio border.

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

i.       BWC must select the physician who is to complete the IME.

ii.      The administrative agent may provide the date and time of the IME.

f.       Complete scheduling of the IME within the number of days of receiving the request as directed by claims operations.

g.     Schedule the IME for a date that allows for at least 14-day notice to the IW prior to the IME if possible. An IME may be scheduled in less than 14 calendar days if the IW agrees that the IME be scheduled more quickly.

h.     Send the appropriate IW Notice of Exam letter, using the letters found on the claims management system.

i.       If the IW’s letter is returned by the post office due to incorrect mailing address, the C-92 CA or CSS shall attempt to find a new address for the IW by:

a)     Contacting the IW by phone or email;

b)     Contacting the IW’s representative by phone;

c)     Contacting the MCO;

d)     Contacting a treating provider; or

e)     Researching on the internet.

ii.      If contact with the IW or IW’s representative is made after the receipt of returned mail and the IME information can be provided in time for the IW to attend the IME, the C-92 CA or CSS shall:

a)     Document in notes that the IME information was provided by phone;

b)     Update the IW’s address information in the claims management system; and

c)     Resend the notice to the IW at the updated address.

iii.     If contact is made with the IW or IW’s representative after the receipt of returned mail and confirms the IW is not able to attend the exam, the C-92 CA or CSS shall:

a)     Notify the exam scheduler to cancel the scheduled IME;

b)     Update the IW’s address in the claims management system;

c)     Complete all work items associated with the original referral;

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

e)     Create a new medical exam scheduling case or transition the existing case to begin the rescheduling process.

iv.    If it is not possible to obtain a new address for the IW, the C-92 CA or CSS shall:

a)     Cancel the scheduled IME;

b)     Complete all work items associated with the original referral; and

c)     Proceed with processing the claim as if the IW failed to appear, as outlined in Section V.G of this procedure.

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

j.       If the exam scheduler knows that interpreter services are required:

i.       Notify the C-92 CA or CSS of the date and time of the IME; and

ii.      See the Interpreter and Translation Services policy and procedure for additional information.

2.     Upon notification by the exam scheduler of a scheduling issue or of the IME being scheduled, the C-92 CA or CSS shall take the actions detailed above.

 

F.     BWC IME Cancelations

1.     If it is necessary for BWC to cancel or reschedule an IW’s IME, the exam scheduler shall make two attempts to contact the IW or IW’s representative by phone.

2.     The exam scheduler also shall send written notice of the cancelation and, if applicable, the reschedule date.

 

G.    Failure to Appear and Requests to Cancel Without Rescheduling

1.     Immediately upon notice from the DEP physician that the IW failed to appear without explanation or notice for a BWC-scheduled IME, the C-92 CA or CSS shall contact:

a.     The IW’s representative; or

b.     The IW directly, if the IW is not represented.

2.     If the initial attempt to contact the IW or IW’s representative is not successful, the C-92 CA or CSS shall:

a.     Attempt one additional contact by phone;

b.     If the IW is not represented and there is not a valid phone number for the IW on file, send a letter requesting that the IW call the C-92 CA or CSS;

c.      Allow three business days for response to phone messages, or six business days for a letter; and

d.     Document all attempts to contact the IW or IW’s representative in claim notes.

3.     If the IW:

a.     Provides an explanation for missing the IME, the C-92 CA or CSS shall reschedule the IME as soon as possible.

b.     Fails to respond or fails to provide an explanation, proceed to Section V.G.5 of this procedure.

4.     If the IW contacts BWC and requests that an IME be cancelled and not rescheduled, the C-92 CA or CSS shall:

a.     Explain to the IW that failure to appear for a BWC-scheduled IME may result in the dismissal of the application;

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

c.      Document the conversation in claim notes.

5.     If the IW fails to appear without notice or explanation for a C-92 IME, or if the IW requests that an IME be canceled and not rescheduled, the C-92 CA or CSS shall dismiss the application by issuing a C-92 Dismissal TO.

 

H.    Requests to Reschedule an IME

1.     When contacted by an IW to reschedule an IME (including where the IW has failed to appear for a previously scheduled IME), the C-92 CA or CSS shall:

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

b.     Verify or obtain the IW’s availability to attend the rescheduled IME (i.e., when is the IW not available to attend) and explain that BWC will reschedule as soon as possible;

c.      Contact the appropriate exam scheduling region to cancel the scheduled IME, if appropriate; and

d.     Complete a new exam scheduling case or re-open the existing case.

2.     The exam scheduler shall:

a.     Contact the examining physician to cancel the scheduled IME if appropriate; and

b.     Reschedule the IME as soon as possible.

 

I.       Requests for Diagnostic Testing by DEP

1.     The DEP physician must obtain prior approval for diagnostic testing that, in rare circumstances, may be needed to complete the evaluation of the IW.

2.     The MSS shall:

a.     Review the Medical Evidence for Diagnosis Determination (MEDD) policy and procedure or other online resources to evaluate the appropriateness of diagnostic testing;

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

c.      Document in notes the specific diagnostic testing requested, the decision regarding the request, and the method used to provide notification of the decision to the DEP physician.

 

J.      Referral for PFR

1.     The MSS may refer a C-92 application for a PFR when an IME is not indicated and BWC receives a request for:

a.     An increase in %PP of 20% or less;

b.     A newly allowed condition for a body part that was included in a previous %PP award; or

c.      Accrued %PP when an IW is deceased.

2.     When referring a claim for a PFR, the MSS shall complete a Report of C-92 Increase (C-253) form.

3.     The MSS shall then:

a.     E-mail the form to the selected DEP physician; and

b.     Image the form and a copy of the e-mail (with C-92 CA or CSS last name redacted) to the claim file.

 

K.     IME and PFR Reports

1.     Exam schedulers shall review the claims management system for the receipt of the IME report 10 calendar days after the IME date or 14 calendar days for out of state IME dates. If the IME report is not received within the 10 or 14 calendar days immediately following the IME, the exam scheduler shall:

a.     Make three attempts to follow-up with the DEP physician to request the report between:

i.       10 and 21 calendar days after the in-state IME; or,

ii.      14 and 21 calendar days after the out of state IME.    

b.     Document all attempts to contact the DEP physician in claim notes and in the action plan in the exam scheduling case; and

c.      If the IME report is not received after 21 calendar days, notify BWC’s DEP Central Unit.

2.     The MSS that requested the PFR shall review their e-mail for a completed PFR within five calendar days after the request was made.

a.     If the PFR is not received within the five calendar days immediately following the request for PFR, the MSS shall:

i.       Make up to two additional attempts to contact the DEP physician; and

ii.      Document all attempts to contact the DEP physician in claim notes.

b.     If the PFR is not received following these attempts, the MSS shall report this to BWC’s DEP Central Unit.

3.     Upon receipt of the IME or PFR report, claims services staff shall image the report into the claim, even if an addendum will be requested.

4.     Reviewing the report:

a.     The MSS shall review a sample of the reports according to claims operations direction. The C-92 CA or CSS shall review C-92 IME reports not reviewed by the MSS.

b.     The reviewer shall verify that:

i.       IW information is correct throughout the report (e.g., proper pronoun for the IW’s gender and the correct IW’s name is used throughout the report);

ii.      The report is not altered in any way;

iii.     The report includes the DEP physician’s name and is typed, dated and contains the DEP physician’s signature; and

iv.    The narrative report:

a)     Specifically acknowledges the conditions allowed and disallowed in the claim;

b)     Includes an opinion based on allowed or, when appropriate, requested conditions;

c)     References medical evidence relied upon to answer questions;

d)     Includes responses to all questions, including rationale for the responses; and

e)     Includes the IW’s name and claim number on every page.

v.      The IME was completed using the BWC-approved edition of the American Medical Association guides.

c.      The reviewer shall report quality assurance problems to BWC’s DEP Central Unit.

5.     Upon completion of the review, the C-92 CA or CSS that requested the IME or PFR shall act on any recommendations by the reviewer.

6.     Claims services staff that mail the TO shall also enclose a hard copy of the report to all parties to the claim.

 

L.     Addendums

1.     Upon receipt of an IME or PFR report, the C-92 CA or CSS shall review the report and determine if an addendum is needed. If it is, the C-92 CA or CSS shall forward a request for an addendum to the MSS.

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

3.     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.

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

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

6.     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.

7.     Claims services staff shall send copies of the addendum as indicated above. Claims services staff may wait to mail copies of the original report to be included with the addendum.

 

M.    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.     If a C-19 is received by a claims office, claims services staff shall image the C-19 into the claim. The claims management system will notify MB&A that the bill was received.

 

N.    Industrial Commission (IC) Ordered IMEs

1.     The C-92 CA or CSS shall schedule an IME immediately upon receipt of an interlocutory order from the IC requesting that an IME be scheduled, following the procedures detailed in this document.

2.     Upon receipt of the IME report, the C-92 CA or CSS 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.

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