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OhioBWC - Basics:  Examinations and Reviews

Examinations and Reviews

90-Day Examination
90-day examinations are required by statute and are conducted when an injured worker has received 90 consecutive days of temporary total disability compensation. This exam addresses a number of issues, including continuing compensation, return-to-work barriers and potential solutions, the need for further medical treatment or supportive care and the potential for rehabilitation.

200-Week Examination
200-week examinations are required by statute and are conducted when an injured worker has received 200 consecutive weeks of temporary total disability compensation. This exam addresses a number of issues, including continuing compensation, return-to-work barriers and potential solutions, the need for further medical treatment or supportive care and the potential for rehabilitation.

American Medical Association's (AMA's) Guide to the Evaluation of Permanent Impairment
BWC requires that the fifth edition of the AMA’s Guides to the Evaluation of Permanent Impairment be used for the basis of injured worker disability evaluations. This publication may also be referred to as the AMA Guides or Guides.

BWC Physician Review/Exam
Periodically, physicians conduct injured worker claim file reviews or physical examinations. These file reviews and exams are performed either to meet statutory obligations (i.e., an injured worker has received temporary total compensation for either 90 consecutive days or 200 consecutive weeks) or at the request of the injured worker (i.e., to determine or increase a percent of permanent partial disability award). All of these reviews and exams are completed by physicians participating in BWC’s Disability Evaluators' Panel.

C-92 Examinations
A C-92 examination provides an unbiased, objective estimate of the whole person percent impairment for a given allowance referred to as percentage of permanent partial, %PP, %PPD, or, most frequently, C-92 awards. This must be based on the most current edition of the American Medical Association's Guides to the Evaluation of Permanent Impairment, using the available medical documentation, history, and physical examination.

C-92 Medical File Review
A C-92 medical file review requires physicians to review medical files for the purpose of granting additional impairment by application of newly submitted medical documentation. Injured workers who are permanently and partially disabled can file for compensation awards based on the extent of their disability. The extent of disability is determined through a BWC independent medical examination, and the injured worker’s physical impairment is expressed as a percentage. These awards are referred to as percentage of permanent partial, %PP, %PPD, or, most frequently, C-92 awards.

C-92 medical file reviews do not require clinical decision making in terms of alternative treatment, diagnosis, or examination of the patient. However, they do require a good knowledge and application of the American Medical Association’s Guides to the Evaluation of Permanent Impairment. Additionally, physicians who conduct these reviews may be involved in auditing and dispute resolution of C-92 issues in the C-92 Quality Assurance Program.

Concurrent and Retro Review
Concurrent and retrospective (i.e., retro) reviews are two types of health care quality assurance practices. Fundamentally, Ohio’s workers’ compensation system relies on three measures when evaluating medical services being provided to injured workers. These are medical necessity, medical relatedness (particularly to the conditions allowed in the claim) and cost-effectiveness. Concurrent reviews evaluate these measures while a service or services is being rendered (i.e., a current review). On the other hand, retrospective review are done after a service or services have been provided (i.e., an after-the-fact review).

BWC requires managed care organizations (MCOs) to respond to treatment requests within three business days of receiving them from either the physician of record or a treating physician. These requests should be submitted on the Physician’s Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupation Disease (C-). If a MCO does not respond to the C-9 within three days and the provider initiates treatment, the MCO must review the C-9 after the course of treatment has begun. If the MCO decides the treatment is not necessary, the MCO must notify all parties that treatment should be discontinued. Additionally, the MCO is required to pay for all services rendered up to that point.

Independent Medical Examinations (IME)
An IME is an objective medical evaluation conducted by an independent, qualified medical specialist at BWC’s request for the purpose of clarifying an injured worker’s medical and disability status.

Medical File Review (Non C-92-A)
Injured workers who are permanently and partially disabled can file for compensation awards based on the extent of their disability. The extent of disability is determined through a BWC independent medical examination), and the injured worker’s physical impairment is expressed as a percentage. These awards are referred to as percentage of permanent partial, %PP, %PPD, or, most frequently, C-92 awards.

These file reviews usually require physicians to review medical records to answer specific questions in areas, such as treatment continuation, specific treatment requests, appropriateness of medication or claim allowance. Physicians should be knowledgeable of appropriate treatment and up to date with commonly accepted practice guidelines. They do not need to have a clinical practice, and many may be in retirement or surgeons who no longer perform surgical procedures.

Medical Review
Medical reviews are evaluations focusing on the necessity, relatedness and cost of medical services requested by a physician. Under Ohio worker’s compensation law, managed care organizations (MCOs) are responsible for the medical management of injured worker claims, including performing medical reviews. MCOs are required to respond to physicians’ treatment requests within three business days. If this time frame cannot be met due to the MCO needing a medical review, they must provide notice to the physician. Reviews must take place and a decision made within five days of this notice.

It is important to note that these reviews should not be confused with the medical file reviews conducted by BWC’s Disability Evaluators' Panel physicians.

Utilization Review
Utilization review is conducted by a managed care organization to assess medical care provided to an injured worker. This assessment typically considers factors, such as medical necessity, the appropriateness of the place of care, level of care and the duration, frequency or quality of services provided in relation to the allowed condition being treated in a workers’ compensation claim.



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