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Policy and Procedure Name:
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C-92 Independent Medical Examinations (IMEs) and
Physician File Reviews (PFRs)
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Policy #:
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CP-09-08.2
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Code/Rule Reference:
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R.C. 4123.57;
OAC
4123-3-15; OAC
4123-3-15.1
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Effective Date:
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04/09/21
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Approved:
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Ann M. Shannon, Chief of Claims Policy and Support
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Origin:
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Claims Policy
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Supersedes:
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Policy # CP-09-08.2, effective 12/31/20
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History:
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New
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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
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.
This policy applies to BWC claims services staff.
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.
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.
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.
- 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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.