Table of
Contents
I. POLICY PURPOSE
II. APPLICABILITY
III. DEFINITIONS
Abatement of Substantial Aggravation
Alternative Dispute Resolution (ADR)
Exam
Extraordinary Unforeseen
Circumstances
Extent of Disability (EOD)
Good Cause
In-State Exam
Maximum Medical Improvement (MMI)
Occupational Disease (OD)
Out-of-State Exam
Parties to a Claim
Scheduled Loss Compensation (SL)
Statutory Occupational Disease
Temporary Total Compensation (TT)
IV. POLICY
A. Authority
to Schedule IMEs and Obtain PFRs
B. DEP
Selection Criteria for IMEs and PFRs
C. IME
Scheduling
D. Attending
an IME
E. IMEs
Prior to Initial Determination
F. EOD
IMEs
G. SL
IMEs
H. ADR
IMEs
I. Additional
Allowance (AA) IMEs
J. Abatement
of Substantial Aggravation IMEs
K. Claim
Reactivation IMEs
L. IME
Reports
M. Failure
to Appear
N. Refusal
to Submit to or Obstruction of an IME
O. IW-Requested
IMEs
P. Employer-Requested
IMEs
Q. Employer-Scheduled
IMEs
R. IME
Costs
S. Obtaining
a PFR
T. PFR
Reports
U. Addendums
V. DEP
Requirements
V. PROCEDURE
A. General
Claim Note and Documentation Requirements
B. Preparation
for Scheduling an IME or PFR
C. Multiple
IMEs or PFRs
D. IME
and PFR Not Indicated
E. Selecting
a DEP Physician
F. Contacting
the IW for an IME
G. Creating
an Exam Packet
H. Requesting
an IME
I. Scheduling
the IME
J. BWC
IME Cancellations
K. Failure
to Appear and Requests to Cancel Without Rescheduling
L. Requests
to Reschedule an IME
M. Diagnostic
Testing
N. Initial
Determination IMEs- Statutory OD
O. Initial
Determination (Other Than Statutory OD) IMEs
P. AA
IMEs- Physical, Psychiatric, Reflex Sympathetic Dystrophy (RSD)/Complex
Regional Pain Syndrome (CRPS)
Q. EOD
IMEs
R. SL
IMEs
S. Claim
Reactivation IMEs
T. ADR
IMEs
U. Evaluation
of Substantial Aggravation IMEs
V. IME
Reports
W. IC-Ordered
IMEs
X. MSS
Referral for PFR and Decision
Y. Referral
for PFR
Z. PFR
Receipt
AA. Addendums
BB. Employer-Scheduled
IMEs
The purpose of this policy is to ensure that BWC and managed
care organizations (MCOs) properly process and obtain independent medical
examinations (IMEs) or physician file reviews (PFRs) when required by statute
or when needed to support the claims management process.
This policy applies to BWC Claims Services staff and MCO
staff.
Abatement of Substantial
Aggravation: A determination that a condition that was
allowed for the substantial aggravation of a pre-existing condition has reached
a state such as would have existed had the injury not occurred; and, therefore,
compensation based on and medical treatment for the condition is no longer
payable.
Alternative Dispute Resolution
(ADR) Exam: An exam conducted as part of processing a
medical dispute between an employer of record (EOR), an injured worker (IW), a
provider and/or an MCO arising from the MCO’s decision regarding a medical
treatment reimbursement request. An IW or EOR shall exhaust the ADR process
prior to filing an appeal pursuant to R.C. 4123.511 regarding an MCO’s decision
on a medical treatment reimbursement request.
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.
Extraordinary Unforeseen
Circumstances: The basis for which a determination of
good cause is made. Extraordinary unforeseen circumstances include, but are not
limited to:
- Death of an immediate family member;
- Hospitalizations or medical emergencies;
- Auto accidents;
- Notice of the exam was not received due to an incorrect
address;
- Proper notice of the exam was not provided to the injured
worker; or
- Weather emergencies.
Extent of Disability (EOD):
An evaluation of IW’s allowed condition(s) in the claim regarding:
- The IW’s ability to return to the former position of
employment;
- Restrictions which prevent the IW’s return to the former
position of employment;
- The IW having reached maximum medical improvement (MMI);
- The feasibility of a referral for vocational
rehabilitation services; and
- The IW’s eligibility for continued temporary total
compensation (TT).
Good Cause:
For purposes of this policy, a failure to attend an exam for good cause is
demonstrated by a showing of extraordinary unforeseen circumstances, as defined
above.
In-State Exam:
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: 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.
Maximum Medical Improvement
(MMI): A treatment plateau (static or well-stabilized)
at which no fundamental functional, physiological, or psychological change can
be expected within reasonable medical probability in spite of continuing
medical or rehabilitative procedures. An injured worker may need supportive
treatment to maintain this level of function.
Occupational Disease (OD):
A disease contracted in the course of employment, where the employment is shown
to create a risk of contracting the disease in greater degree and in a
different manner from the general public. The disease’s causes and the
characteristics of its manifestation must demonstrate a relationship to the
work environment, or the condition of the employment environment must be shown
to result in a hazard which distinguishes the employment in character from
employment generally.
Out-of-State Exam:
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, EOR, EOR representative, and BWC.
Percentage of Permanent Partial Disability
Compensation (%PP): 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 OD in state fund or self-insured (SI)
claims.
Physician File Review: 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.
Scheduled Loss Compensation (SL):
An award pursuant to R.C. 4123.57(B) made to an IW for the amputation of, or
loss of use of, a body part or a facial disfigurement.
Statutory Occupational Disease:
For purposes of this policy, a scheduled occupational disease that requires an
IME prior to claim determination.
Temporary Total Compensation
(TT): Compensation paid to an IW who is unable to
return to the former position of employment on a temporary basis due to the
work-related injury or OD, and who has not been found to have reached MMI.
1. It
is the policy of BWC to:
a. Schedule
IMEs or obtain PFRs as required by law, or when the need is identified during
the management of a claim; and
b. Require
that IWs appear for BWC-scheduled IMEs.
2. Statutorily
Required IMEs
a. It
is the policy of BWC to schedule an IME as required by statute.
b. Statute
requires an IME to be scheduled in the following circumstances:
i.
Prior to the initial determination of a claim for a statutory OD;
ii. After
the first instance of 90 consecutive days of TT compensation (90-day exam) to
determine EOD; and
iii. For the initial
determination of %PP.
3. BWC
Discretion
a. Other
than for those required by statute, BWC will use its discretion when
determining whether to schedule an IME or obtain a PFR.
b. BWC
will consider factors that include, but are not limited to:
i.
Has there been sufficient contact with the treating physician to
identify the treatment plan for the IW and the IW’s compliance with the
treatment plan or to otherwise resolve the outstanding issue?
ii. Has
necessary medical evidence been requested and received?
iii. Is there
sufficient evidence in the claim to make a decision without an IME or PFR?
iv. Is the
issue to be resolved a medical issue and not a legal issue (e.g., not a coming
or going issue)?
v. Are
there outstanding issues that should be resolved prior to scheduling an IME or
obtaining a PFR (e.g., additional allowance or referral to vocational
rehabilitation pending)?
4. Multiple
IMEs
a. BWC
will schedule multiple IMEs or obtain multiple PFRs when the allowed or
requested conditions require the expertise of multiple specialists.
b. BWC
will make efforts to coordinate the scheduling of multiple IMEs to avoid
conflicts for the IW.
1. It
is the policy of BWC to ensure equitable distribution of IMEs to DEP
physicians. Considerations include, but are not limited to:
a. IW’s
travel distance to the IME facility;
b. DEP
physician’s availability; and
c. DEP
physician’s specialty.
2. The
medical specialty of the DEP physician selected for an IME or PFR must be
appropriate for the allowed conditions in the claim, or the issue presented for
consideration.
3. Conflicts
of Interest
a. BWC
will attempt to avoid conflicts of interest when selecting DEP physicians.
b. The
DEP physician must, as a condition of the DEP agreement:
i.
Identify any conflicts of interest; and
ii. Withdraw
from completing an IME or PFR when a conflict of interest exists or appears to
exist.
c. Possible
conflicts of interest include, but are not limited to, when the DEP physician:
i.
Is in the IW’s immediate family;
ii. Works
with a member of the IW’s immediate family in the DEP physician’s practice or
clinic;
iii. Is in the
immediate family of the IW’s treating physician or physician of record (POR) in
the current claim;
iv. Previously
provided treatment to the IW as part of the current or another workers’
compensation claim;
v. Performed
an IME of the IW as part of the current or another workers’ compensation claim
for BWC, the IC, the EOR or the IW in the last 36 months;
vi. Completed
a PFR of the IW’s current or another workers’ compensation claim within the
last 12 months for BWC, the IW or the EOR;
vii. Is in the same
practice or clinic with a provider described above;
viii. Has a personal, professional, or
contractual relationship with the IW, the EOR, or their representatives;
ix. Has a
personal, professional, or contractual relationship with the MCO assigned to
the current claim (merely being on an MCO’s provider panel or network as a
treating physician does not in and of itself disqualify a DEP physician);
x. Is
the medical director for the MCO managing the current claim, or is a member of
the same practice or clinic with the medical director for the MCO managing the
current claim; or
xi. Has five
percent or greater financial interest in the MCO managing the current claim.
1. BWC
will select the physician to conduct an in-state IME. In-state IMEs are either
scheduled:
a. Directly
with the examining physician; or
b. Through
an administrative agent, when the DEP physician uses one.
2. Out-of-state
IMEs are scheduled through an administrative agent contracted with BWC.
3. BWC
will consider the geographic proximity between the IW’s residence and IME
location.
a. The
IME will be scheduled at a location that is closest to the IW’s home, taking
into consideration available times, specialty of physician needed, and possible
conflicts of interest.
b. The
IW will be reimbursed for expenses when attending an IME that requires travel
outside a certain radius of the IW’s permanent or temporary residence, as
detailed in the Travel
Reimbursement policy and procedure.
4. BWC
will provide the IW and examining DEP physician written notice at least 14
calendar days in advance of the IME date.
1. The
IW must provide photo identification at the time of an exam.
2. The
IW may have the following parties present during an IME:
a. A
relative;
b. Chaperone;
or
c. An
interpreter, as needed (see the Interpreter
and Translation Services policy and procedure for additional
information).
3. BWC
prohibits the following from being present during an IME:
a. IW
representatives;
b. EORs;
c. EOR
representatives; or
d. MCO
representatives.
4. BWC
prohibits audio or video recordings in the exam room.
1. BWC
will schedule an IME prior to making the initial decision in a claim as
required by statute or when BWC identifies the need for an IME.
a. An
IME is required before determining an OD claim for these conditions:
i.
Berylliosis;
ii. Silicosis;
iii. Asbestosis;
iv. Coal
miners’ pneumoconiosis;
v. Cardiovascular
or pulmonary disease for firefighters or police officers; or
vi. Any other
OD of the respiratory tract resulting from injurious exposure to dust.
b. Depending
on the situation, BWC may schedule an IME for:
i.
Other ODs;
ii. Forced
sexual conduct; or
iii. Other initial
determinations as identified by BWC.
c. It
is the policy of BWC to require the minimum evidence as described in IC
Resolution R15-1-01
prior to scheduling an IME for certain ODs. See the Occupational
Disease Claims policy and procedure for additional information.
2. Failure
to appear for an IME regarding the initial determination of a claim for reasons
other than good cause, may result in denial of the claim.
1. BWC
must schedule EOD IMEs as required by statute or when BWC identifies the need
for an IME.
2. BWC
will schedule a 90-day exam no later than 30 calendar days after the first 90
consecutive-day period for which the IW is paid TT, unless the exam is waived
by the employer or BWC.
a. The
employer may waive the 90-day exam, either permanently or temporarily. If the
waiver is:
i.
Temporary, a date must be given for when the 90-day exam is necessary
again.
ii. Permanent,
the 90-day exam will no longer be necessary.
b. The
waiver may be verbal or in writing, using a Waiver of Examination (MEDCO-6)
or equivalent form.
c. If
the employer is out of business or fails to respond to BWC’s request to waive
the IME, BWC may waive the IME.
d. If
the employer objects to waiving the IME, BWC will schedule the IME.
3. BWC
may schedule an EOD IME immediately after the IW has received 200 weeks of TT.
4. BWC
may schedule an EOD IME at any time when:
a. TT
is ongoing; or
b. TT
is requested on the date the IME is scheduled.
5. If
the IW returns to work prior to the IME taking place, BWC will cancel the IME.
6. Failure
to appear for an EOD IME for reasons other than good cause may result in
suspension of TT.
7. See
the Temporary
Total Compensation policy and procedure for additional information.
1. BWC
may schedule an IME regarding requests for SL.
2. Failure
to appear for an IME regarding SL for reasons other than good cause may result
in the suspension of the request for SL.
3. See
the Scheduled
Loss Compensation policy and procedure for more information.
1. ADR
IMEs may be completed by a BWC-certified physician who is not on the DEP.
2. Failure
to appear for an ADR IME for reasons other than good cause may result in the
suspension of medical treatment in the claim.
3. See
the Alternative
Dispute Resolution Exams policy and procedure for additional
information.
1. BWC
may schedule an IME for the determination of additional conditions.
2. Failure
to appear for an AA IME for reasons other than good cause may result in
suspension of the request for the AA.
3. See
the Additional
Allowance policy and procedure for additional information.
1. BWC
may schedule an IME to evaluate the status of a condition allowed for
substantial aggravation of a pre-existing condition to determine whether the
condition:
a. Continues
to be payable; or
b. Has
abated.
2. Failure
to appear for a scheduled IME to evaluate a condition allowed for substantial
aggravation of a pre-existing condition for reasons other than good cause may
result in suspension of the compensation or treatment requested based on that
condition.
3. See
the Aggravation
and Substantial Aggravation of a Pre-Existing Condition policy and
procedure for additional information.
1. BWC
may schedule an IME regarding the reactivation of a claim.
2. Failure
to appear for a scheduled IME regarding the reactivation of a claim for reasons
other than good cause may result in a suspension of the request for
reactivation.
3. See
the Claim
Reactivation policy and procedure for additional information.
1. It
is the policy of BWC that completed IME reports:
a. Be
submitted within 10 calendar days of the IME, except in the case of:
i.
ADR IMEs, which must be submitted within five calendar days; and
ii. Out-of-state
IMEs, which must be submitted within 10 business days.
b. Not
be altered in any way, such as cross outs or white outs (see the Standard
Claim File Documentation and Altered Documents policy and procedure for
further guidance on altered documents);
c. Be
typed, dated, and contain the DEP physician’s signature; and
d. Contain
the IW’s name and claim number on each page of the report.
2. BWC
will provide a hard copy of all IME reports (with the exception of %PP reports)
and any addendums to any party to the claim upon request.
1. When
an IW fails to appear for an IME, BWC will evaluate if the reason the IW failed
to appear was for good cause.
2. Depending
upon the issue being adjudicated, failing to appear for an IME may result in
dismissal or denial of an application, or suspension of compensation or
benefits, as described above.
3. BWC
will lift a suspension as the result of failure to appear for a BWC-scheduled
IME when:
a. The
IW appears for a rescheduled IME; or
b. The
issue that resulted in the BWC or MCO-scheduled IME is moot.
1. If
an IW refuses to submit to, or otherwise obstructs an IME, BWC will conduct an
investigation.
2. If
it is determined that the refusal to submit or obstruction was justified, the
IME will be rescheduled, and processing will continue.
3. If
it is determined that the refusal to submit or obstruction was not justified,
processing will continue as if the IW failed to appear for the IME.
1. If
the IW or the IW’s representative requests an IME to support allowance of a new
condition or an increase in %PP, the cost of this IME is the IW’s
responsibility.
2. BWC
will refer requests to schedule IMEs on behalf of the IW to the IC.
1. State-Fund
(SF) Claims
a. Requests
by the EOR in a SF claim for an IW to be scheduled for an IME must be made in
writing.
b. When
an EOR in a SF claim requests that an IW be scheduled for an IME, BWC will
retain the discretion to decide whether the IME is appropriate.
i.
BWC will schedule an IME if BWC determines it is pertinent to the
management of the claim and BWC has jurisdiction to make the decision related
to the request; or
ii. When
the IME request is related to issues outside of BWC’s jurisdiction or BWC does
not agree with the request, the request will be referred to the IC.
2. SI
Claims
a. BWC
may, at the written request of an EOR in a SI claim, schedule an IME with a BWC
DEP physician on behalf of the EOR.
b. The
EOR in a SI claim will pay:
i.
The provider’s costs associated with the IME; and
ii. Expenses
and lost wages to the IW for attending the IME.
1. SF
Claims
a. The
EOR in a SF claim may schedule an IW for an IME:
i.
One time;
ii. On
any issue asserted by the IW or the POR/treating physician; and
iii. By a physician
of the EOR’s choice;
b. The
EOR will pay:
i.
The provider’s costs associated with the IME; and
ii. Expenses
and lost wages to the IW for attending the IME (lost wages will be paid within
three weeks).
c. The
EOR will provide to BWC, the IW, and the IW’s representative:
i.
The time and place of the IME;
ii. The
questions asked of the examining physician; and
iii. The information
provided to the examining physician.
d. The
EOR must file the doctor’s report with BWC immediately upon its receipt.
e. If,
after one employer-scheduled IME of the IW, the EOR asserts that another IME by
a physician of the employer’s choice for the same issue is essential in the
defense of the claim, the EOR may file a written request with BWC to require
that the IW attend another IME.
f.
Treatment by a company doctor constitutes an employer-scheduled IME.
2. SI
Claims
a. Upon
notification that an EOR in a SI claim has paid 200 weeks of TT, BWC may
schedule an EOD IME.
b. This
IME must be paid for by the EOR.
1. Except
for statutory OD IMEs where the claim is subsequently denied, the cost for an
IME will be charged to the claim.
2. For
statutory OD claims, where the claim is subsequently denied, the cost of the
IME will be charged to the Surplus Fund for those employers who contribute to
the Surplus Fund.
1. BWC
retains the right to obtain a PFR when necessary, in the course of claims
management.
2. Reasons
a PFR may be obtained include, but are not limited to:
a. Identification
of the proper diagnosis for the initial determination of a claim;
b. Determination
of requests for the allowance of additional conditions;
c. Evaluation
of requests for claim reactivation, including appropriateness of medical
treatment;
d. Processing
requests for an increase in %PP;
e. Determining
the IW’s eligibility for a SL award;
f.
Determining if drugs requested or currently being reimbursed by BWC are
reasonably related or medically necessary and appropriate for the treatment of
allowed conditions in a claim; and
g. Determination
of a claim or an issue in a claim when an IME is not possible due to physical
limitations that prevent an IW from being examined, or the IW has died.
1. BWC
requires DEP physicians who complete PFRs to expressly accept all findings of
the POR/treating physician(s), but not necessarily their opinion about those
findings.
2. BWC
will provide copies of PFR reports to all parties to the claim upon request.
1. Addendum
Requests
a. Only
BWC or the MCO may request an addendum to an IME or PFR.
b. The
initial addendum request may be made by telephone but must be followed up with
a written request.
c. The
request for an addendum must be sent to all parties to the claim.
2. DEP
Reimbursement for Addendums
a. 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.
b. The
DEP physician may request additional payment if the addendum request:
i.
Requires the review of additional information; or
ii. Is
needed because of an error on the part of BWC (e.g., BWC did not ask the
correct questions).
1. The
DEP physician must:
a. Include
in a narrative report an opinion based on the allowed conditions with
references to the medical relied upon; and
b. Respond
to all questions with supporting rationale.
2. BWC
prohibits the DEP physician from communicating with the parties to a claim, or
their representatives, regarding the examination or report.
3. DEP
physicians will complete a Service Invoice (C-19) and submit it directly
to BWC’s Medical Billing and Adjustment (MB&A) unit.
a. If a
C-19 is received in a claims office, it is the policy of BWC to image the C-19
into the claim.
b. Refer
to the Disability Evaluators Panel Handbook and the BWC Provider
Billing and Reimbursement Manual for billing codes and other additional
information.
4. It
is the policy of BWC to refer all concerns or complaints regarding a DEP
physician to BWC’s DEP Central Unit.
1. BWC
staff will refer to the Standard
Claim File Documentation and Altered Documents policy and procedure for
claim note and documentation requirements; and
2. Must
follow any other specific instructions for claim notes and documentation
included in this procedure.
1. Prior
to scheduling an IME or PFR, the claims service specialist (CSS), medical
claims specialist (MCS), or claims assistant (CA):
a. Must
verify that the conditions listed in the claim accurately reflect the narrative
description of conditions as they appear on a BWC or IC order, or as
appropriate in SI bankrupt claims (see the ICD
Modification policy and procedure for additional information); and
b. May
refer the claim for medical service specialist (MSS) review to determine
whether an IME versus a PFR is warranted.
2. Upon
referral to the MSS, the CSS, MCS, or CA will:
a. Enter
a note in the claims management system describing the reason for the referral;
and
b. Create
a case event for the MSS.
1. Claims
services staff will schedule multiple IMEs or obtain multiple PFRs when
necessary, based on the allowed or requested conditions in the claim.
2. When
scheduling multiple IMEs, claims services staff will:
a. Notify
the IW, either over the phone or in writing, that more than one IME will be
scheduled; and
b. Coordinate
the scheduling of the IMEs to avoid conflicts for the IW to attend the IMEs.
1. Claims
services staff will not schedule an IME for EOD in a claim where the IW has
been found to be permanently and totally disabled (PTD) without evidence of new
and changed circumstances.
a. Claims
services staff must review the claim with a BWC attorney before considering an
EOD IME in a PTD claim.
b. IMEs
may be scheduled in PTD claims for other issues, such as AA or treatment.
2. Claims
services staff will not schedule an IME or obtain a PFR:
a. When
there is sufficient evidence on file upon which to base a decision; or
b. Based
solely on a request made by another party to the claim.
3. Claims
services staff will not refer a medical issue to the IC recommending that a
request be denied without an IME or PFR report that supports BWC’s position.
1. Claims
Services Staff and MCO Shared Responsibilities
a. Claims
services staff and the MCO will ensure that any physician selected for an IME
or PFR be a BWC DEP physician; and
b. Consider
the following when selecting a physician for an IME or PFR:
i.
The physician must be a BWC-certified physician for ADR IMEs scheduled
by an MCO;
ii. Select
a physician with the same or a similar specialty as the treating physician
whenever possible (BWC staff may use the Medical Specialty Guide found on
COR as a resource); and
iii. Base DEP
physician selection on the services that the physician has agreed to provide.
2. Claims
Services Staff Responsibilities
a. Claims
services staff will obtain and image in the claim the Medical
Servicing Providers Report that lists physicians who have previously billed
BWC for treatment or previous DEP IMEs or PFRs performed in the claim;
b. Identify
other physicians who have examined the IW or reviewed the IW’s claim but have
not billed BWC for the IME or PFR (e.g., IMEs in SI claims, IMEs obtained by
the employer or IW);
c. Not
select a DEP physician for whom conducting an IME or PFR would represent a
conflict of interest or the appearance of a conflict of interest, as described
in this policy; and
d. Not
select a DEP physician with whom claims services staff have a personal
relationship.
1. Prior
to scheduling an IME, the CSS will attempt to contact the IW by telephone.
2. During
the contact, the CSS will:
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. Explain
to the IW that failure to attend the IME may result in the dismissal or denial
of an application, or suspension of compensation or benefits (see the Failure
to Appear and Requests to Cancel Without Rescheduling section of this
procedure for additional information); and
e. Obtain
the IW’s availability and explain 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.
3. If
phone contact is made, the CSS will include the IW’s exam availability in the
note regarding the contact.
4. If
phone contact is not successful, the CSS will:
a. Leave
a detailed message for the IW (when possible) and allow three calendar days for
the IW to respond with availability to attend the IME. The detailed message
must include:
i.
The information outlined above;
ii. That
if BWC does not hear back from the IW, the IME will be scheduled at the next
available time; and
iii. That BWC will
send the IW a letter with the date and time of the IME.
b. Contact
the IW’s representative, if represented.
c. If
it is not possible to leave a detailed message or contact the IW’s
representative, attempt one additional phone contact on a different day.
5. If
phone contact as described in this section is not possible, or no response is
received to the messages left by the CSS, the CSS will continue with scheduling
the IME.
1. Claims
services staff will complete the exam packet within seven calendar days of the
date of receipt of the IME referral.
2. Claims
services staff will create an exam packet prior to requesting an IME.
3. The
exam packet will contain the documents as outlined in the IME Packet Content
document found on COR, under Operational Guidelines and Workflows, on the IME
policy page.
4. Claims
services staff will rename the packet according to the indexing and renaming
guidelines as directed by Claims Operations.
1. The
CSS (or MSS for AA Physical or SL) will:
a. Obtain
and image in the claim the Medical Servicing Providers Report that lists
physicians who have previously billed BWC for treatment or previous DEP IMEs or
PFRs performed in the claim; and
b. Ensure
the report is within seven calendar days of the date of the IME referral.
2. The
CSS (or MSS for AA Physical or SL) will select a new medical exam scheduling
case and create a case event for the exam scheduler to schedule an IME.
3. The
exam scheduling case will include at least the following information:
a. Type
of IME requested;
b. IW
availability, if known;
c. Type
of physician required for the IME;
i.
The CSS will include the specialty recommended by the MSS, when
applicable.
ii. Two
specialty options should be provided; however, if only one type of specialist
would be appropriate, the reason for only providing one will be included in the
additional information section (e.g., a psychiatrist is needed to evaluate
treatment that includes prescription medications for psychiatric conditions);
d. Physicians
who have examined the IW or performed a file review of the IW’s claim(s) who
are not listed on the Medical Servicing Providers Report;
e. Need
for an interpreter, if applicable; and
f.
Additional exam questions, if any. A BWC attorney must review and
approve additional questions that are not already programmed into the claims
management system before the questions are added.
1. The
exam scheduler will:
a. Prior
to scheduling the IME, review the claim notes regarding the IW’s exam
availability (see note titled “IW Availability”).
b. Schedule
the IME based on the IW’s availability when possible;
c.
Ensure equitable selection and distribution of IMEs to DEP physicians
based upon Claims Operations physician selection guidelines.
d. Consider
proximity to the IW’s home and select a DEP physician closest to the IW’s home
when possible (the exam scheduler may consider scheduling further from the IW’s
home, if necessary, to obtain a timely IME and accommodate the IW’s
availability);
e. Work
with BWC’s contracted administrative agent to schedule IMEs for IWs who live in
another state and are more than 50 miles from the Ohio border;
f.
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;
g. Complete
scheduling of the IME within five calendar days of receiving the request;
h. Schedule
the IME for a date that allows for at least 14-day notice to the IW (except
when there is a documented request from the IW that the IME be scheduled more
quickly);
i.
Send the appropriate IW Notice of Exam letter, using the letters
found in the claims management system.
i.
If the IW’s letter is returned by the post office due to an incorrect
mailing address, the CSS will attempt to find a new address for the IW by the
following means:
a) Researching
on the internet; or
b) Contacting:
i)
The IW by phone;
ii) The
IW’s representative by phone;
iii) The MCO; or
iv) A treating
provider.
ii. If
contact with the IW or IW’s representative is made after the receipt of
returned mail, and the IW is:
a) Able
to attend the IME at the original scheduled time, the CSS will:
i)
Confirm the appointment date, time, and location;
ii) Document
in notes that the IME information was provided by phone;
iii) Update the IW’s
address information in the claims management system; and
iv) Resend the
notice to the IW at the updated address.
b) Unable
to attend the IME at the original scheduled time, the CSS will:
i)
Notify the exam scheduler to cancel the scheduled IME;
ii) Update
the IW’s address in the claims management system;
iii) Complete all
tasks associated with the original IME referral;
iv) Update exam
scheduling information in the claims management system to close out the
original IME referral; and
v) Create
a new medical exam scheduling case or transition the previously closed exam
scheduling case for the same issue and create case event.
iii. If it is not
possible to obtain new contact information for the IW, the CSS will:
a) Notify
the exam scheduler to cancel the scheduled IME; and
b) Proceed
with processing the claim as if the IW failed to appear.
j.
Send the DEP physician the Physician Notice of Exam letter,
including the appropriate exam reason and questions.
k. When
interpreter services must be scheduled, notify the CSS of the date and time of
the IME (see the Interpreter
and Translation Services policy and procedure for additional
information).
2. Scheduling
Exceptions
a. When
scheduling an AA IME, claims services staff must follow the Additional
Allowance policy and procedure.
b. When
scheduling an IME for a C-92 IME, claims services staff must follow the
procedures outlined in the C92
Independent Medical Examinations (IMEs) and Physician File Reviews (PFRs)
policy and procedure.
3. See
below for more information regarding specific IME types.
1. If
it is necessary for BWC to cancel or reschedule an IW’s IME, the exam scheduler
will make two attempts to contact the IW or IW’s representative by phone.
2. The
exam scheduler also will send written notice of the cancelation and, if
applicable, the reschedule date.
1. The
CSS will contact the IW’s representative immediately upon notice from the DEP
physician that the IW failed to appear for a BWC-scheduled IME. If the IW is
not represented, claims staff will contact the IW directly.
2. If
the initial attempt to contact the IW’s representative or IW is not successful,
the CSS will:
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 CSS;
c. Allow
three business days for response to phone messages, or six business days for a
letter; and
d. Continue
with the failure to appear process if no response is received.
3. Determination
of Good Cause
a. When
speaking with the IW or IW’s representative, the CSS will determine if the IW
failed to appear for or is requesting to cancel an appointment for good cause.
b. When
determining if the IW failed to appear or is requesting that an IME be
rescheduled for good cause, the CSS will take into consideration BWC’s efforts
to schedule within the IW’s availability.
4. If
it is determined that good cause does exist, benefits will continue, and the
CSS will reschedule the IME as soon as possible.
a. Generally,
the CSS will not require the IW to provide evidence to support the good cause
reason for failure to appear, canceling or rescheduling the IME.
b. The
CSS may require evidence (e.g., obituary, medical reports/bills) if the IW has
a history of failure to appear for, canceling or rescheduling this or other
IMEs.
5. If
it is determined that good cause does not exist for the failure to appear, or
the IW requests that an IME be canceled and not rescheduled, claims staff will
staff the claim with a supervisor. The supervisor will:
a. Verify
the Contacting the IW for an IME section of this procedure was followed when
the IME was scheduled;
b. For
EOD examinations, ensure the completed Failure to Appear for an IME
Checklist found on COR is imaged to the claim file.
6. If
the IW contacts BWC and requests that an IME be cancelled and not rescheduled,
the CSS will:
a. Explain
to the IW that failure to appear for a BWC-scheduled IME may result in
dismissal or suspension of an application and/or suspension or denial of
benefits; and
b. Contact
the IW’s representative, if one exists, to provide notice that a BWC-scheduled
IME has been cancelled at the IW’s request.
7. If
good cause does not exist for the failure to appear, or the IW fails to appear
without notice, or if the IW requests that an IME be canceled and not
rescheduled, claims services staff will proceed with processing as follows,
with supervisor approval:
a. EOD
IME:
i.
Suspend TT compensation beginning with the next scheduled payment period
(payment for the current scheduled payment period should be permitted to pay);
ii. Send
the TT Suspension Letter found on the claims management system to the IW
and IW representative; and
iii. Suspend any
subsequent request for compensation other than for Lump Sum Settlement (LSS).
iv. Medical
benefits are not suspended.
b. Statutory
OD IME: Deny the claim by sending an Initial Denial Order if unable to
reschedule or the IW fails to appear for the second scheduled IME.
c. Initial
determination IME other than statutory OD: Make an initial determination based
on evidence in the claim, which may include a PFR obtained in lieu of the IME.
d. Evaluation
of substantial aggravation IME: Send the Suspension Letter to suspend
the compensation and/or medical benefits requested based on the substantially
aggravated condition.
e. ADR
IME: Send the Suspension Letter to suspend the request for treatment.
f.
Other requests: Send the Suspension Letter to suspend the
request.
8. If
the IW appears for the re-scheduled IME, the CSS will:
a. For
EOD IMEs:
i.
Send the TT Reinstatement Letter from the claims management
system; and
ii. Pay
TT beginning the date the suspension began.
b. For
all other IMEs, continue processing the request and issue the appropriate
decision.
c. Process
any other requests that were suspended because of the failure to appear
suspension.
9. If
the issue for which the IME was scheduled becomes moot (e.g., IW returns to
work after the IME date, withdraws request, or new medical evidence is
received) the CSS will:
a. For
EOD IMEs, if the IW returns to work after the IME date and later requests a new
period of TT compensation, the suspension will be lifted for the new period and
TT will be considered.
i.
The period of TT suspended because of the failure to appear will remain
suspended.
ii. If
the IW files a Motion (C-86) requesting payment for the suspended
period, the CSS will refer the request to the IC.
iii. If the IW
attends an EOD IME for the new period of TT, the CSS will staff with a BWC
attorney to determine if payment should be considered for the previously
suspended period.
b. For
other IMEs, dismiss the application as appropriate or continue processing based
on newly received evidence.
10. If the IW withdraws a
request and subsequently refiles the same or a similar request, the CSS will
consider scheduling an IME for the new request.
1. When
contacted by an IW to reschedule an IME (including where the IW has failed to
appear for a previously scheduled IME), the CSS will:
a. Determine
the reason for the request to reschedule the IME;
b. Explain
to the IW the importance of attending a BWC-scheduled IME and the consequence
of not attending an IME;
c. Verify
or obtain the IW’s availability to attend the rescheduled IME and explain that
BWC will reschedule as soon as possible which may result in less than 14-day
notice of the IME;
d. Contact
the exam scheduler to cancel the scheduled IME if appropriate;
e. Create
a new exam scheduling case, or update the existing exam scheduling case;
f.
Reschedule the IME as soon as possible; and
g. If
applicable, suspend processing of the claim or application, or dismissal of an
application as described in this procedure.
2. The
CSS must process the IW’s claim or application as follows:
a. EOD
IME:
i.
If the reason for rescheduling is for good cause, the CSS will allow TT
to continue; or
ii. If
the reason for rescheduling is not for good cause, claims staff will follow the
failure to appear procedure above.
b. Statutory
OD IME:
i.
Withhold making a decision regarding the claim until the IW attends the
rescheduled IME or fails to attend the rescheduled IME.
ii. If
the IW fails to attend the second IME for reasons other than good cause, the
CSS may deny the claim.
iii. The CSS will
staff with a supervisor prior to denying the claim.
c. Initial
determination IME other than statutory OD:
i.
If the IME can be rescheduled within the 28-day decision timeframe,
withhold making a decision in the claim until the IW attends the IME; or
ii. If
the IME cannot be rescheduled within the 28-day decision timeframe, make the
initial determination based on evidence in the claim, which may include a PFR
obtained in lieu of the IME.
d. Evaluation
of substantial aggravation IME:
i.
If the reason for rescheduling is for good cause, continue processing
the claim; or
ii. If
the reason for rescheduling is not for good cause and the IW fails to appear
for the IME, send the Suspension Letter to suspend the compensation
and/or medical benefits requested based on the substantially aggravated
condition.
e. Other
requests, not including C-92 IMEs: Staff with supervisor to determine if the
request will be suspended or not until the IW attends the IME.
1. The
DEP physician must obtain prior approval for diagnostic testing that may be
needed to complete the evaluation of the IW.
2. The
CSS will create a “MSS Referral” work item for a decision and follow-up with a
phone call or email to the MSS.
3. The
MSS will:
a. Review
the Medical
Evidence for Diagnosis Determination (MEDD) policy and procedure or
other on-line 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
CSS will schedule an IME before determining an OD claim for the following
conditions:
a. Berylliosis;
b. Silicosis;
c. Asbestosis;
d. Coal
miner’s pneumoconiosis;
e. Firefighter
or police officer filing for cardiovascular or pulmonary disease; or
f.
Any other occupational disease of the respiratory tract resulting from
injurious exposure to dust.
2. Claims
services staff will obtain the minimum evidence required to schedule a
statutory OD IME as described in IC Resolution No. R15-1-01.
a. The
ODs included are:
i.
Silicosis;
ii. Asbestosis;
iii. Coal miners’
pneumoconiosis; or
iv. Any other
OD of the respiratory tract resulting from injurious exposure to dust.
b. The
required minimum evidence necessary to schedule the IME is:
i.
A written interpretation of x-rays by a certified “B reader” or a
high-resolution computed tomography;
ii. Pulmonary
function studies and interpretation by a licensed physician; and
iii. An opinion of
causal relationship by a licensed physician.
3. Additional
evidence that can assist the DEP physician with IMEs for berylliosis,
cardiovascular, pulmonary (including asbestosis) or respiratory disease
incurred by firefighters or police officers includes:
a. POR report
which provides an opinion on causality;
b. Detailed
work history that indicates toxic and/or chemical exposures (claims staff
should obtain information regarding all previous employment to determine the
employer of record);
c. Medical
history inclusive of:
i.
Chief complaint;
ii. History
of present complaint and illness;
iii. Past medical
history (childhood illnesses, accident, hospitalizations, allergies, etc.);
iv. Family
history;
v. Review
of systems;
vi. Pre-existing
conditions;
vii. Diagnostic tests
(i.e., toxicology tests, auditory exams, MRI, or CT-scan);
viii. Smoking history;
ix. Prescription
medications;
x. Other
drugs, substance abuse, illicit drug use; and
xi. IW’s
outside interests or lifestyle that would indicate toxic/chemical exposures.
4. The
CSS or MSS may combine the following exam questions with the initial allowance
questions:
a. TT
eligibility;
b. SL;
or
c. EOD
in unusual circumstances, and after staffing with BWC Legal.
5. The
CSS will issue an initial determination order within 28 calendar days from
receipt of the report from a statutorily required IME.
6. See
the Occupational
Disease Claims policy and procedure for additional information.
1. The
CSS may obtain an IME for the initial determinations of claims other than those
required by statute.
a. The
CSS must obtain MSS review or staff with a supervisor before scheduling an IME
for initial determination.
b. Unless
otherwise approved by a supervisor, the CSS must obtain the IME and issue a
decision within BWC’s 28-day determination timeframe.
2. The
CSS or MSS may combine the following exam questions with the initial allowance
questions:
a. TT
eligibility;
b. SL;
or
c. EOD
in unusual circumstances, and after staffing with BWC Legal.
1. Responsible
Parties
a. The
MSS will be responsible for taking action on AA Physical and RSD/CRPS IMEs; and
b. The
CSS will be responsible for taking action on AA Psychiatric IMEs.
2. Depending
upon the issue, the CSS or MSS will determine the need for and attempt to
obtain medical evidence according to the Medical
Evidence for Diagnosis Determination (MEDD) policy and procedure prior
to scheduling an IME for the allowance of additional conditions.
3. The
CSS or MSS will add the condition to be examined to the claims management
system prior to scheduling an IME and request that the condition description be
modified if necessary.
4. The
CSS or MSS may combine the following exam questions with the AA questions:
a. Evaluation
of substantial aggravation;
b. Claim
reactivation;
c. TT
entitlement;
d. TT
entitlement after MMI; or
e. SL.
1. Prior
to scheduling an EOD IME, the CSS will:
a. Verify
that a job description for the injury position is in the claim or request one
if necessary; and
b. Contact
the POR/treating physician prior to scheduling an IME to ask about the EOD,
which may be done by using the MMI Clarification Letter to Treating
Physician found on COR.
2. The
CSS will create the “MSS Referral” work item.
3. Upon
receipt, the MSS will:
a. Determine
whether an IME is appropriate;
b. Select
the appropriate physician specialty; and
c. Modify
the work item for QA.
4. For
90-day IMEs only, the CSS will create the:
a. 90-day
exam scheduling case; and
b. “MSS
QA” work item.
5. The
CSS may schedule multiple EOD IMEs if warranted by the conditions in the claim
(e.g., claim is allowed for psychological and physical conditions).
6. The
CSS will schedule an EOD IME for all conditions in the claim that the treating
physician(s) identifies are currently preventing a full duty release to the job
IW held on the date of injury.
7. If
an IW is being treated concurrently by two physicians, most often for
psychological and physical conditions, both treating physicians are required to
complete and submit a Physician’s Report of Work Ability (MEDCO-14). If
the physicians identify physical and psychological conditions as preventing a
full duty release to the job the IW held on the date of injury, the CSS will
schedule EOD IMEs for both the physical and psychological conditions.
8. If
not examining on all conditions, the CSS will enter a note indicating the
reason. Reasons for not examining on all conditions include, but are not
limited to:
a. The
IW was previously found MMI on some condition(s) in a claim and there has been
no additional treatment for the condition(s) found MMI;
b. There
is a condition allowed for substantial aggravation of a pre-existing condition
which is no longer payable; or
c. Other
times as advised by the local BWC attorney.
9. Prior
to scheduling, the CSS will review any prior EOD IME report(s) for the
conditions being examined and document in notes if any recommendations for
treatment were made by the DEP physician and if those recommendations were
acted upon or not.
10. The CSS will schedule an EOD
IME at the time indicated by the examining physician in a prior EOD IME if the
IW is receiving TT compensation at the time, unless there is a good reason,
staffed with a supervisor and documented in notes, for not scheduling an IME.
11. 90-Day Exam
a. The
CSS will schedule an EOD IME within 30 calendar days of the first payment of 90
consecutive days of TT compensation as required by the statute.
b. If
the treating physician provides a statement that the IW is MMI, a 90-day exam
is not scheduled.
c. The
EOR or BWC may waive the 90-day exam.
i.
The CSS will evaluate the claim to determine if a waiver should be
considered. Issues to consider include:
a) Surgery
is scheduled or was recently performed;
b) Type of
surgery and mode of anesthesia;
c) Normal
recovery time for surgery;
d) Post-operative
passive physical therapy (PT) is being performed;
e) The
IW remains hospitalized for the allowed conditions;
f)
Referral for or active participation in a vocational rehabilitation plan
is underway;
g) The
disability management coordinator’s (DMC) recommendation on potential success
and IW’s compliance with vocational rehabilitation plan;
h) Projected
discharge date from inpatient hospitalization and normal healing times;
i)
Notes from POR/treating physician documenting the IW’s progress in
treatment plan; or
j)
Other medical factors that justify waiving an IME.
ii. The
CSS will contact the employer of record if it is determined that a waiver is
advisable.
a) The
employer may agree to the waiver verbally by phone or in writing, using a
MEDCO-6 or equivalent form.
b) The waiver
information obtained must include:
i)
The name and title of the person requesting or agreeing to waive the
IME;
ii) If
the waiver is temporary or permanent;
iii) The reason the
IME is waived; and
iv) When the claim
is to be reviewed again to consider rescheduling the IME if the waiver is
temporary.
c) If
the employer agrees to waive by phone, the CSS will send the 90-Day Exam
Agreement to Waive letter found on COR to the employer and employer
representative.
d) The waiver
may be permanent or temporary. If the waiver is:
i)
Permanent, the CSS will update the exam scheduling information in the
claims management system and no 90-day exam will be conducted, but an EOD IME
may be scheduled when appropriate.
ii) Temporary,
the CSS will review the claim at the end of the waiver period indicated and
either recommend an extension of the waiver period or schedule the 90-day exam.
e) The injury
management supervisor (IMS) may waive the IME if the employer:
i)
Fails to respond to the request to waive the IME; or
ii) Is
out of business.
f)
Upon waiving the IME, the IMS will determine a future date for the IME.
g) Upon
receipt of the 90-day exam, the CSS will set a follow-up work item to review
for reexamination as recommended by the physician.
i)
If the IW is still receiving TT, the IW will be referred for a new EOD
IME.
ii) If
the IW returns to work or reaches MMI, the EOD IME is no longer necessary.
12. 200-Week Exam: The CSS may
schedule an EOD IME after payment of 200 weeks total of TT compensation.
13. Other EOD IMEs: The CSS may
schedule an EOD IME whenever necessary for management of a period of disability
when the IW is receiving or has requested TT.
14. Psychiatric Conditions
a. Prior
to scheduling an EOD IME for psychiatric conditions, the CSS will:
i.
Send an e-mail to the MCO case manager as notification that an EOD IME
for a psychological condition is being considered.
a) The
purpose of the email is to gather any input the MCO case manager may have
regarding pending IME.
b) The CSS
will set a work item for MCO email response within two calendar days.
ii. Request
the following data reports and image them into claim file as MISC document
type:
a) Psych
Detailed and Summary Medical Bill History for Claim for the six months prior to
the allowance of the psychological condition to present; and
b) RX drug
review for the previous two years.
b. The
MCO will:
i.
Respond to BWC CSS’s email regarding IME input within two business days.
ii. Enter
a thorough treatment compliance summary claim note within five business days
from the CSS’s initial email, to include:
a) The
IW’s compliance with current treatment regime;
b) The amount
of treatment provided and specific periods over which it was provided; and
c) Identification
of gaps in treatment and an explanation for such gaps, if known.
iii. The CSS will
follow-up with the MCO case manager if there is no response after five calendar
days.
a) The
CSS will staff with a supervisor if unable to obtain a response from the MCO.
b) Depending
on the result of the staffing, the CSS will then:
i)
Continue to attempt to obtain a response from the MCO; or
ii) Move
forward with scheduling the IME.
iv. Provide
up-to-date treatment reports for psychological counseling and medication
management.
15. The CSS will create the AA
Psych exam scheduling case and the “MSS QA” work item at the same time.
16. The CSS or MSS may combine
the following exam questions with the EOD questions:
a. TT
entitlement (in limited circumstances);
b. AA;
c. Evaluation
of substantial aggravation of a pre-existing condition; or
d. SL.
17. See the Temporary
Total Compensation policy and procedure for information about
additional processing when the outcome of an EOD IME is a finding of MMI.
1. The
CSS will grant a request for SL without scheduling an IME when sufficient
medical evidence is present in the file to support the award.
2. The
CSS will refer requests for SL based on loss of use to the MSS for review to
determine if an IME is needed.
3. The
CSS or MSS may combine the following exam questions with SL exam questions:
a. Initial
determination;
b. TT
entitlement;
c. TT
entitlement after MMI;
d. AA;
e. EOD;
f.
Claim reactivation; or
g. Evaluation
of substantial aggravation of a pre-existing condition.
1. If
an IME is indicated for claim reactivation, the CSS must schedule the IME and
obtain the report in order to make the reactivation decision within 28 calendar
days of receipt of the request unless otherwise approved by a supervisor.
2. The
CSS or MSS may combine the following exam questions with claim reactivation
exam questions:
a. Initial
determination;
b. TT
entitlement;
c. TT
entitlement after MMI;
d. AA;
e. EOD;
or
f.
Evaluation of substantial aggravation of a pre-existing condition.
1. ADR
IMEs may be completed by a BWC-certified physician who is not on the DEP.
2. Failure
to appear for an ADR IME for reasons other than good cause may result in the
suspension of medical treatment in the claim.
3. See
the Alternative
Dispute Resolution Exams policy and procedure for additional
information.
1. The
CSS will schedule an IME to determine if a condition allowed for the
substantial aggravation of a pre-existing condition will be abated only if the
IW is receiving or requesting medical treatment or compensation based on the
condition.
2. Employer
requests to abate a condition allowed for substantial aggravation will be
referred to the IC without scheduling an IME.
1. The
exam scheduler will 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 will:
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
c. If
the IME report is not received after 21 calendar days, notify BWC’s DEP Central Unit.
2. Claims
services staff will image the IME report into the claim upon receipt, even if
an addendum will be requested.
3. The
MSS will complete a quality assurance review of all IME reports and enter a
claim note.
a. The
reviewer will 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 and dated and
contains the DEP physician’s signature; and
iv. That 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.
b. A
completed C-143 must be included with EOD IME reports.
c. Following
the quality assurance review, the MSS will:
i.
Enter a note in the claims management system, summarizing the contents
of the report; and
ii. Complete
the “Medical Referral Completed” work item if an addendum is not requested.
d. The
MSS or IMS will report quality assurance problems to BWC’s DEP Central Unit.
4. The
CSS will review IME reports to determine the necessary action.
5. The
CSS will:
a. Provide
a hard copy of any IME report to a party to the claim, upon request;
b. Notify
the MCO case manager by email or phone that the IME report is imaged in the
claim and discuss treatment recommendations, if necessary; and
c. Send
IME reports to the IW’s physician of record (POR) or treating physician by
mail, fax, or email.
1. The
CSS will schedule an IME immediately upon receipt of an Interlocutory Order
from the IC requesting that an IME be scheduled.
2. Claims
services staff will follow the same procedures (e.g., contact for availability
selecting DEP physician) as are followed for scheduling a BWC IME.
3. Upon
receipt of the IME report, the CSS will:
a. Complete
a notice of referral (NOR) to the IC to return the claim to the IC to be reset
for hearing; or
b. Continue
processing the claim as ordered by the IC.
4. See
the Notice
of Referral to the Industrial Commission policy and procedure for
additional information on referrals to reset for hearing.
1. Prior
to obtaining a PFR for the allowance of additional conditions, the CSS or MCS
will determine the need for and attempt to obtain medical evidence according to
the Medical
Evidence for Diagnosis Determination (MEDD) policy and procedure.
2. Except
for C-92 PFR referrals, if the CSS or MCS determines that a medical review is
necessary, the claim will be referred to the MSS. For C-92 PFRs, refer to the C92
Independent Medical Examinations (IMEs) and Physician File Reviews (PFRs)
policy and procedure.
3. Upon
receipt of a referral, the MSS will:
a. Make
the decision on whether a PFR is warranted, utilizing the criteria detailed in
the policy above;
b. Ensure
equitable selection and distribution of PFRs to DEP physicians based upon
Claims Operations guidelines;
c. Enter
a note in the claims management system noting their decision and detailing the
criteria used in making the decision; and
d. If
the MSS determines that a PFR:
i.
Is not warranted, the MSS will complete the “Medical Referral
Completed” work item.
ii. Is
warranted, the MSS will:
a) Obtain
and image in the claim the Medical Servicing Providers Report; and
b) Create a
medical file review case in the claims management system.
1. When
referring a claim for a PFR, the MSS will complete a Physician Review
(MEDCO-21) form.
2. The
MSS will then:
a. Email
the form to the selected DEP physician; and
b. Image
the form and a copy of the email (with MSS last name redacted) to the claim
file.
1. The
MSS that requested the PFR will review 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 the PFR, the MSS will:
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 will report this to
BWC’s DEP Central Unit.
2. Upon
receipt of the DEP physician’s report, the MSS who made the referral will
complete a quality assurance review of the report.
a. The
reviewer will 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 dated; and
iv. That 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.
b. The
MSS or IMS will report quality assurance problems to BWC’s DEP Central Unit.
3. Following
the quality assurance review, the MSS will:
a. Enter
a note in the claims management system, summarizing the contents of the report;
b. Complete
the “Medical Referral Completed” work item if an addendum is not requested; and
c. Image
the report into the claim immediately, even if an addendum is requested.
1. Requests
a. The
MSS will request an addendum when the report contains an error, does not
address all questions asked of the DEP physician, or additional information is
needed.
b. If
an addendum is necessary because the DEP physician states the supporting
medical evidence is insufficient and mentions specific supporting medical
evidence that is needed, the MSS will refer the issue back to the requestor to
obtain the missing information.
c. CSS,
MCS, or CA will:
i.
Determine if the evidence needed exists and is available by contacting
the MCO to request;
ii. Obtain
the required evidence;
iii. Refer to the MSS
to process the addendum; and
iv. If the
requested evidence does not exist, document, and continue processing the
request.
d. When
the MSS requests an addendum, the MSS will:
i.
Summarize the need for the addendum in a note in the claims management
system;
ii. Send
an email to the DEP physician requesting the addendum and image the email to
the claim file; and
iii. Follow-up with a
written request for the addendum using “Ad Hoc” correspondence in the claims
management system, copying all parties to the claim.
e. The
physician has five business days from the date of the addendum request to
submit their report.
f.
If the addendum has not been received, the MSS will follow up in six to
eight calendar days from the date of the addendum request.
2. Receipt
a. Upon
receipt of the addendum, the requesting MSS will:
i.
Complete a quality assurance review of the addendum; and
ii. Enter
a note in the claims management system, summarizing the outcome of the review.
b. Upon
notice that the addendum has been received, the CSS, MCS, or CA:
i.
Will send copies of the addendum to all parties to the claim, if
requested; and
ii. May
wait to mail copies of the original report until the addendum is received.
1. Initial
Employer-Scheduled IMEs
a. The
employer may require that the IW be examined by a physician of the employer’s
choice one time on any issue asserted by the IW or their POR.
i.
If, without good cause, the IW refuses to submit to an IME scheduled by
the employer or refuses to release or execute a release for any medical
information, record, or report required to address an issue related to his/her
claim, the employer may file a C-86 requesting the IW’s claim be suspended
during the period of refusal.
ii. BWC
will complete a NOR to the IC citing the C-86 filed by the employer.
iii. The decision to
suspend the claim is within the jurisdiction of the IC.
b. See
the Industrial
Commission Suspensions policy and procedure for additional information.
2. Subsequent
Employer-Scheduled IMEs
a. If a
claim is pending before the IC and the employer requests another IME, claims
services staff will review the claim for recent IMEs.
i.
As it concerns authorization of TT, an IME performed within the past 30
calendar days is regarded as “recent”.
ii. If
the question involves an AA alleging a causal relationship to the allowed
injury/occupational disease, an IME performed within the past 60 to 90 calendar
days may be regarded as “recent” (depending on the nature and type of the
condition and/or disability).
b. After
reviewing the claim, claims services staff will determine whether the issue is
within BWC’s jurisdiction and immediately take appropriate action on the
request. If the issue:
i.
Is within BWC’s jurisdiction (e.g., TT, AA), claims services
staff will:
a) Issue
a subsequent order if the decision is to allow the additional IME; or
b) If BWC
determines that the request should be denied (e.g., IW recently examined by a
physician selected by the employer on same matter) for any reason, claims
services staff must refer the request to the IC for further consideration.
ii. Is
not within BWC’s jurisdiction, BWC must complete a NOR to the IC for
further consideration.