Sometimes workers’ compensation cases have diagnostic or therapeutic challenges. In those cases, attending providers are allowed to arrange most consultations with specialists without obtaining prior authorization.
Treatments that do not require authorization
It’s true! But, for some reason both injured workers and treatment providers rarely believe me. Don’t take my word for it. Here is what L&I says about it: https://lni.wa.gov/patient-care/authorizations-referrals/authorization/retrospective-authorization. There are only two exceptions to this rule:
(1) mental health evaluations require prior authorization; and
(2) Independent Medical Examinations (IMEs) can only be arranged by the Department of Labor and Industries (L&I) or Third-Party Administrator.
That leaves the door open for many kinds of consultations to happen without prior authorization.
In fact, there are many treatments that do not require pre-authorization. Every year L&I publishes an updated fee scheduled and payment policy (MARFS) excel sheet. These sheets contain a column identifying whether an item requires pre-authorization. Did you know most items do not require pre-authorization? While surprising, it is a terrific benefit for injured workers!
More information and conclusions
L&I wants to keep claims moving forward. There’s no doubt about it. That means there is less red tape for making referrals and providing treatment than providers and injured workers often realize. If a claim is presenting challenges, so long as the referral is not for an IME or mental health evaluation, providers should feel empowered to arrange the referrals they feel are appropriate. If treatment providers are reluctant to schedule consultative appointments, injured workers should feel empowered to tell providers that pre-authorization is not required.
For more information, the L&I website contains lots of information regarding treatment authorizations and referrals.
Do you know any workplace heroes? Now is the time to nominate them for the 2019 Governor’s Lifesaving Awards.
Recognizing lifesaving workers in Washington State
L&I and the Washington State Governor’s office are calling for nominations for the 2019 Governor’s Lifesaving Awards. The purpose of the award is to recognize heroic workers whose quick actions have made the difference between life and death. According to the L&I newsletter, there are workplace lifesavers in Washington State every year. The Governor’s award is a chance to recognize them for their heroic deeds.
The 2018 award recipients included six Washington State Department of Transportation (WSDOT) workers. Some of these workers saved two people and two dogs from a canoe that tipped over into the frigid waters of Hood Canal. The others are coworkers who rescued a fellow worker that was pinned by a remote-controlled demolition machine.
Nominating workplace heroes
Now through June 30, 2019, nominations are open for the 2019 award. To be eligible, the heroic act must have occurred during work hours between June 1, 2018 and May 31, 2019. All workers covered by the Washington State Industrial Insurance Act are eligible for nomination. In addition, the Governor’s office gives a humanitarian award to people who engaged in a heroic act, but despite best efforts, were unable to save the victim’s life.
According to the L&I Newsletter, the 2019 award recipients will be featured guests at the Governor’s Industrial Safety & Health Conference. The conference will take place on September 25, 2019 at the Tacoma Convention Center. To nominate someone for the award, you can complete the online nomination form at www.gishab.org. You can find out more information about this award by calling 1-888-451-2004 or emailing firstname.lastname@example.org.
I’m often asked if injured workers can collect unemployment benefits while their workers’ compensation claim is open. In general, the short answer is – usually no. Injured workers cannot collect unemployment benefits and time-loss compensation benefits at the same time. Unemployment benefits are for individuals who are willing and able to work but are unable to get a job. Time-loss compensation is for people who are unable to work because of work injuries or occupational diseases.
Examples when injured workers can collect unemployment benefits
There are some circumstances whereby injured workers can collect unemployment benefits. The best example I can think of is when an injured worker is declared as capable of working but haven’t obtained a job yet. Usually, once a vocational counselor determines that an injured worker can return to work, then time-loss compensation benefits are immediately terminated. However, finding that an injured worker can return to work doesn’t mean they have a job to return too. When this happens, unemployment benefits can be a saving grace. They can provide the injured worker with some income and access to job search resources through WorkSource.
In summary, it is important for injured workers to know they cannot simultaneously collect unemployment and time-loss compensation benefits. However, under certain circumstances, it is fine to collect unemployment benefits. For example, when searching for a job or for options to return to work after an industrial injury or occupational disease. Additionally, WorkSource can provide many useful resources. These resources include help writing a resume, searching for available positions and work opportunities, and others.
Last week L&I announced that a food service employee will be required to repay more than $11,000 in disability payments. The employee was caught working at a nursing home and hotel while collecting time-loss workers’ compensation benefits. Time-loss benefits are only payable when an injured worker is incapable of working. L&I provides these benefits while the injured worker is recovering from an industrial injury or occupational disease.
Workers’ compensation willful misrepresentation and fraud
Under RCW 51.32.240, it is “willful misrepresentation” for an injured worker to obtain workers’ compensation benefits they are not entitled too. Willful misrepresentation includes intentional, conscious, or deliberate false statements. It also includes misrepresentations, omissions, and concealment of facts. The key is that these actions are with the intent of obtaining or increasing workers’ compensation benefits. Injured workers failing to disclose work-type activities that results in income, repeatedly, may face willful misrepresentation.
If L&I determines that willful misrepresentation occurred, it can charge the injured worker 50% penalty in addition to recouping over-payments. On top, if L&I thinks it is warranted, it will seek criminal fraud charges. However, it is important to note that criminal charges are for fraud. And recall that fraud has a different legal definition than willful misrepresentation.
Misunderstanding and confusion among injured workers
Many injured workers that I represent do not understand the meaning of willful misrepresentation and fraud. The lack of understanding causes anxiety regarding simple activities and daily living. Some injured workers fear that activities such as grocery shopping or volunteering could be willful misrepresentation or fraud. To ease anxieties, I often remind injured workers that being totally disabled doesn’t mean being physically or mentally helpless. In other words, injured workers should certainly engage in appropriate activities.
L&I has an active fraud division to investigate alleged willful misrepresentation. According to L&I: “workers’ comp fraud is not a victim-less crime. Cheaters take resources away from legitimately injured workers and raise costs for employers and employees who pay into the […] system”. Most importantly, injured workers who collect appropriate benefits and are not engaging in intentionally deceptive behavior have nothing to worry about.