Category: Medical Conditions (Page 4 of 19)

Self-Insured IME Exams: L&I Implements New Rules in Washington State

The Department of Labor and Industries (L&I) implemented new rules for self-insured independent medical examinations. In short, we call this exam a self-insured IME exam. These rules passed the legislative section during 2019-2020. I’m happy to share that the new rules officially kicked in on April 23, 2022.

Self-insured IME exams – The rules

There are several changes under the new regulations. The most significant updates are summarized below. The first change relates to IME scheduling and notices. Previously, self-insured claim administrators provided injured workers a 14 days notice before an IME. However, under the new rule, the new time window is 28 days.

The second major change has to do with the notice form. Moving forward, self-insurers must include a standard form to notify workers’ compensation claimants of an upcoming IME. The form is available on the L&I website (although I wasn’t able to find it). More importantly, the form mandates insurers to provide critical information to workers. For one, it has to include the reason for the IME request.

Disputing independent medical exams in self-insured claims

The third rule change focuses on IME disputes. Here, workplace injury claimants can dispute upcoming IME exams. Moreover, the worker’s attending provider can also dispute an IME. Either way, it’s important to file the IME dispute at least 15 calendar days before the exam. The dispute must specify the reasons why the IME is inappropriate. In turn, L&I may postpone the IME. Moreover, there’s a very interesting case when an IME exam is under dispute yet the claimant attends it. If L&I determines the IME was in violation of RCW 51.36.070, then the IME report can’t be part of claim administration.

No more infinite IME exams

The fourth area of change is around the number of IME exams. From here on, there’s a limit on the number of independent medical exams that self-insurers can request. The actual number depends on the underlying issues and the reason for the IME. For example, IME doctors can perform only one exam when contending a new medical issue. The purpose of the one-time IME is to resolve the new medical issue before issuing a final order.

The fifth and final change I wanted to cover is for case-progress IME criteria. This happens when self-insured claim managers request an IME for accepted conditions. More explicitly, L&I considers IME exams for accepted conditions as case-progress exams. Self-insurers can only request these exams when:

1) The worker is not receiving necessary and proper treatment; or

2) Treatment stalled without any real improvement to physical or mental conditions.

So – what’s next?

The new rules are fresh out of the over. They are so new that it isn’t clear how they’ll impact the claim administration process. However, I applaud L&I for adopting the new rules. Clearly, they help protect work injury claimants. The changes eliminate excessive and inappropriate IME requests. These unnecessary IME exams tend to impede and inhibit productive claim progress.

Changing an Attending Provider During an Open L&I Claim: What are the Rules?

/ L&I attorney / 2 Comments

I recently ran into issues with designating an attending provider. So, I decided to write this article to help shed some light on the topic. In L&I claims and self-insured employer claims in Washington State, the opinions of attending providers receive special consideration. Therefore, selecting the attending provider is an important decision. Can you choose your attending provider? Think you can change your attending provider? Let’s dive in and find out.

Attending provider – The first Step

After a work injury, to open a claim, a medical provider completes and files an initial Report of Accident (ROA) form. Many times, the provider that completes the form automatically becomes the initial attending provider. However, this designation can change.

First, it’s always important to remember that work injury claimants get to choose their attending provider. Sometimes, after a workplace injury, employers direct the injured worker to specific facilities. Usually, these are easily accessible urgent care type facilities. For example, Concentra, or occupational medicine divisions like Franciscan Occupational Medicine. Others include Kaiser Occupational Medicine and The Everett Clinic Occupational Medicine.

Choose your attending provider

People are often surprised to learn they don’t have to see these specific clinics. You can choose any attending provider you wish. The only requirement is – they must be part of the L&I medical provider network (MPN). More importantly, you can even transfer your attending provider during the claim! Below is some important information you need to know if you want to change providers.

Under RCW 51.36.010(2)(a) work injury claimants covered by the industrial insurance act receive proper and necessary medical and surgical services at the hands of a physician or licensed advanced registered nurse practitioner of the worker’s own choice. With one limitation: The location of the provider must be convenient for the injured worker.

Change attending provider

Under WAC 296-20-065, workers can freely choose a treating provider. More explicitly, it says that “no reasonable request for transfer to a network provider will be denied”. However, there are certain exceptions. If L&I denies your request, they must notify you. The Department of Labor and Industries (L&I) must also provide a reason for denial.

Some valid reasons for denying a request to change a provider include:

(1) When there are other providers that can give the necessary treatment. Here, their location must be more convenient to the work injury claimant.

(2) In cases where the new attending provider fails to cooperate with L&I rules.

(3) Whenever L&I pays ongoing time loss but there’s no reasonable progress towards returning to work.

(4) When you need special treatment which is outside the license or practice of the provider.

(5) If the claim administrator says the change is appropriate but the worker refuses or delays compliance.

(6) When the qualifications of the provider aren’t suitable to treat each of several accepted conditions.

Bottom line

If you want to transfer to a new attending provider, L&I might deny your request. When they do, please determine whether one of the exceptions above apply. Then, if none applies, you can elevate your request up the chain of command within L&I. As always, you can also contact a workers’ compensation attorney to discuss your options.

How to Prepare for an IME exam: 6 Steps You Must Follow

/ L&I attorney / 1 Comment

Work injury claimants call my office all the time asking for advice about IME exams. Many of them heard bad things about IME tests. They don’t know what to expect. Others ask how to prepare for the IME and what to do. The best advice I can give is to plan and be ready. To help, below are 6 steps that every work injury claimant must follow.

How L&I claims work

After an injury at work, you open a claim with L&I or your self-insured employer. From there, you get medical or mental treatment as appropriate. The Department of Labor and Industries (L&I) should cover your medical care. They also pay wage replacement benefits such as time-loss compensation. The attending provider is your go-to person for treatment under the claim. Your attending provider oversees your condition and refers you out as necessary.

One of the main turning points in every workers’ compensation claim is the IME. In fact, IME exams can cause L&I to stop paying benefits. It can also result in denying medical coverage. But first, let’s try to understand why L&I needs IME exams.

Why must I go to an IME?

L&I makes many decisions during your claim. It’s part of the claim administration process. For example, L&I decides to allow some conditions under the claim. They can also reject certain conditions. Similarly, your employer can push back and request to deny conditions. Furthermore, the employer can protest some monetary benefits.

Your claim manager or claim administrator is not a medical expert. They just follow process. Hence, whenever L&I needs input about your medical or mental condition, they can request an IME. According to L&I, the IME provides “objective medical-legal examination to establish medical findings, opinions, and conclusions”. After the exam, L&I receives the IME report. After that, they can make decisions in your claim to move it forward.

IME exams can be intimidating

Not surprisingly, work injury claimants are often nervous when they have an upcoming IME. Sometimes, I even get calls asking if a workers compensation attorney can get people out of having to go. The short answer is No. That’s unless there are special considerations or circumstances. Moreover, if you fail to attend an IME, then L&I can flag you as non-cooperative. In turn, L&I can penalize you for non-cooperative behavior. They can even suspend your benefits.

Prepare for IME exam

Here are 6 steps that every worker must follow before and after an IME exam.

#1 – Take an observer

You can bring an observer with you to the exam, except for mental health exams. For example, a family member or a friend can be an observer. The observer cannot disrupt the IME provider. However, the observer can watch the exam and take notes. The observer can also serve as a witness in case you need one later.

#2 – Go over the general timeline of your claim before the exam

IME doctors often comment about whether the worker is a “good historian”. In my experience, IME doctors that state that the injured worker is a “poor historian” are less favorable. You don’t need to know every little detail. You just need to explain what happened in your claim and when.

#3 – Practice describing your symptoms

It’s going to make it easier for everyone if you can communicate with the IME clearly. It’s important for you to accurately describe your symptoms without being overly dramatic. Practice telling the IME about your symptoms. In fact, you can practice with friends and family before the IME exam.

#4 – Listen to your body and give accurate feedback

The IME doctor will perform tests and maneuvers that require your response. It’s very important to listen to your body. This way, you can give honest and accurate feedback. If a test or maneuver doesn’t, it’s alright to say it does not hurt. Similarly, if a test or maneuver produces symptoms, it’s important to describe them accurately.

#5 – Pay attention

Pay attention to the circumstances of your examination and take notes. Write down things like what time the examination begins and when it ends. Take notes of whether the examiners review medical records. Also write down how many examiners are present. Track and record if they use measurement devices or medical tools.

#6 – Plan to review the IME report with your attending provider

In most cases, L&I sends the IME report to your attending provider. However, attending providers don’t always receive it. If they didn’t – you must make sure they get the report. Your attending provider must review the IME report. It’s very important to see how your provider reacts to the report. Therefore, you must schedule an appointment with your attending provider a few weeks after the IME. This appointment will give you a chance to discuss the report. It’ll also give your attending provider an opportunity to respond to L&I.