Tara Reck, Managing L&I Attorney at Reck Law PLLC - Workers' Compensation Attorneys

Category: Medical Providers (Page 1 of 17)

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. 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.

 

Rules for self-insured medical exams

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?

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.

 

The first attending provider

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 own 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.

 

Request to 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.

PPD Rating in L&I Claims (and Why Most Doctors Won’t Do It)

After a workplace injury or work illness, some people are left with some sort of permanent disability. In legal terms, we call it permanent measurable residuals. Usually, these work injury claimants are eligible to a permanent partial disability award (or PPD award in short). Timewise, the Department of Labor and Industries (L&I) provides the PPD award when an L&I claim closes. Furthermore, the same goes for self-insured employers and insurance companies, like Sedgewick.

 

PPD rating

L&I doesn’t decide the amount of the PPD award arbitrarily. In fact, it’s based on PPD rating and the L&I PPD award schedule. First, your L&I claim doctor must consider the area of the body involving the work injury or industrial disease. The body parts in question determine the methods they are going to use to decide the PPD rating. Here, there are 2 different categories.

 

If the industrial injury or workplace illness affects a body part that doctors can amputate, then doctors base the PPD award on the American Medical Association guides. However, if amputation is not an option, then the doctors base the PPD award on various categories in the Washington Administrative Code (WAC).

 

 

Amount of PPD award

The PPD award schedule is the official term for calculating the PPD payout. The monetary amount of the PPD award depends on the PPD rating. For reference, L&I maintains a PPD awards table. The table shows the payment amount versus the PPD rating decision. Interestingly, the award rate also depends on the date of the work injury (or the manifestation date for a workplace disease). Once the L&I doctor makes the PPD rating, L&I looks up the award schedule to find the PPD award value. Furthermore, additional information about this process can be found under the PPD section of the L&I website.

 

I’ve been representing work injury claimants for many years. Over time, I came to realize that many L&I attending doctors don’t do PPD ratings. Consequently, when your L&I claim is getting ready to close, L&I usually sends you to an independent medical exam (IME). There, the IME panel confirms your maximum medical improvement and gives a PPD rating. However, the methods for finding the PPD rating are relatively straightforward and simple. Therefore, I’m confused as to why more attending doctors don’t provide PPD ratings regularly.

 

Recommendations and personal thoughts

Personally, I think (and hope) that many more attending providers should perform PPD ratings. First, in general, attending doctors are in the best position to know their patients’ permanent residuals. Hence, it should be fairly simple for them to determine the appropriate rating method and measurements. Second, it would allow work injury claimants to feel more confident that their PPD rating and compensation are fair and proper. I get so many calls from injured workers who are concerned that IME providers didn’t take accurate measurements. Unsurprisingly, PPD readings by attending physicians are bound to limit these types of concerns. Finally, if more attending doctors perform PPD ratings, we wouldn’t need so many IME doctors and appointments. That way, we can keep L&I claim costs down. Moreover, we could reach L&I claim closure more quickly and efficiently, once workers reach maximum medical improvement (assuming no further vocational issues).

 

I often ask L&I doctors why they don’t perform PPD ratings. Sadly, the most common answer I get is that they don’t feel competent and lack training. For me, it seems that this is a relatively easy problem to fix. All we need is little education, some training, and someone within the L&I ranks with enough energy to push for change.

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