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

Category: Medical Providers (Page 2 of 18)

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.

L&I Claim and Arthritis Around the Spine – A Challenging Medical Condition

Recently, I’ve encountered an interesting diagnosis in several L&I claim matters in Washington State. The name of the condition is diffuse idiopathic skeletal hyperostosis (or DISH in short). It relates to arthritis mostly around the spine. Sometimes, we encounter the condition in the context of work injury involving the lower or upper back.

 

Arthritis in the spine area

Diffuse idiopathic skeletal hyperostosis is an arthritic condition. It happens when various musculoskeletal structures such as ligaments and tendons harden overtime. The condition is most common around the ligaments and tendons of the spine. However, it can also manifest itself in the hips, knees, shoulders, feet, and hands.

 

Some of the most common symptoms include stiffness, decreased mobility, and pain. After a work injury, many people report experiencing the symptoms especially upon waking in the morning. Over time, diffuse idiopathic skeletal hyperostosis can cause bone spurs around the affected areas. Then, if bone spurs form, they can also cause additional inflammation and impact nerves in the area. Unfortunately, depending on the areas in question, bone spurs that impact nerves can become quite dangerous. Moreover, they require surgical intervention. However, it’s important to note that many people do not experience any symptoms. Frequently, medical doctors diagnose the condition after performing imaging studies following an acute workplace injury.

 

A unique arthritis condition

Interestingly, diffuse idiopathic skeletal hyperostosis is largely an asymptomatic condition. On top, it’s an interesting condition for other reasons. First, medical professionals still do not fully understand its causes. In fact, various medical sources suggest that causes include genetics and the aging process. Some studies imply causes such as inflammation, metabolism, and possibly body mechanics. Furthermore, another interesting feature of the condition is that it impacts certain types of people. For example, it’s more frequent in men, especially over 50 years old.

 

Individuals who have diabetes or conditions that raise insulin levels also have higher likelihood of developing the condition. Additionally, researchers found some connections to certain acne medication and excessive vitamin A intake or production. Finally, other sources found that diffuse idiopathic skeletal hyperostosis might relate to repetitive heavy lifting.

 

Challenging condition in the workers’ compensation claim setting

We can all agree that this type of arthritis has unusual features. Also, it can be very difficult to diagnose the condition. Hence, it’s also difficult to handle diffuse idiopathic skeletal hyperostosis under an L&I claim. Personally, in the cases I encounter, the individuals didn’t know they had the condition. Surprisingly, doctors discovered the condition while treating clients after an industrial injury or workplace accident.

 

Naturally, the discovery of the condition raises questions about the origins of the symptoms that these individuals are experiencing. Do their symptoms originate from their work injury? Do their symptoms originate from diffuse idiopathic skeletal hyperostosis? Is it a combination of the two? Would the condition become symptomatic if it wasn’t for the industrial injury?

 

Conclusion

We have to leave these questions to the medical experts to answer. However, the difficulty is that there’s a lack of consensus amongst medical professionals. Therefore, it is common to have differing opinions in response to each of these questions. Consequently, it means that there’s much higher likelihood to run into disputes when encountering the condition in an L&I claim or self-insured employer claim. Should L&I cover the condition under the claim? If not, why not? And so on.

 

Some work injury claimants intend to pursue acceptance of the condition under their workers’ compensation claim. Therefore, it’s important to have strong medical opinion. These medical opinions must explain the causal connection in light of the unique nature of this condition.

« Older posts Newer posts »