Category: Medical Providers (Page 9 of 18)

L&I Claim Medical Aid Rules and Fee Schedule

With an L&I claim or workers’ comp claim in Washington State, it can be very difficult to understand treatment payments, policies, and procedures. This is a big problem for L&I medical providers in the provider network (or MPN) and for people that have a work injury claim. For doctors, it’s challenging to know which billing codes to use. On top, it’s hard to tell the rates that the Department of Labor and Industries (L&I) pays for services. Finally, it’s unclear if and what services require pre-authorization.

L&I resources for medical questions

L&I created resources to address the challenges mentioned above. Unfortunately, many medical providers as well as work injury claimants don’t know that these resources exist or where to find them. Yet, questions about medical billing and fees arise in every workers’ compensation claim.

The L&I treatment policies are available in the Medical Aid Rules in chapter 296-20 of the Washington Administrative Code, or WAC in short. Reading or referencing the WAC can be frustrating and time consuming. After all, it’s code that people use mostly for legal purposes. Furthermore, not everyone is familiar with the administrative code writing style and language.

The L&I fee schedule reference

Fortunately, L&I has some useful and user-friendly tools on its website. For example, L&I publishes its annual Payment Policies and Fee Schedules, by year. One of the resources within these publications is a Quick Reference Card. Interestingly, this card contains the most common and frequently used codes. However, for services that are not available in the Quick Reference Card, there are several ways to find the fee schedule and payment policies.

Billing code lookup in an L&I claim

If you know a billing code, then L&I has a Fee Schedule Lookup tool that you can use. Here, simply enter the code and a box appears outlining coverage, fees, and authorization requirements. For example, for billing code 10004, we get the following information from the L&I website.

Even better, in cases where you must obtain pre-authorization, you can click the link that writes “Yes – Claim Manager”. After that, it redirects you to the pre-authorization form that you’ll have to use. Finally, it’s worth noting that many providers find it surprising that many treatments and services do not require pre-authorization.

L&I Claim and Workers’ Compensation Claim in Washington State: Common Mistakes and How to Avoid Them

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As a workers’ compensation attorney, the most common question I get is: “What mistakes should I not make in my L&I claim?”. There is no easy answer for this question. Interestingly, while there’s a clear definition for potential L&I claim benefits, there is no list of potential pitfalls.

Every L&I claim is different

Generally speaking, the administration process for every workers’ compensation claim in Washington State follows certain administrative codes. However, every claim is individual and different. Every work injury or work-related disease has its own challenges. Similarly, every claim outcome is ultimately unique to the person that suffered the work injury. However, from my experience as an L&I attorney, here are a few tips I can offer for avoiding common mistakes and keeping your workman’s comp claim on track.

Use common sense to avoid L&I mistakes

Throughout your L&I claim process, you will need to make many decisions and response to communications. Therefore, it’s very important to use common sense. You should do what is logical. Frequently, I see that people get very anxious and worry about not messing up their work injury claim. Meanwhile, they forget to be logical. You must avoid this common mistake. If it helps, take a step back and think about the big picture. If you use common sense and remain logical, that’s probably the easiest way to keep your workers’ comp claim on track.

Recovery first

The first and most important thing in an L&I claim is to focus on your recovery. Let’s be honest: Whether you got hurt on the job or developed an illness at work, you want to recover. Nothing is more important than your health. Realistically, if you let other claim issues get in the way, it can distract or even derail your path to recovery. I sometimes see work injury claimants prioritize the handling of their claim over their personal health, which may lead to unfortunate outcomes.

L&I mistakes: Pay attention

It’s extremely important to pay attention to everything that is going on in your workers’ compensation claim. I am well-aware that keeping track of all the small details can feel like a full-time job. However, it’s not helpful to ignore certain steps or bury your head in the sand. In fact, it’s necessary to know what’s happening in your claim so that you can follow through and take appropriate actions. Monitoring your L&I claim progress will also help you spot red flags early. It’s critical to read notices and decisions from the Department of Labor and Industries (L&I) and address any issues while you still have time.

Ask for help

Most importantly – don’t wait too long to ask for help. Many work injury claimants may never need help from an L&I attorney. However, that isn’t true for everyone. If certain issues arise in your claim, then don’t delay asking for help. Specifically, if an issue in your case is heading to the Board of Industrial Insurance Appeals (i.e., BIIA or Board), it is advisable to speak with a workers’ comp attorney immediately. Appeals before the Board have timelines and certain litigation schedules. Waiting too long to contact an attorney can make it difficult for any lawyer to get involved. Remember, your attorney will need time to get up to speed or to provide meaningful advice. Moreover, if you are looking for a workers’ compensation attorney, it’ll take them time to prepare a winning case.

Final comments

In summary, when you have an L&I claim, there’s no concrete list of black and white rules to follow. However, I always recommend people to remember the key principles above. Use common sense and focus on recovery. Over time, follow closely and pay attention to what is happening in your claim. Finally (and arguably most importantly), do not delay asking for help.

State-Funded L&I Claim Versus Self-Insured Employer Workers’ Compensation Claim: Some Differences

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A workers’ compensation claim here in Washington State can follow one of two administration paths. The term “state-funded claim” means that the Department of Labor and Industries (L&I) administers the workers’ comp claim. We often refer to such a claim as an L&I claim. Conversely, we refer to a workman’s compensation claim as “self-insured” (or self-insured employer claim) when the managing entity is a third party administrator (TPA). In fact, there are many TPAs out there, including Sedgwick, Corvel, Gallagher Basset, Helmsman, and others. Both work injury claim types follow the same basic rules and have the same available benefits. However, there are some important differences that warrant a deeper discussion.

Differences between L&I claim and self-insured employer claim

The first difference I notice often between the two types of claims is transparency. Here, with a state-funded L&I claim, the claim file documents like orders, notes, letters, reports, and treatment records are accessible online. Anyone (with permission) can log onto Claims and Account Center and browse the records. In general, documents are available as soon as L&I employees scan them into the system. If you are a work injury claimant, you can view documents at the same time they become available to L&I.

The same level of transparency is not available with self-insured employer workers’ compensation claims. With third party administrators, the claim file isn’t available online. A person with a work injury claim can request a copy of the file or any updates from the TPA every 30 days. The TPA has 15 days to send the file or the update. Therefore, there may be cases where work injury claimants are unaware of things that may be happening in their claim file.

If a TPA hires an workers’ compensation attorney or legal representative, some claim file materials may be withheld under attorney-client privilege protections. Hence, this lack of transparency can make it difficult for people with a work injury to follow what’s happening in their claim.

Confusion between the claim administrator and the employer

Some people that suffer an injury on the job find it difficult to distinguish between their employer and the TPA. Surprisingly, I often speak with folks who do not understand that the actions of the TPA aren’t necessarily the actions of their employer. Some work injury folks ask: “Why is my employer fighting my claim so hard, I thought we had a good relationship?”.

In actuality, the employer may have little or no awareness of what the TPA is doing on the workers’ compensation claim. This confusion is less common in a state funded L&I claim because there is a clear distinction between the employer and L&I.

Challenges in self-insured employer workers’ comp claim

In general, there’s a perception that a self-insured employer claim is more challenging than an L&I claim. Personally, I’m not confident that this is entirely true. Yet, self-insured workman’s comp claims indeed have some inherent challenges.

In my opinion, claim challenges arise due to lack of transparency and accountability. Also, increasing attorney involvement in self-insured cases is another contributing factor. With L&I claims, claim administration rarely involves an attorney. However, it’s very common for a TPA to hire a workman’s comp attorney to assist with claim administration. Some attorneys are more aggressive in their representation than others.

The Industrial Insurance Act does not have much legislation holding a TPA accountable for their actions. Albeit, there are some regulations that allow L&I to impose penalties on a TPA for unreasonably delaying benefits. However, in the big scheme of things, these penalties are relatively minor. Additionally, it takes a lot of documentation before L&I actually imposes any penalties. Consequently, it can be a long and difficult process to hold a TPA accountable for workers’ compensation claim administration failures.

Summary and takeaways

In conclusion, workers’ comp claims in Washington’s State can be either state-funded claims or self-insured claims. The claim benefits available to people that were hurt at work are essentially the same. But, the claim administrator overseeing the benefits is different.

Since self-insured workers’ comp claims involve a TPA, they often also involve an attorney. Furthermore, because claim files are not available online, staying on top of the claim progress and actions can be more challenging than with L&I claims.