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

Category: Medical Treatment (Page 1 of 33)

The L&I Claim SIMP Program for Chronic Pain Management

Are you familiar with the SIMP program? SIMP is an abbreviation for Structured Intensive Multidisciplinary Program. More simply, it’s a chronic pain management program. L&I regularly refers work injury claimants to SIMP during L&I claims. In fact, L&I recommends SIMP for chronic pain when workers don’t respond to conservative care.

 

What is the SIMP program in L&I claims?

SIMP can be helpful when chronic pain interferes with your ability to work. Furthermore, SIMP is useful when work injury claimants develop dependency on pain medication. However, the program is a somewhat complex and expensive way to treat chronic pain.

 

The SIMP program is “structured”. That’s because workers receive care in a consistent manner. The care is regular and steady. It has a schedule for modules of assessment. In addition, it includes education, treatment, and follow up evaluations. During the program, caregivers custom-tailor plans to address specific treatment needs for workers.

 

Key parts of the L&I claim SIMP program for chronic pain

SIMP is also “intensive” because it requires 6-8 hours of daily treatment. The routine continues 5 days a week for up to 4 weeks. The program is also “multidisciplinary”: A team of providers with different yet complementary expertise provide the care. Moreover, providers address pain management in multiple ways. That includes traditional medicine, psychology, physical therapy, and occupational therapy.

 

Sometimes, the program also includes vocational services and nursing services. Finally, the “program” portion focuses on outcomes. To get there, the program offers coordination and goal-oriented processes. In fact, caregivers regularly measure and document the workers’ progress. Consequently, failure to make progress can result in discharge from the program.

 

Phases in the SIMP pain management program

If L&I approves a SIMP program, then 3 essential phases follow. The first phase is evaluation. The second phase is treatment. Then, the third is the follow up. Usually, Evaluation is a lengthy process. Program providers conduct a history review and physical exams. They evaluate the likelihood that the work injury claimant will benefit from the program. Plus, they develop a treatment plan during the evaluation. Upon completion, SIMP caregivers submit a report with their findings and recommendations.

 

After L&I approves the program, the work injury claimant enters the treatment phase. Treatment comprises several important components, which include:

  • Exercises
  • Cognitive behavioral therapy
  • Coordination of services
  • Education and skill development
  • Pain and function tracking
  • Ongoing assessment of unrelated conditions
  • Doing real or simulated work or daily functional tasks
  • Establishing return to work goals
  • Developing a discharge care plan.

When the plan completes, providers provide workers with a discharge report.

 

Finally, the Follow Up can last up to 6 months after treatment concludes. The goal of the follow-up phase is to reinforce pain management gains. On top, the follow-up supports return to work goals. Additionally, it helps identify setbacks or issues that require intervention.

 

Takeaways and conclusions

Work injury claimants must give good faith efforts to comply with SIMP treatment plans. After all, in theory, SIMP is ideal for treating complex chronic pain in L&I claims. However, there are ongoing debates as to whether such programs deliver on their promise.

 

Personally, as an attorney representing injured workers that regularly participate in SIMP, I see too few results. From my perspective, optimal outcomes on paper don’t match reality. I would like to see more attention and legitimacy to how workers feel about their own progress and symptoms. That said, SIMP is one of the only L&I-approved treatments for pain. That’s because pain is subjective. For that, I am grateful even if I don’t always agree with SIMP outcomes.

 

L&I Claim Reimbursement for Out-of-Pocket Expenses: Will They Pay Me Back?

Can work injury claimants pay out-of-pocket and get reimbursed later? For example, say I have an L&I claim. I need medication, massages, and braces. I also need therapeutic furniture, equipment, and medical procedures. So, can I just go ahead and pay? And then ask for reimbursement later? Surprisingly, in general the answer is – No!

 

Can I get reimbursed for L&I claim out-of-pocket expenses?

Interestingly, it’s very unlikely to get reimbursed from L&I for these kinds of expenses. The reason is coverage. While frustrating, you need to wait for L&I to make a coverage decision. That way, you can be sure that they’ll cover expenses. Don’t pay for services yourself. Moreover, if you decide to pay out-of-pocket, don’t plan on reimbursement.

 

However, L&I does reimburse for some limited out-of-pocket expenses. But there are only a few expenses that qualify. Usually, pre-authorization is required. Simply put, NEVER assume that L&I will reimburse you.

 

Will L&I reimburse me for any expenses?

The Department of Labor and Industries (L&I) will reimburse work injury claimants for certain expense. In fact, there are 2 categories for which they’ll pay you back. One is Travel. The other is Property. L&I will reimburse you if you travel for treatment, However, that’s only if you meet the following 2 conditions:

1) The treatment provider is more than 15 miles away from your home address; and

2) There are no other providers that can treat your condition within 15 miles.

Also, L&I assumes your home address is the address in your L&I claim file.

 

Meeting the criteria above is not enough. If you want a reimbursement, you need your claim manager to pre-authorize it. In practice, you need to tell your claim manager that you meet the 2 conditions. Then, ask them for pre-authorization. After that, the claim manager issues a letter pre-authorizing the travel reimbursement. You must have this letter before going to your appointment.

 

L&I reimbursement for travel and property expenses

If you have pre-authorization, then you must fill out and submit a Travel Reimbursement Request. On top, you must submit a copy of all expense receipts. If you meet the criteria and have pre-authorization, you’ll get reimbursement for parking over $10, tolls, and other travel expenses.

 

For property, L&I provides reimbursement for a limited number of personal items. For example, property you lost or that was damaged because of a workplace injury. These items include prescription, eye glasses or contacts, and clothing. In addition, it includes boots or shoes, and personal protective equipment.

 

Per L&I, for reimbursement, you need to complete and submit a Statement for Miscellaneous Services. The form itself makes it seem like there are plenty of things that qualify for reimbursement. Don’t be a fool! Regardless of what the form implies, work injury claimants rarely get payments for anything beyond the travel and property mentioned above.

 

Your L&I claim, your expenses

In short, only limited travel and personal property is eligible for reimbursement. It’s better to not count of it. Whenever possible, wait for L&I to make a coverage decision. Finally, if you think you qualify for travel reimbursement, then make sure you get pre-authorization first.

 

Late L&I Claim Filing: What Happens If I Delay Or Wait Long to File an L&I Claim?

People regularly call my office asking for advice about their L&I claim. Many times, they ask about common mistakes. More correctly, they want to know what mistakes to avoid. By far, the biggest mistake I see is when work injury claimants wait too long to file their claim. In the legal setting, we refer to it as “delayed claim filing”.

 

Do not delay your L&I claim filing

If you wait and delay claim filing, it can cause many issues. The most significant issue is – raising red flags for L&I and claims administrators. It’s unclear to them if your claim is even valid. I mean, if the claim is legitimate, then why wait so long to file? However, there are other problems with filing late. Follow-on issues include insurance coverage problems, delay in medical treatment, and difficulties in obtaining benefits.

 

By law, you have one year from the date of your work injury to file a claim. For an occupational disease (OD) claim – the limit is 2 years. In OD claims, the clock starts ticking when a medical professional notifies you (in writing) about your occupational disease.

 

Is your L&I claim valid?

Just because you have one to two years to file a claim, it doesn’t mean it’s wise to wait that long. If you wait, you’ll have to face claim validity questions. In my experience, this happens almost every time when employees don’t file a workers’ comp claim right away. It doesn’t matter if you wait one month or eleven months. Every time, filing delays call into question whether there was an injury in the first place.

 

Naturally, you can expect any logical person who suffers an injury to get immediate medical attention and file an L&I claim right away. That’s the though-process that claim managers follow. On average, out of ten claims that L&I rejects, at least eight involve filing delays.

 

Good reasons for waiting to file a workers’ compensation claim

Sometimes, work injury claimants have good reasons for filing late. Common reasons I see frequently include:

1) Not wanting to upset the employer;

2) Thinking the injury is minor and will resolve on its own; and

3) Begin afraid of the workers’ compensation claim system.

All these reasons are very understandable. They make sense. However, it’s best to not delay. None of these reasons are worth risking L&I claim rejection. Therefore, it’s best to report your injuries right away. Even if they are minor work injuries. It’s important to seek immediate medical attention and file a workman’s compensation claim promptly. Even if the injury turns out to be minor. It’s far better to have a claim than to litigate later after claim-rejection.

 

Filing a claim late can result in insurance coverage issues

Another common problem with waiting too long to file a claim is insurance coverage. Sometimes, when workers have an accident on the job or develop a workplace illness, they get medical attention right away. However, they may use private insurance to cover the treatment rather than filing a claim. Initially, it might seem easier and less burdensome. But later, it can cause confusion and complication. Especially if you file a claim afterwards.

 

Private insurance carriers aren’t happy when they learn they’ve been covering treatment for a work injury. After all, L&I or self-insured employers are responsible for workplace injury insurance coverage. Moreover, L&I or the self-insurer won’t have the medical records for your early treatment. Later in the process, they may disregard your early treatment when deciding to allow (or reject) the claim. Finally, switching billing from private insurance to workers compensation can create headaches for medical providers. Filing a claim without delay avoids these kinds of issues.

 

Medical treatment delays after a late L&I claim filing

Filing late can also mean treatment delays. These delays can occur when there are questions concerning the validity of the claim. For example, if L&I rejects your claim, you might have to file an appeal. After that, the appeal litigation process can take a long time. In fact, it may take more than a year to get a final decision. Even if they allow the claim without litigation, there’s still a risk of other delays. For example, treatment delay when switching between insurance carriers. Again, filing a claim without delay can dramatically reduce the likelihood of unnecessary delays.

 

Getting workers compensation benefits after filing a claim late

Work injury claimants can receive a variety of benefits. Medical treatment is one. However, there are many others. For example, wage replacement benefits such as time loss compensation or loss of earning power benefits, or vocational services. Securing these benefits can be challenging regardless of when you file the claim. In addition, if you file late, then you must obtain these benefits retroactively. However, it’s always difficult to obtain retroactive benefits. Sometimes it’s even impossible. This is another reason why workers must file an L&I claim right away.

 

Conclusions

In summary, there are many reasons for filing a workers’ compensation claim right away. Avoid delays and don’t wait long. It doesn’t matter what your reasons might be. There’s high likelihood of running into claim problems later. It’s not worth it. You must always submit an incident report at work. Then, go see a medical provider and explain your work injury or work-related condition. Medical providers will have the appropriate accident report forms. On top, they will complete and handle the provider’s initial report.

 

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