Category: Medical Treatment (Page 14 of 36)

L&I Workers’ Compensation Claim: Reality vs Expectations for Work Injury Victims

One challenging aspect of my job is to help work injury claimants set realistic expectations regarding their L&I claim. Very often, people have unrealistic presumptions after a work injury, for several reasons. One key reason is misinformation concerning how a workers’ compensation claim works. L&I claim reality can be very different than the worker’s expectations.

Misinformation and common mistakes

For me, it’s not easy to be the person delivering the reality check. However, it’s a critical part of my work. Moreover, it’s very important for anyone with a work injury claim to understand the true status of their L&I claim.

For example, many individuals think there’s a quick resolution to their workers’ compensation claim. Furthermore, almost everyone believes there will be a big payday. And, in the process, people tend to ignore the costs associated with the burden of proof. In fact, these are the most common unrealistic assumptions I encounter almost daily.

Quick resolution in L&I claim and self-insured employer claim

Very often, workers’ compensation claim disputes don’t have a quick resolution. That’s because there’s a process and procedure for everything. Every workers’ compensation attorney like me pursues legal remedies to their full extent to resolve disputes. However, these legal remedies involve assembling evidence.

Gathering evidence requires input from experts (such as medical doctors), filing protests, and filing appeals to the Board of Industrial Insurance Appeals (i.e., the Board). Moreover, it entails presenting evidence on appeal, and appealing to higher courts like Superior Court. Each of these legal remedies takes time. Furthermore, in most cases, we don’t have much control over the timeline. On top, if a dispute involves previously denied benefits, or terminated benefits, then it can be particularly frustrating.

L&I claim payments: A big payday is coming

Many work injury claimants believe their claim will result in a big settlement. While this indeed happens in some cases, I frequently find that people have inflated expectations. Frequently, false expectations arise after clients find incorrect information online. Other times, people hear stories about someone who cashed in big on their workers’ compensation claim.

In reality, workers’ compensation claim benefits in Washington State are set by the statute. Therefore, it’s relatively straightforward to estimate the value of an L&I claim on the basis of available benefits. As with everything, there may be exceptions relating to medical treatment and L&I calculations.

Unfortunately, the value of benefits is often surprising to people with a work injury claim. I always use the Permanent Partial Disability (PPD) award table as a very concrete example. For reference, an injury occurring in 2020, with total 100% bodily impairment, is only worth $214,222.98. This should tell you something about the relative value of benefits under an L&I claim or self-insured employer workers’ compensation claim.

L&I claim, burden of proof and costs

When the Department of Labor and Industries (L&I) makes a decision you disagree with, you may appeal the decision to the Board. However, the work injury claimant has the burden of proving that the decision is wrong. Here, for each type of benefit, there’s a specific burden of proof. With few exceptions, that burden requires presenting expert medical and vocational testimony.

Expert testimony is expensive. It can cost several thousand dollars for this kind of testimony. Moreover, the cost is the responsibility of the work injury claimant. Personally, with Board appeals, it can be tough for me to tell clients that we cannot simply submit records and reports to meet the burden of proof. Furthermore, the expert opinions must be stated on a more probable than not basis. It’s for this reason that every Board appeal almost always involves a discussion around costs versus potential benefits.

These are not easy conversations to have. They can be very upsetting to people after a work accident. Nonetheless, successful Board appeals are one of the most powerful tools that every L&I attorney has. Board appeals help ensure that each work injury victim receives the benefits he or she deserves under the law.

Personal experiences

Many years ago, as a young attorney, I found it incredibly difficult to discuss expectations with my clients. I didn’t want to upset or disappointed them. Over time, the years of experience taught me that having realistic expectations is the best way to avoid disappointment.

Presently, I’m now a lot more comfortable having straight forward conversations with my clients, to set realistic expectations. I think it’s critically important for work injury claimants and their workers’ compensation attorney to be on the same page. I wholeheartedly believe that all parties must align on claim outcome expectations and what it takes to achieve them.

L&I Control Over Medical Treatment: The MPN and Best Practices

/ L&I attorney / 0 Comments

Approximately 10 years ago, I remember attending a presentation with other workers’ compensation attorneys. The presenter was a representative of the Washington State Department of Labor and Industries (L&I). The main topic of discussion was rolling out the Medical Provider Network or MPN.

Concerns and challenges under the medical provider network

Every workers’ compensation attorney I know was understandably concerned. From our perspective, the MPN was merely an opportunity for L&I to control L&I claims. We feared that people with a work injury claim would have few providers to choose from. Moreover, we thought this would infringe on their ability to select their own medical provider. On top, we were suspicious of the requirement for providers to follow L&I’s “best practices”. Finally, we suspected that this MPN was more about cost savings than improving the quality of care.

I don’t think the Medical Provider Network turned out to be as terrible as we originally feared. However, not being as terrible as feared doesn’t mean it’s good. The MPN is problematic. I think the years have shown that our initial concerns over the MPN were valid. The MPN created challenges for people with a workers’ compensation claim to find a doctor or attending provider. This is especially true when work injury claimants need new doctors after the claim has been open for some time. Furthermore, finding treating psychiatrists has been incredibly difficult if not impossible.

L&I claim and best practices

Obviously, I’m very biased in my opinions. Naturally, I have the best interest of my clients and other work injury victims in mind. Therefore, I remain suspicious of L&I’s “best practices”. For example, according to L&I, the goal of their best practices is to improve quality of care and L&I claim outcomes.

From my perspective, best practices seem like a simple way for L&I to exert control over the medical aspects of a workers’ compensation claim and reduce costs. In fact, it’s not necessarily surprising for an administrative agency like L&I to have such goals. I think L&I has the obligation to eliminate excessive or unnecessary L&I claim costs. However, my concern is that best practices unfairly inhibit medical providers’ ability to use their own experience and judgment to appropriately treat people that suffer a work injury. Also, I think that following best practices creates more administrative work that burdens and frustrates providers.

My personal perspective

It’s clear that L&I is committed to maintaining the Medical Provider Network. It is here to stay. In fact, L&I has several pilot programs and initiatives to establish and test new best practices. Workers’ compensation claims are very complex. Hence, the ongoing initiatives try to tackle many aspects of medical claim management.

Medical providers already have many burdens without additional administrative work. Sadly, I find it very discouraging when medical providers avoid involvement in L&I claims because of the overhead. Simply put, they don’t want to be burdened with L&I claim administration demands. I genuinely applaud L&I’s efforts to improve the quality of care. At the same time, I’d like to see L&I taking steps to make things easier for providers. We must take steps to simplify processes and paperwork. Surely, it’ll make treating work injury claimants more appealing for medical (and other) providers.

l-and-i claim closure and medical expenses

L&I Claim Closed – Who is Paying for Future Medical Expenses?

/ L&I attorney / 0 Comments

What happens after my L&I claim closes? I get this question all the time. It’s one of the biggest points of stress for people after a work injury in Washington State. Moreover, this stress is particularly high for people that know they will incur additional medical costs after their L&I claim is closed. In this write-up, I’m hoping to enlighten workers about claim closure and who pays for future medical expenses.

Paying for medical expenses after L&I claim closure

Under WAC 296-20-124, the Department of Labor and Industries (L&I) will not pay for services after a workers’ compensation claim closes. However, L&I and self-insured employers are responsible to pay for services that relate to the claim reopening application. Furthermore, there are a couple of other important exceptions.

Workers’ compensation claim closure and payment exceptions

The first exception is for certain periodic medical exams. Here, L&I and self-insured employers must pay for certain periodic medical surveillance examinations. For example, these exams are very common in cases involving asbestos diseases. Generally, doctors recommend these exams under the medical protocol whenever they need to perform routine medical monitoring or maintenance.

Another exception is for medical equipment replacement. Under WAC 296-20-1102, L&I may cover repair or replacement of prosthetics, orthotics and other special equipment. However, after L&I claim closure, you need to get pre-authorization from the prescribing medical provider. Explicitly, your doctor needs to provide a document to L&I to explain the need to replace or repair the item. For example, your doctor will have to explain that the medical device incurred damages, broke, or is worn out. Finally, note that crutches, cervical collars, and lumbar and rib belts (as well as other low-cost orthotics) don’t require preapproval. Of course, there are also limitations on the kinds of items that L&I will cover. As an example, L&I will not cover inversion traction equipment, vibrators or heating pads. They will also not cover home furnishings, hot tubs and exercise equipment.

Personal recommendation

In my opinion, I always think it’s a good idea for people with a work injury claim to plan for their L&I claim closure. In part, they should discuss medical expense (and other) concerns before claim closure becomes final. On top, there are special considerations when medical surveillance exams or equipment repair applies in your L&I claim. In such cases, I recommend that claimants, medical providers and L&I get on the same page regarding process and procedure after claim closure.