Category: Medical Treatment (Page 30 of 36)

LNI Workers compensation diagnostic referrals

Some Workers’ Compensation Treatments Do Not Require Prior Authorization for Injured Workers in Washington State

Sometimes workers’ compensation cases have diagnostic or therapeutic challenges. In those cases, attending providers are allowed to arrange most consultations with specialists without obtaining prior authorization.

Treatments that do not require workers compensation authorization

It’s true! But, for some reason both injured workers and treatment providers rarely believe me. Don’t take my word for it. Here is what L&I says about it: https://lni.wa.gov/patient-care/authorizations-referrals/authorization/retrospective-authorization. There are only two exceptions to this rule:

(1) mental health evaluations require prior authorization; and

(2) Independent Medical Examinations (IMEs) can only be arranged by the Department of Labor and Industries (L&I) or Third-Party Administrator.

That leaves the door open for many kinds of consultations to happen without prior authorization.

In fact, there are many treatments that do not require pre-authorization. Every year L&I publishes an updated fee scheduled and payment policy (MARFS) excel sheet. These sheets contain a column identifying whether an item requires pre-authorization. Did you know most items do not require pre-authorization? While surprising, it is a terrific benefit for injured workers!

More information and conclusions

L&I wants to keep claims moving forward. There’s no doubt about it. That means there is less red tape for making referrals and providing treatment than providers and injured workers often realize. If a claim is presenting challenges, so long as the referral is not for an IME or mental health evaluation, providers should feel empowered to arrange the referrals they feel are appropriate. If treatment providers are reluctant to schedule consultative appointments, injured workers should feel empowered to tell providers that pre-authorization is not required.

For more information, the L&I website contains lots of information regarding treatment authorizations and referrals.

Non-Cooperative Injured Workers Are At Risk of Claim Closure and Loss of Benefits

/ L&I attorney / 0 Comments

When you have an open and active L&I claim, it is imperative that you remain claim compliant. Injured workers who become non-compliant or non-cooperative, are likely to have their benefits suspended.

Non-cooperative injured worker behavior according to L&I

Behavior that L&I considers to be non-cooperative includes:

1) Failing to attend or not cooperating with medical examinations or vocational evaluations. These appointments are requested by the Department of Labor and Industries or self-insured employer;
2) Failing to attend scheduled appointments or evaluations with attending providers or vocational counselors;
3) Engaging in unsanitary or harmful actions that could jeopardize or inhibit recovery;
4) Refusing to accept medical or surgical treatment that is considered reasonably essential for recovery;
5) Refusing to transfer care to an attending provider within the Medical Provider Network; or
6) Failing to follow the accountability agreement in a vocational retraining plan.

If the Department or Self-Insured Employer believes that an injured worker is engaging in non-cooperative behavior, they will typically attempt to correct the issue. They normally do so by contacting the injured worker (or their attorney) to discuss the behavior and potential consequences. Additionally, they will send an informal letter recapping the discussion. If the non-cooperative behavior continues, a formal non-cooperation letter is sent to the injured worker (or their representative). The letter will outline the behavior believed to be non-cooperative. The letter will also request an explanation form the injured worker for the behavior. This letter must contain notice that benefits may be suspended under RCW 51.32.110. Under WAC 296-14-410, the injured worker has just 30 days to submit a response explaining the reasons for the behavior.

Claim closure and suspension of benefits

In some cases, injured workers fail to respond within 30 days. Alternatively, even if they respond, L&I may not believe the injured worker’s explanation. In either case, L&I may issue an order suspending the injured workers right to further benefits until cooperation resumes. If non-cooperation occurs during vocational retraining, the retraining plan must be salvageable despite the lack of cooperation. For retraining plans that lack additional time or funding, non-cooperation can result in plan failure. Plan failure due to the worker’s own actions usually results in swift claim closure.

The penalties for non-cooperation are very severe. Therefore, I always advise injured workers to remain cooperative and communicative throughout their claims. If benefits are suspended and the injured worker lacks good cause for the behavior deemed non-cooperative, it is difficult (if not impossible) to secure benefits while non-cooperation continues. However, in my experience, the analysis of whether good cause exists for non-cooperative behavior is very subjective. I do not always agree with the Department’s position regarding what constitutes good cause and what does not.

L&I Discontinues Use of Its Own PPD Worksheet in Favor of WAC Rules

/ L&I attorney / 6 Comments

Back in January, I wrote an article outlining a frustrating experience I had cross-examining a witness regarding a low back Permanent Partial Disability (PPD) rating. The witness was an Independent Medical Examiner (IME) that examined my client at the request of the Department of Labor and Industries (L&I). In his report, the doctor concluded that the PPD rating for my client’s low back condition was a Category 2. He based his opinion on the use of a worksheet that L&I developed and circulated to doctors for determining PPD ratings.

PPD Worksheet Rating

The problem was when I confronted the doctor with the language of the Washington Administrative Code (WAC). The WAC outlines the Categories of Low Back Impairment. After that, his opinion regarding the appropriate PPD rating changed. This wasn’t an uncommon occurrence with the use of the PPD worksheet, and as I explained in January:

“Some people argue that the worksheet yields more favorable ratings and some argue it yields less favorable ratings. But most experienced attorneys agree that it is inconsistent with the WAC.”

During the cross-examination, I attempted to ask questions designed to get the witness to think about the various categories outlined in the language of the WAC. Our exchange became increasingly argumentative and counterproductive. My takeaway from that experience was that I better use my energy to try and effectuate change with respect to the use of the misleading PPD rating worksheet. Fighting with a particular witness about the worksheet itself does not help the bigger picture problem.

Big win for Washington State injured workers

I’m pleased to report that last week L&I announced that effective June 1, 2019, it will no longer accept its own worksheets as a valid basis for supporting cervical and lumbar PPD ratings. Specifically, there are two worksheets that will no longer be valid. One is the “Doctor’s Worksheet for Rating Cervical and Cervico-Dorsal Impairment”. The other is called “Doctor’s Worksheet for Rating Dorso-Lumbar and Lumbo-Sacral Impairment”. According to L&I, if a rating report utilizes the discontinued worksheets, the provider must be asked for an addendum referencing the language from the appropriate WAC, and not the worksheet.

My hope is that this change will help ensure that PPD ratings for cervical and lumber conditions will be more consistent with WAC language. Hopefully, this will minimize disagreements like the one I descried back in January, which is an issue that I encounter frequently.