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

Category: Uncategorized (Page 2 of 68)

Important Dates You Must Remember in Your L&I Claim

Calendar dates can be very important in an L&I claim. In fact, certain dates associated with specific events can impact your L&I claim benefits. In some cases, incorrect dates can even have long lasting negative implications in claims. The purpose of this article is to discuss some of the most important claim dates that work injury claimants must track and remember.


Date of injury in a workers’ compensation claim

The date of injury (DOI) is the date an Industrial Injury occurred. If you were injured at work on a specific day, that is your date of injury. It’s very important that you use the correct date of injury when filling the accident report. This date will also appear in other early claim documents. Personally, I’ve seen circumstances where L&I doubted the validity of the claim because the date of the work injury was wrong. For example, take a workplace injury that occurred on a Friday. Yet, the date of injury in the report form is listed as Saturday. This real-life error caused the employer to question the claim because the worker wasn’t at work on Saturday. One tiny mistake and the injured worker had to spend months convincing the employer and L&I that the injury actually happened on Friday while at work. Not at home over the weekend.


The date of injury is also very important because L&I uses it to calculate wages. Work injury claimants may be eligible to wage replacement benefits like time-loss compensation or loss of earning power. L&I pays these benefits when workers cannot work after their work injury. Or, when workers can only work in limited capacity. To determine compensation, L&I looks at the wages on the date of injury. Therefore, an accurate date of injury is important. It’s imperative that L&I calculates wages correctly and accurately.


Date of manifestation

The date of manifestation (DOM) is the date associated with the onset of an occupational disease claim. Under the law, the date of manifestation is “the date the disease required medical treatment or became totally or partially disabling, whichever occurred first”. The date of manifestation is set exactly according to this definition. It doesn’t matter when you actually filed your L& claim.


As with industrial injury, establishing a correct date of manifestation is very important. I’ve seen instances where L&I questioned a claim because the date of manifestation on the form was long after the first treatment date. This caused L&I to suspect that the work injury claimant wasn’t honest. It also opened the door for questions about whether the condition was actually an occupational disease. Or, for example, something that occurred naturally regardless of work activity.


If L& rejects a claim on this basis, it puts work injury claimants in a bad position. They end up having to fight an uphill battle to get the claim allowed. Using the correct date of manifestation from the beginning can eliminate this risk.


Incorrect dates can impact your claim benefits

The date of manifestation can also impact monetary benefits. Here are a few examples. Nearly every year, L&I sets a “compensation schedule”. For instance, say that the date of manifestation is in 2010. In addition, say that the work injury claimant is ultimately eligible for a permanent partial disability award. Eventually, L&I will pay the worker according to the PPD rates for 2010.


Another example is wage replacement benefits. Let’s assume that the work injury claimant is working when the industrial disease requires treatment. Then, L&I will base the wage replacement compensation on the monthly wage paid on that date. However, if the work injury claimant wasn’t employed at the date of manifestation, then L&I calculates the compensation using the last monthly wage of earnings. That is, so long as the worker didn’t retire voluntarily. In fact, voluntary retirement disqualifies work injury claimants from receiving wage replacement benefits.


L&I claim dates associated with letters and communications

Many L&I claim deadlines are a function of the date in which L&I sends out a document or notification. For example, if L&I sends an order, you have 60 days from the date you receive the order to file a protest or appeal. If you don’t file a protest within 60 days, then the order becomes final and binding. After that, you can no longer challenge the decision.


By law, L&I must send orders to work injury claimants at their last known address “as shown by the records of the department”. Hence, L&I considers the order delivery as “complete” when the mail arrives at the work injury claimant’s last known address. It’s important to note that workers can rebut this presumption. To do so, you must present evidence and show you didn’t receive the order. However, no one ever wants to be in this position. In my opinion, the best way to ensure you’re calculating deadlines properly is to simply write the date of receipt on every document. That’s how law firms do it. Every time a piece of mail comes in the door – we date-stamp it. Having a similar standard practice can help throughout your workman’s comp claim.


Terminal dates and claim reopening

Terminal dates are important when trying to reopen a claim. There are two important terminal dates. Both play a role during the claim reopening application. The first terminal date (called T1) is the latter of: (1) The date L&I closed the claim; or (2) The most recent date L&I denied a reopening application. The second terminal date is called T2. It is the most recent date when you filed an application to reopen the claim. Both T1 and T2 dates can change over time.


Let’s go over an example. A work injury claimant suffered an injury on the job on 1/1/2010. L&I allowed their claim on 1/5/2010. Later, L&I closed the claim on 12/31/2015. The worker applied to reopen the claim on 1/1/2016. In turn, L&I denied the reopening application on 2/1/2016. Here, the first terminate date is 12/31/2015. The second terminate date is 2/1/2016. Further, assume that the worker does not protest or appeal the denial. Instead, say the worker files a new application to reopen on 1/1/2017. Additionally, say that L&I denies the new reopening application on 2/1/2017. After that, the new T1 will be 2/1/2016 and T2 will be 2/1/2017.


Terminal dates are important in reopening applications. For L&I approval, you must show that claim-related conditions got worse between the terminal dates. Furthermore, you must show the need for further treatment or an increase in disability. So, it’s extremely important for both work injury claimants and their medical providers to understand the terminal dates.


L&I claim closing date

When L&I closes a claim, they send you a “Notice of Decision”. Sometimes, L&I sends a final “Payment Order” instead. Either way, the L&I claim closing date refers to the date that appears on that letter. This is one reason it’s very important to always read L&I orders completely and carefully.


When L&I decides it’s time to close your claim, they must issue their decision in writing. In it, L&I must clearly state that the claim is closed. Like any decision, to protest or appeal it, you must submit a written notice within 60 days. If L&I receives the protest in time, then L&I has to issue a new order. If L&I affirms its decision to close the claim, then the date on the new order becomes the claim closing date. Technically, a claim isn’t closed until 60 days after the written notice of closing arrives to the worker.


Sometimes, people don’t understand that L&I must communicate claim closure in writing. They mistakenly think that if a doctor tells them that treatment concludes, then the claim is closing. Other times, workers think that if a claim manager tells them the claim is closing, then it’s closed. In fact, I’ve talked to work injury claimants who believed their claims closed for years. Only to find out that their claims are still open. During this entire time, workers skipped medical treatment and benefits.


Appointment dates – Don’t forget your L&I appointment!

By far, the most important date(s) to remember in your L&I claim is your appointment date. Work injury claimants miss appointments way too frequently. Sure, unexpected issues and emergencies arise from time to time. However, it’s unacceptable to forget and ignore appointments repeatedly.


Whether it’s an appointment with your attending provider or IME appointments. Whether we’re talking about physical therapy, consultation appointments, or vocational meetings. It doesn’t matter. There is no justification to miss appointments. As such, it’s critical to know the date and attend your appointment on time. If you repeatedly miss appointments, it’s one surefire way to interrupt your L&I claim progress. Often, it will result in suspension of benefits. There is nothing more frustrating than finding out a work injury claim has gone down the toilet simply because the claimant failed to attend appointments.


I know a claim can be difficult. I’m well-aware it can be scary to manage all the appointments and administrative responsibilities. However, if your claim is important to you, know your appointment date and show up. Unless you have a very good reason for missing it.


L&I Delivers Bad News to Injured Workers and Some of the Best Medical Advocates in Workers’ Compensation

I recently posted an article about L&I’s Medical Aid Rules and Fee Schedules, which were recently published for 2023. In particular, the L&I Medical Aid Rules can be a great resource for helping work injury claimants understand treatment options. Furthermore, the L&I Fee Schedules can also have a significant impact on work injury claimants and stakeholders.


L&I cuts funding for Nurse Case Managers

 As a workers’ compensation attorney who regularly publishes on issues relating to workers’ compensation issues in Washington State, I feel I would be remiss if I did not publicly address and unambiguously condemn L&I’s new fee structure for Nurse Case Managers. I am well aware that L&I has a duty to responsibly manage the Accident Fund. However, cutting fees for Nurse Case Managers is not the way to do it.


Last year, Nurse Case Managers were entitled to bill $116.60/hour for their work in L&I claims. This is a very reasonable rate given their level of education and experience requirements. This year, the 2023 L&I Fee Scheduled caps their fees at a flat rate of $200 per month. While I don’t personally have statistics on this, I strongly suspect the $200 flat fee comes nowhere close to adequately compensating Nurse Case Managers for the work they do. I anticipate that these funding cuts will result in experienced Nurse Case Managers declining to provide services in L&I claims. In fact, I’m already starting to see it happen.


What are Nurse Case Managers?

Nurse Case Managers (NCMs) are registered nurses with one of the following case management certifications: Certification of Disability Management Specialists (CDMS), Commission for Case Manager Certification (CCMC or CMC), Certified Rehabilitation Registered Nurse (CRRN), Certified Occupational Health Nurse (COHN), and/or Certified Occupational Health Nurse-Specialist (COHN-S). In other words, NCMs are highly educated and skilled healthcare professionals. An NCM can be assigned to assist in an L&I claim in many situations. For example, when there has been a catastrophic work-related injury not otherwise being managed under the “Catastrophic Project”. Another example is an L&I claim where the work injury claimant lives or has moved out of Washington State and needs assistance locating a provider. Other examples include an L&I claim involving medically complex conditions, or when there are other barriers impacting successful claim resolution.


As an L&I attorney representing work injury claimants, I have partnered effectively with NCMs on countless occasions to achieve results that benefit not only work injury claimants, but also L&I and other stakeholders. This is particularly true in Out-of-State cases, complex or catastrophic medical cases, and cases with other issues creating a barrier to appropriate claim progress.


How are Nurse Claim Managers useful in Out-of-State claims?

NCMs are instrumental in assisting us to obtain Out-of-State treatment providers. Usually, before we request assistance from a NCM, my staff undertakes to assist our clients with this process. However, due to the meager L&I fees for service providers, we are finding it more and more challenging to find willing Out-of-State treatment providers. Furthermore, we often find that despite our best efforts, treatment providers are turned off when a law office contacts them to inquire about providing L&I treatment to a work injury claimant. They usually assume our involvement means the claim is messy or legally contentious. This is often not the case.


Once my office has exhausted our resources trying to get an Out-of-State provider, we ask for an NCM to be assigned. In approximately 4 out of 5 cases, having a NCM assigned results in our ability to track down a willing Out-of-State provider despite our prior failed efforts. When a willing Out-of-State provider cannot be found, we are left with only one option: L&I must bear the expense of having the injured worker regularly travel to Washington State for treatment. Yes, this means L&I is paying for flights or other transportation, hotels, and meals, on regular intervals for work injury claimants to travel to Washington State for treatment. Again, in approximately 4 out of 5 cases, NCM involvement has saved L&I and work injury claimants from the expense and stress of travel to Washington for treatment.


Complex or catastrophic claims

When I say complex or catastrophic claims, I am referring to injuries that result in significant, often irrecoverable, disability. The best example I can give is an injury that results in quadriplegia. Treatment and care for individuals paralyzed by their injuries is incredibly complex. There are so many moving parts from acute treatment to long term treatment. During acute treatment, many families are unsure whether their loved one is even going to survive. Most workers do not have attorneys in these early, but incredibly stressful hours and days. NCM’s can help guide these families to understand the system and make informed decisions.


Families of work injury claimants will bear the load

Once the acute treatment phase has passed, the real work begins. Paralyzed work injury claimants require a team of medical providers resulting in a complex schedule of appointments. Simply managing and getting to appointments is a full-time job. For this, usually a family member must take on the role of a full-time caregiver or a professional caregiver is needed. NCM’s are incredibly skilled in connecting families with the resources they need to determine if they can provide care themselves or need assistance from professionals. A number of other challenges must be addressed as well, including but not limited to: finding appropriate transportation for a paralyzed individual (imagine trying to get a paralyzed individual into a small family sedan), making appropriate home modifications or helping families relocate if needed (imagine trying to bring a paralyzed work injury claimant home to a second floor apartment with no elevator), and obtaining all of the necessary durable medical equipment needed such as wheel chairs, toilet seats, shower accessories, appropriate medical bedding to prevent bed sores, catheters, and the list goes on.


Certainly, if the family elects to hire an attorney, we can help with some of these logistics. Yet, at the end of the day, we are legal professionals. We do not have the knowledge, skill or medical experience to help families with all of the medical logistics needed for a catastrophic injury. I know from personal experience that NCM’s spend countless hours in the early days of claims helping families get everything they need in place. There is no way $200 comes close to compensating NCM’s for the services they provide in this kind of setting.


The role of Nurse Case Managers in L&I claims with other barriers to progress

When I speak of other barriers to progress, I’m generally referring to medical complications that impact claim progress. For example, work injury claimants with underlying health conditions such as diabetes, COPD, pacemakers, thyroid disease, and more may need to coordinate care between specialists and L&I treatment providers before treatment progress can be made. For example, an injured worker with a pacemaker may need clearance from a cardiologist before surgery can be considered. Similarly, work injury clients taking medications for an underlying thyroid disease may now be facing adverse drug interactions for claim related treatments. The list goes on and on.


NCMs are particularly helpful in these situations because they can utilize their medical experience to ensure that appropriate coordinated care is occurring. Another example is when weight loss is needed for treatment progress. For example, medical best practices dictate that people must be under a certain BMI to be eligible for knee replacement surgery. If a work injury claimant needs to lose weight in order to have a particular treatment, then weight loss treatment is covered under the claim. However, only specific methods of weight loss are authorized. NCMs are an invaluable resource in helping work injury claimants find appropriate, authorized weight loss treatment programs, connecting with dieticians, and helping to monitor weight loss progress to ensure it remains on track. Similarly, NCMs are often instrumental in aiding in opioid addiction recovery under the medical treatment guidelines. Again, as attorneys, there are many things we can do to assist work injury claimants with all of these claim related issues. However, at the end of the day, since we are not medical professionals, there are things NCMs can accomplish with more efficiency and experiences than we can.


Cutting funding will have serious negative implications

In summary, claims involving catastrophic work-related injuries not otherwise being managed under the “Catastrophic Project”, work injury claimants that live or have moved out of state and need assistance locating a provider, medically complex condition(s), and or other barriers impacting successful claim resolution are difficult enough as they are. Historically, having access to experienced NCMs has made these challenging claims much more manageable for work injury claimants, their families, attorneys, and L&I alike.


The new fee schedule is going to gut the usefulness of the NCM program. I predict that any savings L&I may see by capping NCM fees at $200 per month will be eclipsed quickly by increased L&I claim costs. I understand the need to avoid excessive hours spent and overbilling, but the 75 hours of service per referral cap already accomplishes that. It is with an unnerving sense of dread for what this will mean for work injury claims that I must unequivocally say: I am incredibly disappointed in L&I. This new Fee Schedule is doing nothing to reduce to a minimum the suffering and economic harm suffered by work injury claimants and their families. In fact, I predict it will do just the opposite.


How L&I Makes Medical Treatment Decisions in Washington State

The Department of Labor and Industries (L&I) maintains a set of Medical Aid Rules and accompanying Fee Schedules. Many workers compensation professionals refer to these as “the MARFS”. Typically, the Department updates the L&I medical treatment rules annually in July. The medical aid rules and fee schedules are very important. Many work injury claimants can use them to get answers regarding medical treatment under their L&I claim. The guidelines can even provide answers for certain medical conditions relating to your workplace injury and your claim.


L&I medical aid rules and fee schedules

Under the Industrial Insurance Act (Title 51 of the Revised Code of Washington), L&I is responsible for supervising and providing prompt and efficient treatment to workers injured during their employment. Namely, this treatment must be “at the least cost consistent with promptness and efficiency”. Managing medical treatments for many work injury claimants is complex. Even for large government agencies. To help, L&I created a framework to define the scope and rules around medical treatment. The medical treatment framework, known as Medical Aid Rules and Fee Schedules, is under Chapter 296-20 of the Washington Administrative Code (WAC). L&I uses this framework for claim administration. The framework defines the medical services that L&I and self-insured employer companies can purchase. Additionally, the framework sets the fees they can spend for medical services. Furthermore, it dictates the decision-making process for medical treatment under an L&I claim.


How L&I makes medical treatment decisions

The medical aid rules in WAC 296-20 contain much more information beyond treatment codes and fee structures. In fact, the medical aid rules explain much of L&I’s decision making when it comes to treatment authorizations. For example, the medical aid rules describe the function and role of the chiropractic and medical advisory committees. These committees advise L&I regarding coverage, decisions, treatment guidelines, treatment authorization criteria and the like. The guidelines also contain information about many important topics, including:


In short, the medical treatment guidelines can help work injury claimant and providers alike. That is, they can help understand how L&I and self-insurers make treatment decisions. Even further, they outline the kinds of treatment that L&I and self-insured employers allow.


What are the medical fee schedules?

The L&I fee schedules explain how much money L&I can spend on every medical service. It explicitly dictates the amount of money that L&I pays for each specific medical procedure. The fee schedules are typically used by medical providers and medical administrators. As before, the L&I fee schedules take effect annually each July. The most recent fee schedules for July is available on the L&I website. The website also provides the fee schedules for previous years.


Additionally, L&I has several tools to assist in understanding the fee schedules. Moreover, there are resources on how to appropriately submit bills for services. For example, L&I publishes a “Professional Services Fee Schedule”, which is a spreadsheet of the complete fee schedule (with a few exceptions). Also, L&I provides a “Code Lookup Tool”. These tools are available on the L&I Website. Finally, L&I publishes a guide called Payment Policies for Healthcare Services. L&I provides these for injured workers and crime victims. This payment policy manual is full of detailed information.


What are the L&I medical treatment guidelines?

L&I also has a number of Treatment Guidelines that more explicitly define the kinds of treatment that may be authorized for specific diagnoses and conditions.  Specifically, these treatment guidelines cover:


The treatment guidelines may cover your conditions and diagnosis. Therefore, you should carefully read and understand the treatment guidelines that apply to you. Most importantly, the guidelines provide a clear picture of what treatments L&I will and will not allow. Also, they contain information about treatment options. For example, they outline the order that patients must follow to carry out certain treatments. Finally, these guidelines provide references to medical studies and literature.


How to appeal L&I medical decisions

It’s very unlikely that a claims manager for L&I or a self-insured employer will allow treatment inconsistent with the treatment guidelines. However, it’s important to note that, in most cases, the medical treatment guidelines are not legally binding. For example, say that L&I denies your specific treatment recommendation because it’s not in the treatment guidelines. Still, work injury claimants can successfully appeal the decision. In turn, the appeal would go to the Board of Industrial Insurance Appeals (Board). There, the Board will make an independent determination.


How does the Board of Appeals make a treatment decision? The Board of Appeals decides based on whether the proposed treatment is “necessary and proper”. By law, work injury claimants must receive proper and necessary health care services. Specifically, the law entitles the worker to a diagnosis and treatment of conditions. Of course, these conditions must be causally related to the workplace injury or occupational disease.


Important terms in the L&I medical treatment guidelines

In general, proper and necessary services may be either curative or rehabilitative. The term “Curative” means treatment to produce permanent changes. These changes hope to eliminate or lessen the clinical effects of the condition. Then, “Rehabilitative” treatment aims for workers to regain functional activity on a long-term basis.


Most importantly, the law entitles work injury claimants to proper and necessary health care. That is, until they reach and maintain maximum medical improvement (MMI). A worker is at maximum medical improvement when doctors don’t expect their condition to improve.


Work injury claimants should review the medical guidelines

Under the Industrial Insurance Act, L&I must carefully manage medical treatment decisions. On top, L&I must carefully manage fees for medical services. Too often, L&I and self-insured treatment decisions seem slow, arbitrary, and unfair. This is one reason why I recommend that work injury claimants review and understand the medical guidelines. It’ll help you cut through the mystery. Also, reviewing treatment guidelines can help you advocate for yourself in medical appointments.


The guidelines contain many useful facts. For instance, workers can get a better sense of how many physical therapy sessions L&I or the self-insurer will authorize. Furthermore, workers can identify which upcoming treatments or appointments require L&I pre-authorization. While these are only a few examples, I urge workers to take full advantage of all the information available in the guidelines.


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