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:

• The medical provider network and the requirement to be in that network
• Which kinds of medical providers are permitted to treat work injury claimants
• Medical provider requirements for maintaining records
• Payment to out-of-state medical providers
• The utilization review process
• How to commence treatment and submit claims for benefits
• Who makes medical coverage decisions
• The process for making medical coverage decisions
• Requirements for medical treatment authorizations
• Rules for prescribing medications
• Opioid specific rules
• Handling treatment in claims that remain open for longer than sixty days
• Consultation requirements
• How to transfer treating providers
• Hospitalization rules
• Home nursing rules
• Coverage for hearing aids
• Dental coverage
• Travel expenses and reimbursement
• Billing procedures
• Rules for impairment ratings, and
• Rules for Independent Medical Examinations (IME).

 

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:

• ankle and foot surgery
• beryllium sensitization and chronic beryllium disease
• carpal tunnel syndrome
• cervical radiculopathy and myelopathy
• complex regional pain syndrome (CRPS)
• face neuropathy
• knee surgery
• hospitalization for low back pain
• lumbar spine surgery
• opioid prescriptions
• proximal medical nerve entrapment (PMNE)
• radial nerve entrapment
• treatment of shoulder conditions
• single cervical nerve root
• spinal injections
• neurogenic thoracic outlet syndrome (TOS)
• vascular thoracic outlet syndrome (TOS)
• ulnar neuropathy at the elbow (UNE), and
• work rehabilitation best practices.

 

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.