Page 3 of 68

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.

Over Seven Claim: My L&I Claim Closed More Than 7 Years Ago – Can I Reopen It?

/ L&I attorney / 2 Comments

You can always reopen an L&I claim for medical treatment. Even if you have an old claim. It doesn’t matter how old the claim is. However, if your claim closed over 7 years ago, it will impact your L&I claim benefits. While L&I covers medical treatment, you might not receive other benefits under the claim.

What is an over-seven claim?

The term “Over-Seven Claim” is commonly used by workman’s compensation professionals. That way, we all know what we’re talking about when we use that phrase. The term refers to an L&I claim or self-insured employer claim that closed over seven years ago (or ten years for eye claims).

To reopen an over-seven claim, the requirements for reopening are the same as all claims. This is true for old claims as well. However, once reopening is complete, there is special treatment for over-seven claims. Here, in this article, we’ll first discuss the reopening process and then talk about L&I benefits and limitations.

How to reopen an old over seven claim

To start, you must first file an Application to Reopen Claim. If you look at it, the form requires information from both the work injury claimant and their medical provider. In turn, after L&I receives your reopening application, L&I has sole authority to decide what to do next. This is true for both a state-funded L&I claim and self-insured employer claim. In other words, the Department of Labor and Industries (L&I) determines if there’s merit to reopen your claim.

A work injury claimant can submit a request for reopening without supportive medical documentation. However, without medical evidence, L&I won’t be able to determine whether reopening is appropriate. Therefore, it’s typically best for the injured worker and their doctor to work together on the claim reopening application. Collaboration with your medical provider is very important.

Medical criteria to reopen an old claim in Washington State

The following explanation applies when reopening any claim. Not only an old workers’ compensation claim. To meet the criteria for reopening, you must show an aggravation or objective worsening of your conditions. Remember, these conditions must relate to the work injury. Furthermore, you must show that the aggravation or worsening happened since the latter of: (1) The last date the claim closed; or (2) The most recent date L&I issued an order stating the claim will remain closed.

For aggravation, you must show the following:

A causal connection between the accepted condition at the time of claim closure and the current condition;
A medical opinion stating that the condition is worse than before; and
Objective medical findings to support the medical opinion.

Sometimes, the requirement to provide objective medical evidence doesn’t apply. For example, in case of mental health conditions.

Showing aggravation and worsening of conditions

L&I can give your medical provider a copy of the closing medical records. If you need it – ask for it. These records can help your doctor assess if your condition is getting worse. Also, L&I can authorize additional diagnostic testing if it helps in deciding on reopening. Finally, L&I also has the right to compel the work injury claimant to attend an Independent Medical Examination (IME). The purpose of the IME exam is to determine if reopening is appropriate.

L&I benefits after reopening an over-seven claim

You can apply to reopen an old over seven claim any time, to receive medical benefits. After filing the reopening application, several situations may arise. First, if the claim doesn’t meet the criteria for reopening, L&I will issue a decision denying the reopening. Second, if the claim can be reopened and time-loss is not an issue, L&I will issue an over seven reopening order and notice for medical benefits. The notice informs the work injury claimant that their claim is reopening only for medical treatment.

Of course, medical benefits are just one kind of benefit that L&I provides to workers after they get hurt on the job. Typically, workers’ compensation professionals refer to other benefits as “disability benefits”. The most common disability benefits include time-loss compensation (TLC), loss of earning power benefits (LEP), permanent partial disability awards (PPD), and pensions (TPD). Simply put, work injury claimants with an old over-seven claim don’t receive disability benefits. Even after L&I reopens their claim. With one exception.

Requesting disability benefits for an old over-seven claim

The director of L&I has discretion to grant disability benefits in an over-seven claim. A worker with an old claim can ask for disability benefits any time during the reopening process. Or, they can ask for disability benefits after L&I reopens the claim. If you’re requesting disability benefits in an over-seven claim, the claims manager or claim adjudicator must prepare a briefing paper. Later, they will hand the briefing paper to the L&I director for consideration.

By law, RCW 51.32.160(1)(a) grants the Director the authority to readjust the worker’s rate of compensation on their own motion. Once the Director exercises discretion to approve or deny benefits, L&I will issue an order and notice. The order will notify the work injury claimant of the Director’s decision.

How likely am I to receive benefits for an old claim?

On occasion, the Director will exercise discretion to grant additional disability benefits in over-seven claims. However, this is an exception. It isn’t a rule and it’s not very common. In fact, Washington State Courts said that the meaning of the words “may adjust the rate of compensation” in RCW 51.32.160(1)(a) empowers the Director to modify the value of a worker’s disability benefits. Hence, the Director has the “discretionary authority” to determine the worker’s eligibility for disability benefits.

As always, any party can protest or appeal L&I decisions. This also includes the Director’s decision to grant or deny disability benefits. However, we must remember that for an over-seven claim, the decision to grant or deny disability benefits is discretionary. Consequently, Washington State Courts determined that the standard of review on appeal is “Abuse of Discretion”. In other words, the appealing party must show that the L&I Director abused his discretion in making the decision. For that, they have to convince the Board of Appeals or a higher court that no reasonable person would have made the same decision. Therefore, most lawyers would agree that abuse of discretion is difficult (if not impossible) to prove.

Summary and conclusions

In summary, you can reopen a workers’ compensation claim as long as certain criteria are met. The criteria for reopening are the same for all claims. It doesn’t matter if a claim closed long ago. The age of the claim is also not important.

If your L&I claim closed less than seven years ago, you can reopen it for both medical treatment and disability benefits. However, if you claim closed over seven years ago or more (ten years for eye claims), you can only reopen it for medical benefits. In over-seven claims, the Director of L&I can exercise discretion to grant or deny disability benefits. But, if the Director denies disability befits in an old over-seven claim, it’s very difficult to successfully appeal and reverse the decision.

L&I Help: Where Can I Get Help For My L&I Claim?

/ L&I attorney / 2 Comments

Many work injury claimants struggle with their L&I Claim. It’s difficult to understand how claims really work under the hood. What’s going on in your L&I claim, where the claim is heading, and so on. Moreover, many workers don’t know what to do when things don’t go well. What’s worse, when they run into difficulties, they don’t know where to turn for L&I claim help. Obviously, one answer is to talk to an experienced workers compensation attorney. However, in many cases, you don’t need an attorney. There are other resources available out there. These resources can help work injury claimants understand their workers’ compensation claim. On top, they can help you understand the benefits available and your rights. The purpose of this article is to provide a list of the best resources for L&I help. You can use these resources to find help and navigate your L&I claim.

Getting L&I help from your employer

Not all employers have resources to help injured workers. However, many employers do. Often, they can help employees understand what to do after an injury on the job. First, check if you have an organized employer that has policy and employee manuals in place. If you do, it’s likely your employer also has resources for when employees get hurt at work.

If you think your employer may have these kinds of resources available, then ask for them. In fact, even if you don’t know whether your employer might have such resources, it does not hurt to ask. Most likely, employer resources won’t have thorough information. However, they can be a good starting point for understanding your claim. They are also good to get a feel for how your employer will react to your claim.

Union representatives

Are you part of a union? If so, then your union probably has resources and support to help you navigate your L&I claim. If you suffer an injury at work, or develop an occupational disease, you should reach out to your shop steward. Your shop steward can give you information about your L&I claim and your rights as a work injury claimant. Furthermore, they will also tell you about any assistance the union can provide as you navigate your claim.

L&I mailers

Early in claims, L&I usually sends work injury claimants brochures or pamphlets. These brochures contain useful information about L&I claims. Read the information in the brochures carefully. Also, keep the brochures and pamphlets someplace safe. This way, you can refer to them later during your workers’ compensation claim.

If you misplace a pamphlet, you can find it here. L&I sends other informational pamphlets at various stages of the claim. They explain the benefits you may be getting. They can help you understand your L&I benefits and other aspects of the claim.

The L&I website

The Department of Labor and Industries (L&I) offers a website with tons of information. Admittedly, it can take some time to get used to the website. But, once you do, it offers a wealth of data. In fact, many experienced workers compensation attorneys like me use resources on the L&I website frequently. A good starting place is the “Injured? What you need to know” web page.

L&I help from claim managers and L&I representatives

Many work injury claimants fear their L&I claim manager. It’s true – your claims manager isn’t your advocate. Yet, they can still be a very helpful resource. For me, I find that workers are reluctant to ask their claims manager questions. Some claims managers are better than others at answering questions. But like I said before, it never hurts to try!

Claim managers and other L&I representatives have a lot of knowledge and information about claims. If you ask a question they can’t answer – they will tell you. However, there are many questions that are absolutely appropriate to ask. And remember, if you don’t ask – you’ll never get an answer. In fact, many work injury claimants call my office to schedule a free consultation and ask questions about their L&I claim. Usually, workers can solve their own problems for which they are calling me, and get the answers, by simply asking L&I.

Office of the Ombuds for self-insured injured workers

This section applies to workers with a self-insured employer claim. The Office of the Ombuds advocates for work injury claimants who suffered a workplace injury while working for a self-insured employer. The Office of the Ombuds can answer many questions. Moreover, they can explain your rights as work-injury claimants. In addition, their website contains a lot of useful information for employees. Personally, in my experience, the Office of the Ombuds is also good at letting claimants know they need to speak with an experienced workers compensation attorney. They know how to tell when an issue rises to the level of needing legal intervention.

Project HELP

Project help is an organization that provides assistance for L&I claim matters. They offer L&I help, information, and education. It’s a collaboration between the Washington State Labor Council, AFL-CIO, and Washington State L&I. The Project HELP website is another great resource for understanding basic L&I claim procedures. It also provides education and resources for addressing some of the more common issues that arise in claims.

Project HELP also offers education to a variety of professionals in workers compensation. They host an annual Meeting of the Minds educational seminar. I appreciate everything that project HELP is doing. They indeed provide L&I help, as well as resources and education. However, as an attorney who represents work injury claimants, I think it is important to recognize that Project HELP is closely tied to L&I. It’s not a substitute for experienced legal representation when workers need that level of intervention.

L&I help from an experienced workers compensation attorney

Like me, there are many competent and experienced L&I attorneys in Washington State who represent work injury claimants. There are many L&I claim cases that do not require legal intervention. But then again, there are some that do. The two most common circumstances that warrant legal intervention are: (1) When workers need competent advocacy; and (2) When you need to file an L&I claim protest or appeal.

Sometime, work injury claimants are unable to effectively advocate for themselves. That’s one reason they need an attorney. To do that advocacy for them. Additionally, L&I can make a decision that is averse to a work injury claimant. In turn, workers must decide whether to accept, protest or appeal the decision. Analyzing the need to protest or appeal is something that every L&I attorney does daily. Furthermore, if you need to protest or appeal, an experienced L&I attorney knows the exact requirements to meet the burden of proof and prevail.

For advice, most workers compensation attorneys offer complimentary consultations. In my opinion, if you are in doubt and not sure if you need an attorney, make the call and schedule a free consultation. Personally, I rather consult with a work injury claimant and tell them they don’t need my help, than consult with them when it’s too late. In many cases, the damage in their L&I claim has already been done. Then, it’s already too late to fix it.

Workers Compensation - Washington