Musculoskeletal Program of Care (MSK POC)

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1 Musculoskeletal Program of Care (MSK POC) Questions and Answers Contact Information Health professionals with questions regarding the POCs may call WSIB: Customer Service Representatives at or for general enquiries, payment questions, claim status and; for referral to the Case Manager, before the end of the 6th week of the MSK POC if the worker is not expected to be able to return to all regular work duties and hours at the conclusion of the MSK POC. Health Care Practitioner Access Line at or for general questions about the POCs Clinical Experts at or for clinical care discussion Overview 1. What is the Musculoskeletal Program of Care (MSK POC)? The MSK POC is an evidence-based health care delivery plan, which aims to achieve the best recovery and return to work outcomes for workers with a musculoskeletal injury. It has been developed for workers with one injury or more: to a muscle, tendon, ligament, fascia, intra-articular structure or any combination of these structures, causing mild to moderate tissue damage (Grade I or II) but does not include complete tears and ruptures (Grade III), which may require surgical repair. It is also not for workers with a shoulder or low back injury for which we have the Shoulder POC and the Low Back POC. 2. Will the MSK POC be the first line of care, similar to the Low Back and Shoulder POC s? 1

2 Yes, the injuries listed above must be treated through the MSK POC as the first line of care. The effective date of the MSK POC was for injuries on or after August 1, Why does the WSIB require all eligible workers to be treated through the MSK POC? The WSIB wants to ensure that all workers benefit from evidence-based care as described in the MSK POC to achieve the best recovery and return to work outcomes. The MSK POC is focused on functional recovery and on high quality treatment for workers with musculoskeletal injuries and was developed with health professional associations. 4. What is the duration of the POC and how many visits must be completed? The length of the MSK POC is a maximum of 8 weeks. A minimum of 6 visits is required to bill for the MSK POC, but it is the expectation that the worker is treated as often as is necessary in the judgement of the provider. 5. Who can deliver the MSK POC? Regulated health professionals can deliver the MSK POC if it is within their scope of practice. Health professionals who are not primary care providers must have received a referral from a primary health professional (e.g., Chiropractor, Nurse Practitioner, Physician or Physiotherapist). 6. What is the process if a worker is referred to a health professional who does not want to deliver the MSK POC? When a health professional chooses not to treat an eligible worker through the MSK POC, the worker must be referred to another regulated health professional who will deliver the POC. Alternately, the health professional may call the WSIB for assistance. The POC Directory on the WSIB website lists health professionals who deliver the MSK POC by geographic area. 7. Where can I find more information about the MSK POC? Visit the WSIB website for more information on Programs of Care. Admission Criteria 1. What should the health professional consider when determining if a worker is eligible for the MSK POC? The MSK POC is for workers with: o An allowed claim within 8 weeks from the date of injury or recurrence. o No clinical evidence of red flags and no signs that orange or yellow flags are a barrier to participation in this active rehabilitation program. 2

3 o A diagnosis with one injury or more: To a muscle, tendon, ligament, fascia, intra-articular structure or any combination of these structures, causing mild to moderate tissue damage (Grade I or II) but does not include complete tears, and ruptures (Grade III) which may require surgical repair. 2. Is a worker only eligible for the MSK POC if the claim has been allowed? Yes, the health professional should ask the worker if the injury is work-related and if the claim has been allowed. The health professional can call or to inquire whether a claim has been allowed. Payment will not be made for services for a patient without an allowed claim. 3. What is a Clinical Expert and what do they do? A Clinical Expert is a regulated health professional who has clinical experience with the use of Programs of Care. The Clinical Expert s role is to discuss clinical aspects of the claim including worker diagnosis, appropriate treatment as well as barriers to recovery. Clinical Experts will help health professionals determine the suitability of a worker for a POC, they can discuss appropriate treatment for a worker and provide an opinion on next steps where a worker is not progressing as expected. The Clinical Experts are available by telephone to POC providers for clinical care discussion, for example where further treatment is recommended or the provider assesses the worker as requiring an alternative to POC treatment. To reach a WSIB Clinical Expert line, call (local) or toll free What factors will the WSIB Clinical Expert want to discuss when considering if a worker is thought not to be clinically suitable for the MSK POC? The WSIB Clinical Expert will discuss the presence of clinical red flags or other reasons why, despite a diagnosis of a musculoskeletal injury, the worker may not benefit from the MSK POC. The WSIB Clinical Expert may suggest a referral for further assessment to determine what care is required. Communication with WSIB and the MSK POC 1. What are the expectations of the health professional to communicate with WSIB? Health professionals must notify the WSIB Case Manager by the end of week 6 of MSK POC treatment when a worker is not expected to be able to return to work with all regular duties and hours by the completion of the POC. Call toll free or

4 Program Requirements 1. Can a worker change to another health professional after beginning treatment in the MSK POC? When the worker has already had partial MSK POC treatment and wishes to attend another health professional at a different facility, this health professional should call the WSIB Case Manager to discuss the case. Call toll free or for referral to the Case Manager. Assessment/Treatment 1. If a worker has multiple areas of injury, will fee for service treatment be allowed for areas other than the MSK injury? Up to two different POCs may be delivered at the same time, providing the worker meets the admission criteria for each POC and the claim is allowed. For example, if the worker has a low back injury and an MSK injury, the health professional may deliver both the LB POC and the MSK POC and bill the corresponding fees. If the worker has an injury that can be treated within a POC and another injury that cannot be treated in a POC, the health professional should contact the WSIB Clinical Expert to discuss the case. When a worker has more than two areas of potential POC treatment (e.g the worker falls and has a knee (MSK), shoulder, low back injury), up to 2 different POCs can be delivered at the same time based on the primary areas of injury. 2. Which outcome measures must be used to show functional progress during the MSK POC? The Patient-Specific Functional Scale (PSFS) should be administered at initial assessment and at discharge, with the scores recorded on the Initial Assessment Report and the Care and Outcomes Summary. During the initial assessment, the PSFS is to be administered after the history taking and prior to the physical examination. The PSFS is also useful to monitor ongoing progress throughout the treatment period at the provider s discretion. 3. Should a health professional complete a Form 8 and the MSK POC Initial Assessment Report? If the chiropractor or physiotherapist is the first treating health care professional, both the Form 8 and the Initial Assessment Report should be completed. If the chiropractor or 4

5 physiotherapist is seeing the patient due to a referral from another primary health professional, then only the Initial Assessment Report should be completed. Return to Work in the MSK POC 1. Can you explain the expectation for return to work in the MSK POC? Return to work means being able to return to all regular duties and regular hours. It is expected that the health professional s opinion about the worker s ability to return to work at the conclusion of the MSK POC has been discussed with the worker. 2. How is staying at work or returning to work part of the MSK POC? WSIB has adopted the Better at Work approach as a rehabilitation principle, which is the integration of rehabilitation with return to work. Staying at work or returning to work is not only the result of successful rehabilitation, but is an important part of successful rehabilitation. This approach reflects evidence based practice which shows that people heal faster and that permanent psychological and physical impairments may be reduced with early reactivation, including safe recovery in the workplace. Forms 1. How should reports (Initial Assessment Report, Care and Outcomes Summary Report) be submitted to the WSIB? The reports should be faxed to (toll-free) or Alternatively, reports can be mailed to WSIB s head office, located at: Workplace Safety and Insurance Board 200 Front Street West Toronto, Ontario M5V 3J1 Billing 1. Can I bill a worker directly for treatment provided for a MSK injury? No. A health professional may not bill the worker. Section 33(5) of the Workplace Safety and Insurance Act (WSIA) states: No health care practitioner shall request a worker to pay for health care or any related service provided under the insurance plan. 2. Is there a requirement for health professionals to bill electronically? 5

6 Yes. The WSIB will not pay for paper bills received for MSK POC services. 3. How do I register for electronic billing? Contact the WSIB s external payment processor, TELUS Health Solutions, at or provider.mgmt@telus.com 4. What determines the first date of service/treatment? The date of the initial assessment will be the first date of service or treatment and is considered the start of the MSK POC. 5. How do I bill if fewer than the minimum visits were provided? In cases where the worker has completed the program early or in cases of self-discharge, it may be possible that fewer than the minimum required number of visit were delivered. In these cases, indicate the actual number of units (visit) delivered on both the Care and Outcome Summary form and electronic invoice using the usual billing service codes. Payment for the individual visit(s) will be made. 6. How do I bill for cases where the worker is not expected to be able to return to regular duties and hours? Please refer to the POC fee schedule and billing information. It is important to notify WSIB at week 6 of the MSK POC if the worker is not expected to be able to return to all regular duties and hours. This is essential for case management. Contact WSIB at toll free or and request a call confirmation number. This reference number should be indicated on the second page of the Care and Outcome Summary and will confirm that you may bill the MSK POC fee. You will then be connected with the Case Manager to further discuss the case. 7. What happens if a health professional treats a worker who had an MSK injury and bills for fee-for-service treatment? Where a health professional treats a worker with an MSK injury and bills fee-for-service for treatments delivered after the effective date, the fee-for-service bill will not be paid, and the health professional s remittance statement will reflect this. 6

7 8. What payment will be made when the Care and Outcomes Summary is not submitted or is delayed after the worker is discharged? The Care and Outcomes Summary provides important information about treatment, clinical and functional change and return to work recommendations. Health professionals who deliver the MSK POC must submit the Care and Outcomes Summary report (COS) within two days of the worker s discharge. If the COS is not received within 14 days of discharge or if all the required information on the COS is not provided, the form fee will not be paid. The MSK POC program payment will be held until receipt of the completed report. 7