Independent Medical Exams, Job Analysis & Functional Capacity Evaluations
Today s Topics Independent Medical Exams (IMEs) Reason s s IMEs are arranged Do I have to rate my patient s impairment? Timely review and response why is this important? What if I disagree with the examiner s findings? Job Description and Job Analysis forms Functional Capacity Evaluations (FCEs) Getting paid for completing forms and other services Getting help - L&I has resources to help you and your staff! 1
Independent Medical Exams (IME) Independent Medical Exams are arranged for various reasons to address: Work-relatedness for occupational disease/condition Newly contended conditions/diagnosis Need for additional treatment To assess permanent impairment Worsening (Reopening application filed) Independent Medical Exams can only be arranged by the insurer. The attending provider or employer may request the insurer to schedule an IME. 2
When should your patient undergo an impairment rating? When the patient s condition has reached maximum medical improvement (MMI). Further treatment will not predictably alter the course of their illness or medical condition No fundamental or marked change can be expected, with or without treatment Fixed and stable* does not mean healed, but rather that further recovery not expected Patients may continue to have subjective and objective findings If no progressive permanent reduction in findings are expected, then they are at MMI * Fixed and stable is a legal term indicating no further treatment will improve the patient s condition. 3
Who can rate impairments? Attending providers are encouraged to rate their patient s impairment. Here are some advantages: The attending provider is able to provide a rating based on their management of the patient s care over a period of time Take into account fluctuations in patient s condition, which other examiners may not be able to do The report can be brief and reimbursement is higher than many provider s realize Risks of litigation may be significantly lower Patients often have more confidence in the rating provided by their attending provider (or a consultant chosen by their provider) 4
What if I do not want to rate impairment? You can ask the claims manager to schedule a closing/rating examination, or You can refer your patient for a rating exam with another doctor. Doctors licensed in the following fields may conduct these exams: Medicine and surgery Osteopathic medicine and surgery Podiatric medicine and surgery Dentistry Chiropractic (department approved chiropractic examiners only) 5
Will I receive a copy of the examiner s (IME) report? Yes, claims manager will send you a copy of the examiner s findings and recommendations. The claims manager may ask for your assessment and concurrence of the exam findings. Your review and timely response is important. t Delays can: Impact your patient s claim and further treatment, if indicated Delay the patient s monetary award for impairment, if entitled 6
What if I disagree with the examiners report? If you do not concur, you should notify the claims manager, in writing, as soon as possible. Please include the reasons why you do not agree. Include the following, if you disagree with the examiner(s) : Treatment recommendations or maximum medical improvement - Include your curative treatment plan and provide objective findings to support the need for further curative care Permanent Impairment Rating Explain why and list all objective physical findings to support your rating Note: If the patient s claim was closed based upon the IME, you must protest this decision, in writing, within 60 days if you do not concur. 7
Job Description RCW 51.32.090 - Written description of light or temporary work the employer of injury is able to offer while the worker is recovering from an industrial injury. Must be clear so the attending provider can relate activities iti of the job to the worker s disability and current ability to perform light-duty work. A job description can be developed by any professional on L&I s Early-Return-to-Work team. http://apps.leg.wa.gov/rcw/default.aspx?cite=51.32.090 8
Job Analysis WAC 296-19A-137 - detailed written description of the injured worker s job duties and the physical requirements necessary to perform the job. May include cognitive requirements, temperaments, psychiatric and environmental conditions of work performed. Developed by a registered private Vocational Rehabilitation Counselor (VRC) or registered L&I Vocational Services Specialist (VSS). http://apps.leg.wa.gov/wac/default.aspx?cite=296-19a-137 /WAC/d lt 137 9
What is a Functional Capacity Evaluation? Objective, detailed evaluation completed by a licensed physical or occupational therapist over a 3-6 hour period Documents demonstrated functional abilities Documents if demonstrated activities are a valid reflection of the worker s abilities Includes return to work recommendations Attending providers and/or Vocational Rehab Counselors can request an FCE. These evaluations can assist with return to work decisions and/or vocational services. Your patient t does not have to be at maximum medical improvement to determine their functional capacities Fact Sheet for Workers: L&I will begin sending workers information about the evaluations. 10
Getting paid forms and services L&I realizes we are not like other insurers and require more paperwork. L&I offers local codes to pay providers for the extra paper work unique to L&I. Most of L&I s unique forms have the local code printed on the form 2015 Quick Reference Card: http://lni.wa.gov/ipub/245-414- 000.pdf Additional codes can be found in Chapter 27 of L&I s Payment Policies. For more information, visit: www.lni.wa.gov/claimsins/providers/billing/feesched/2015/mar i /P id /Billi /F d/2015/mar FS/2015PDFs/MARFSComplete.pdf 11
Getting paid - case management services Telephone calls, team conferences and online communications/consultation are payable when: The attending provider, consultant, psychologist or other providers personally participate when discussing or coordinating care or treatment ARNPs, PAs, Psychologists, PTs and OTs need to bill using nonphysician codes Not payable for authorizations, resolution of billing issues, or ordering prescriptions. Documentation is required. For more information, visit L&I s 2015 Payment Policies, Chapter 10: www.lni.wa.gov/claimsins/providers/billing/feesched/2015/marfs/20 15PDFs/MARFSComplete.pdf 12
Most Requested Forms Form Activity Prescription Form Report of Accident (self insurer/pir only) Reopening Application Loss of Earning Power Subacute opioid request without documentation Subacuteopioidrequestwith documentation Chronic opioid request Review of Job Analysis Summary: first one reviewed Review of Job Analysis Summary: each additional review Occupational Disease & Employment History Physician response to VRC/Employer re: RTW (no form) Local Billing Code 1073M 1040M 1041M 1027M 1076M 1077M 1078M 1038M 1028M 1055M 1074M Special Report requested by insurer or VRC (no form) 99080 13
Our job is to help you! Gayleen Lies Provider Account Representative ti Rules, Policies and Guidelines Email: Providerfeedback@Lni.wa.gov Phone: 360-902-6680 Tina Mottern Outreach Bill Payment Representative Complex Billing Issues Email: Providerfeedback@Lni.wa.gov Phone: 360-902-6513 14
Thank you For taking care of injured workers and for partnering with us! 15