practical work comp and mva claims management for … · mva claims management for your practice...

Practical Work Comp and MVA claims management

for your practice

Joan M Takacs DO physiatrist

John P Takacs DO family practice

http://www.anthroclinic.com

A compensable injury is an accidental injury to a person or an accidental injury to a prosthetic appliance arising out of and in the course of employment requiring medical services or resulting in disability or death; an injury is accidental if the result is an accident whether or not due to accidental means if it is established by medical evidence supported by objective findings.

It can be the major contributing cause of the consequential condition

accident examples are: trauma, chemical exposure, post traumatic stress

occupational disease

Major contributing cause of a consequential condition

www.cbs.state.or.us/wcd/communications/publications/3248.pdf

Attending Physician

The worker initiates a workers’ compensation claim by filing a Form 801 “Report of Job injury or Illness” or Form 827 “Workers and Health Care Provider’s Report for Workers’ Compensation Claims”

Notify the workers that they will be responsible for non compensable medical services.The insurer has 90 days to accept or deny a condition and there is no payment until it is accepted. Only the accepted condition will be covered.Conditions other than the work injury are not compensable ( ie if treat bronchitis while seeing for back the bill must be split accordingly)

The law has allowed the patients primary care physician to treat the w/c claim of an established patient if the doctor abides by the insurer or managed care rules

The Attending Physician is primary responsible for the treatment, referrals, time loss / modified work, and eventually claim closure

DO,MD,DPM, oral maxillofacial surgeon

A patient can have a maximum of 3 attending physicians per claim.

Emergency room physicians can authorize up to 14 days of time loss

“Type B” attending physicians ( DC, ND, PA) can treat for 60 consecutive days or 18 visits whichever comes first, and authorize time loss up to 30 days from their first visit.

Chart NotesWorkers name and claim number ideally date of injury

History List all their complaints that they attribute to incident. If it is not in your notes they probably will not be able to add that condition later on. Include preexisting problems in that area, other w/c claims, relevant history. We developed a 3rd party form that you are welcome to plagiarize if helpful that includes a pain diagram

Exam Objective Physical What is abnormal on exam address area of complaint

Other Findings lab, MRI etc

Type of treatment in office treatment, meds, therapy, consults etc

With osteopathic treatment this must be to the accepted area, cannot bill for whole body approach. If treat more than the accepted area discuss with patient that you are splitting bill and charging separately for the other areas treated.

Work Status: limits including dates

Medically stationary Status- estimate the length of further treatment if known

Permanent disability on claim closure

Health Care Providers' Guide to On the Job Injuries

www.cbs.state.or.us/wcd/communications/publications/3248.pdf

WC (workers compensation injuries)

Determine if work related. Component Pre existing, differed status, combined condition, fraudulent, confused, wishful thinking.Could have been previously seen by DC for six weeks.......Provisional DxFile 827 new condition claim, change of attending, aggravation.Info: WC claimed can be emotional /stress, chemical exposure, orthopedic.Time loss & light dutyWork up & tx, return visitLiaison from WC insurer, enrollment in MCO. Your rights/obligations as previous attendingFollow up office visits: claim number, DOI (date of injury), claimed (accepted) conditions, SOAP, work status, prognosis.Communication from insurer: claim accepted, rejected, specifically what is accepted, complicating factors.Attorney involvement, the good, the bad & the uglyRed flagsPCE (physical capacity evaluation)Med stat (medically stationary) one or more conditions, residuals: ROM (range of motion) muscle/nerve, amputation etc. palliative care, work restrictions, acute fluctuations, aggravation.Return to permanent work within capabilities.Vocational rehabAggravation = worsening. Claim reopening.Future careSettlement option

Just get started seeing WC patients, the "system" will coach you,

If you have a question, have your staff call the claim repThe claim rep will explain what comes next:

File 827 claim... Begin tx, insurer has 90 days to accept or deny

Claim acceptance, Dx modification

MCO's: CaremarkLibertyMajorisFarmersKaiser On the JobEtc.

Phone calls from doc directors, Disability Prevention Evaluation (DPC)

PT, exercise therapy, OMT, acupuncture etc.

(PCE) Physical Capacity Evaluation, simple/short or longer, specific to job or general

Vocational Rehab

Claim closure, (ROM) range of motion, neurological: motor strength 0-5/5 reflexes. 2point discrimination, sensation

Special cases of federal & railway employees

Permanent impairmentPermanent Accommodations

State Accommodation Fund $

Vocational RehabilitationPreferred Employee benefitsLawyers on both sides

AdjudicationPermanent impairment & Disability

Oregon State Vocational Rehab: non work comp system back up plan

Questions?

MVA

$100

PIP: personal injury protectionCan be quickly exhausted

Motor Vehicle Accident Injury Treatment

-The dynamics & incentives different from WC:

-Time loss, time to settlement, PIP, one, two year, fragile egg, civil litigation, no holds barred litigation/jury trial/arbitration

-Insurance Company claim #

-SOAP or EMR note: Working? Light duty?

-PIP expired? Tx within PIP

-Difficulty securing Orthopedic Surgical consultation

-Letter of protection from lawyer? Rare instances when used (no health insurance), etc

-Court testifying , phone or office deposition

Questions?

5909 SE Division St. Portland, OR 97206

Phone: (503) 234-1531

http://www.anthroclinic.com