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The Workers’ Compensation Balancing Act

06.01.08 written by

Healthcare professionals who treat injured workers must perform a balancing act between their aspiration to provide excellent patient care and their obligation to comply with numerous requirements of the workers’ compensation system. With so many parties involved in the workers’ compensation system: injured worker, employer, managed care organization (MCO), Bureau of Workers’ Compensation (BWC) and representatives, the system can be overwhelming and adversarial at times. However, the goal should be the same from any parties’ perspective: that the injured worker receives necessary care for a full recovery and a rapid return to the workforce.

To that end, the treating physicians must comply with the sometimes arduous rules and regulations of the workers’ compensation system. As a medical provider who has undertaken treatment in an industrial case, you are obligated to provide the involved parties with information that you may not otherwise disclose to a third party. Though this may be disconcerting, it is a necessary means to reach the ultimate goal of a full and quick recovery for the patient.

Under Ohio law, the treating physician is obligated to submit a treatment plan and updates to the parties which includes the frequency, duration and expected outcome of treatment; the projected or anticipated return to work date; and the factors unrelated to allowed conditions that are impacting recovery. Further, the treating physician is obligated to submit periodic reports which demonstrate results of treatment, subjective complaints, objective findings, results of diagnostic testing, assessment and plan of care. Additionally, a physician (not necessarily the treating physician) may be asked to submit copies of records not only relative to the industrial injury but also those that are historically related. The parties are entitled to use this information to determine whether the current treatment plan and/or disability are related to the industrial injury or are related to other factors or conditions. A quick and candid response to those requests will result in an earlier determination regarding whether the treatment and/or compensation will be paid in the claim.

The denial of treatment in the claim is not necessarily indicative of a determination that the treatment is unnecessary or inappropriate. Rather, it may be an indication that is not necessary or appropriate treatment for the allowed conditions in the current workers’ compensation claim. When that occurs, the treating physician sometimes needs to assume the role of advocate for the injured worker and must take on the additional tasks of writing narrative reports to justify requests for treatment and filing appeals to the denied treatment.

If the injured worker is unable to return to work or has restrictions then the treating physician has the additional obligation to specifically identify and explain the injured worker’s physical capabilities in order for him/her to receive compensation for time off work. A BWC C-84 form must be submitted at least every 30 days along with supporting medical documentation. This documentation includes: the date of the last examination; the ICD code with a narrative description identifying the condition and specific areas of the body being treated; any reason why recovery has been delayed; the date disability began; the current physical capabilities of the injured worker; an indication of need for vocational rehabilitation; objective findings; and clinical findings supporting the period of disability.

The rigors of completing the various workers’ compensation documentation may seem cumbersome and may place the physician in an unaccustomed role. However, complete and accurate completion of the documentation is needed for the prompt and efficient administration of injury claims. Compliance should result in the obtainment of the goal of getting injured workers back to their pre-injury status with a full return to work.

NOTE: This general summary of the law should not be used to solve individual problems since slight changes in the fact situation may require a material variance in the applicable legal advice.