Navigating the Oregon Workers Compensation System

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Jerome Barker
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1 Navigating the Oregon Workers Compensation System Pain Society of Oregon Eugene Chapter January 20, 2016 Jennifer Flood, Ombudsman for Injured Workers DCBS Steve Passantino, Manager Sanctions & Medical Resolution Manager, WCD DCBS Faculty Disclosure PeaceHealth Sacred Heart Medical Center declares that their Continuing Medical Education (CME) coordinator, CME chair, all CME Committee members and the speakers, Jennifer Flood and Steve Passantino, along with anyone in a position to control the content of an education activity disclose that they have no relevant financial relationships with any commercial interest to the provider. The ACCME defines "relevant financial relationships" as financial relationships in any amount occurring within the past 12 months that create a conflict of interest. Any conflicts of interest will be posted. Office of the Ombudsman for Injured Workers Created in 1987 ORS Advocate for injured workers ensuring they understand the claim process and their rights and responsibilities. Inquiries Staff of five inquires a year that contacts. Fatal claims / Scholarship programs Advisory function Outreach and education 1

members and the speakers, Jennifer Flood and Steve Passantino, along with anyone in a position to control the content of an education activity disclose that they have no relevant financial

2 WC Division Medical Resolution Team Medical Resolution Team (MRT) processes disputes from insurer s, providers, worker s, and other parties regarding payment issues, rule violations, and appropriateness of care. Avg. 2,300 disputes annually, a large number being fee disputes. Approximately 70% resolved through Alternative Dispute Resolution (ADR) process Treatment appropriateness, particularly medication disputes are the most complex WC Division Sanctions Unit Sanctions Unit supports the other units in the division Reviews for rule/statute violations and may issue a warning letter or penalty, if appropriate Process approximately 3,500 disputes annually Regulates performance of insurers, provider s, worker s, and attorney s in accordance with the statutes and rules governing Oregon WC claims and processing What s new Compound drugs ie creams New rule 83.5% of the AWP plus $2.00/drug dispensing fee for non sterile preps and $4.00/drug dispensing fee for sterile preps Pain Pump refills Being analyzed by the Division. See charges for the medication up to 2,000% of the invoice charge. 2

Approximately 70% resolved through Alternative Dispute Resolution (ADR) process Treatment appropriateness, particularly medication disputes are the most complex WC Division Sanctions Unit Sanctions

3 Claim process Worker s initial perspective Injured at work Receive medical treatment Receive wage replacement Recover from injury Return to regular work Simple right? Oregon Workers Compensation Subject employer/worker WC insurance Claim filing Provider choice Medical Services Time loss benefits & modified work Claim management accept or deny, IME s, disabling or non disabling, etc Medically stationary & Claim closure Appeal rights & Settlements Red Flags and Speed Bumps Insurance Coverage: No coverage found for employer Claim filing: Employer doesn t want claim filed under WC Worker fears being fired Worker doesn t want to file Provider Choice & Medical Services: Worker can t find doctor to treat WC injury Employer directs worker to provider Worker enrolled in MCO, but attending physician not part of MCO Provider wants preauthorization before providing treatment Delay in surgery review/approval 3

non disabling, etc Medically stationary & Claim closure Appeal rights & Settlements Red Flags and Speed Bumps Insurance Coverage: No coverage found for employer Claim filing: Employer doesn t want

4 continued Red Flags/Speed Bumps Provider hasn t been paid delay in treatment MCO complications Lack of enrollment notification When is authorization required for meds, surgery, post med stat services, diagnostics Curative v. Palliative care TFESI, injections (ie steroid injection for chronic tendonopathy issues) Surgery or delivery of prescription medications. Those billed under 2000 CPT codes often consider surgery, but not by WC delivery of prescription medications continued Red Flags/Speed Bumps Time loss benefits & modified work Inaccurate wage at injury impacts several benefits No Attending Physician authorization Released to regular work worker can t do regular work Released to regular work, but on pain medication that is prohibits regular work (truck driver, crane operator, etc) Released to modified work employer won t offer modified work Released to modified work employer having worker work outside of work restrictions Worker told they will never be able to do job at injury continued Red Flags/Speed Bumps Claim management Accept/deny time frame Compensable injury vs accepted conditions Insurer has right to IME worker has obligation to cooperate Claim adjuster tells medical provider won t pay Claim adjuster won t return calls to worker or medical provider Worker stops seeking treatment Medically Stationary & Claim closure Medically stationary for compensable injury Claim closure for compensable injury 4

Those billed under 2000 CPT codes often consider surgery, but not by WC delivery of prescription medications continued Red Flags/Speed Bumps Time loss benefits & modified work Inaccurate wage at

5 continued Red Flags/Speed Bumps Appeals & Settlement Claim denial on appeal ongoing treatment stopped Claim denied and disputed claim settlement approved outstanding medical bills Claim was CDA d (Claim Disposition Agreement) now medical isn t being paid 5

disputed claim settlement approved outstanding medical bills

What do I do about time missed from work to attend appointments relating to my injury?

What do I do about time missed from work to attend appointments relating to my injury? An injured worker needs to use accrued leave to be paid for time missed from work to attend appointments relating