L&I Didactics Dec 11, 2012

Labor & Industries 101 The Basics and Claim Management Matt Schlough MD, Swedish FH R2 Lee Glass MD JD, Associate Medical Director, Washington State L&I Emily Stinson, former claims manager, Washington State L&I Sources: www.lni.wa.gov, L&I Attending Doctor’s Handbook, L&I Attending Provider’s Return to Work Desk Reference L&I Didactics Dec 11, 2012

Agenda • Objectives • Background • Claim management • Cases • View from the organization L&I Didactics Dec 11, 2012

Objectives • To understand why L&I exists • To understand the various roles L&I serves • To understand the role of the Physician in claims • To gain exposure to basic claim management • Different parties involved, Documentation, Referrals, Pre-authorizations • To gain appreciation of the perspective from L&I L&I Didactics Dec 11, 2012

Background – Why does L&I exist? • Employee: • Poor work safety regulations • If injured, became jobless with no financial assistance • Had to prove employer liability with limited resources • Employer: • Lengthy and costly legal suits L&I Didactics Dec 11, 2012

Background – The Solution: L&I • Injury Prevention • Work safety – site inspection, gives free evaluations, inspects building premises (electrical, boilers, elevators) • Worker's rights - child labor laws, minimum wage • Worker qualification- licensing of plumbers, electricians, amusement park rides, construction contractors • Injury Treatment • Ensure adequate medical care and financial support to get back to work swiftly L&I Didactics Dec 11, 2012

Background – But How? • No Fault Industrial Insurance Fund • Employee – Gets job protection, objective evaluation, medical care, $ • Employer – Cannot be sued for damages • $ in • Premiums paid by employer (70-80%) • Premiums deducted from employee paycheck (20-30%) • premiums vary by industry sector ($8/hr in logging/roofers) • Other - fines from inspections, slight $ from state budget • $ out • Medical expenses, including workplace modification • Time loss • Awards • Pensions L&I Didactics Dec 11, 2012

Background – Some WA numbers • 180,000 claims/year, 85% get accepted, ~700 claims/business day • Injured person on Time Loss for 3 months has 50% chance of being on Time Loss at 12 months • Injured person off the job for 2 years has <15% chance of ever returning to work • <5% of claims account for 84% of costs • Average Time Loss claim costs $20,000 L&I Didactics Dec 11, 2012

Background – Impact of not working • Stress on family relationships • Financial stress (mentally and in the bank account) • Decreased confidence and self-worth • Depression • Acceptance of a Disability Lifestyle • Importance? • As a provider- Goal=GET PT BACK TO WORK • Time is of the essence! Prevent long term disability! L&I Didactics Dec 11, 2012

Claim Management – Claim Initiation 1 • State Fund vs Self-Insured • Concept of Proximate Cause • Occupational Injury vs Disease • What’s not covered (mental stress, “palliative care”) L&I Didactics Dec 11, 2012

Claim Management – Claim Initiation 2 • Where do L&I patients present? • ED, urgent care, family doctor • When will primary care physicians see L&I patients? • ED or urgent care f/u, initial visit, or transfer or care from other L&I provider L&I Didactics Dec 11, 2012

Claim Management – Outcomes • Gets treatment, full recovery, case closed. • Permanent Partial Disability • Maximal Medical Improvement (“Fixed and Stable”) • Permanent Total Disability • When do patients get $? • Time Loss • Awards • Pensions L&I Didactics Dec 11, 2012

Claim Management • MD Responsibility • Identify and treat work related problems • Report on progress • Get vocational assistance when necessary • Rate impairment when maximum medical improvement achieved L&I Didactics Dec 11, 2012

Claim Management – Initial Visit • Who needs a claim application filled out? • Determine if State Fund or Self-Insured • Different Claim application (Accident Report vs Physicians Initial Report) • Determine if Injury or Disease • For acute injury, must be filed <12 months from DOI • For disease, must be filed <24 months from diagnosis • If disease, pt must fill out Occupational History Form • If disease, fill out Date of Injury as “not applicable” L&I Didactics Dec 11, 2012

Claim Management – Documentation • ONLY ADDRESS INJURY RELATED FINDINGS!!!!! • Needs separate encounter, documentation, and billing if you want to address items such as HTN, immunizations, health maintenance, chronic conditions (unless exacerbated by the injury) • SOAPER format • Subjective – Include DOI, detailed timing and mechanism of injury • Objective – Very important to document P/E findings • Assessment (with ICD9 codes) – Acceptable and not acceptable diagnoses, ie Strain, Contusion, Sprain. Absolutely no “symptom” codes. • Plan - Include any functional improvements, risks for long term disability, tx with frequency and expected duration, medication Rx with #tabs • Employment issues - Is pt returning to work, in what capacity, when anticipate return to work • Restrictions to work- What are the barriers, can do modified work?, need for return-to-work assistance?. every time include why is the pt still disabled • Activity Prescription Form L&I Didactics Dec 11, 2012

Claim Management- Initial Treatment No Pre-authorization • Up to 20 office calls • Diagnostic Xrays • First 12 PT treatments • Necessary routine labs • Specialist Consultation Pre-authorization • Pre-existing condition • Subsequent Xrays, MRI/CT • Job/Home/Vehicle modification • Injections • Any surgeries • Psychiatric care • Specialty prgms (obesity treatment, pain mgmt, etc) What is never covered? Acupuncture, exercise, experimental, palliative How Do I get Pre-Authorization? L&I Didactics Dec 11, 2012

Claim Management- Specialist care • Specialist must be an L&I approved specialist • Psychiatric care – a unique referral and treatment • Goal is swift care • Ok to diagnose if meeting DSM criteria (in note, say strong suspicion of PTSD) and start Rx, but must call Claim mgmr that day to inform and refer to Psych L&I Didactics Dec 11, 2012

Claim Management- Ongoing Mgmt 1 • Patient must be seen min every 60 days • 60 day Report • When to close the claim – “Fixed and Stable” • What if going no where after 120 days • What the heck is an IME? L&I Didactics Dec 11, 2012

Claim Management- Ongoing Mgmt 2 • Long term disability prevention • Language barriers and assistance • vocational rehab counselor, even just to explore options • you should initiate a review for return-to-work assistance (ie vocational counselor) if you believe: • pt can do transitional work during recovery, even if a few hrs a day • job modification may speed pt's return to work • pt may not be able to return to old job physically • How to do it: call the claims mgmr L&I Didactics Dec 11, 2012

Claim Management- Other • Transfer of care – Need to fill out transfer of attending form! • Claim Re-opening • Must demonstrate worsening of injury since claim closure! • Must be >60 days from Closure, otherwise Appeal • Appeals L&I Didactics Dec 11, 2012

Claim Management- Important People • Claims Manager • Utilization Review L&I Didactics Dec 11, 2012

Claim Management - Payment • in person conferences • telephone calls • impairment ratings • paperwork - report of accident, physical capacity form, review of job offer, detailed occupational disease history L&I Didactics Dec 11, 2012

Claim Management • Provider Hotline 1-800-848-0811 to answer general and specific claim questions • Injured workers can call 1-800-831-5227 for assistance (Interactive Voice Response) or 1-800-LISTENS (547-8367) (Office of Information and Assistance) or their claim manager • Preferred drug list hotline 1-888-443-6798 • Specific Diagnostic & Treatment algorithms L&I Didactics Dec 11, 2012

Cases • 55 yr old Caucasian F with R hand numbness/tingling • 41 yr old Latino M with burn to arm and nightmares • 42 yr old Fijian M s/p back injury 2001 L&I Didactics Dec 11, 2012

Cases • 55 yr old Caucasian F with R hand numbness/tingling • Take Aways: • Diagnosis based treatment guidelines: FOLLOW THEM! L&I Didactics Dec 11, 2012

Cases • 41 yr old Latino M with burn to arm and nightmares • Take Aways: • Psych care • Long term disability prevention L&I Didactics Dec 11, 2012

Cases - Risk factors for long term disability • Catastrophic injury • Hospitalization • Injury to dominant hand • Pre-existing psych conditions • No objective findings on exam • Injury occurring in course of usual work activities • Time gap in reporting injury • Frequent changes of attending physician • Application for re-opening • Over-utilization of healthcare delivery systems • Number of surgeries required for same problem • No medical progress • 90 or more days of time loss • Drug/alcohol abuse • Depression/PTSD • Hx of victim of abuse • Low education level • English not primary language • Anger at employer • Not active in return-to-work efforts • Pt thinking they will be re-trained for new job • Third party involvement L&I Didactics Dec 11, 2012

Cases • 42 yr old Fijian M s/p back injury 2001 • Take Aways: • Setting expectations; Not getting bullied • Long term disability prevention L&I Didactics Dec 11, 2012

Most Important Points • Goal => Get patient back to work • Think about minimizing long term disability risk • Do not mix Injury and Non-injury related medical care in a L&I encounter • Follow treatment guidelines • When in doubt, call your claims manager L&I Didactics Dec 11, 2012

L&I Didactics Dec 11, 2012