New Communication Guidelines Between Payors and Medical Providers To Reduce Unnecessary Hearings in CT

Effective July 1, 2010 the Connecticut Workers Compensation Commission established new guidelines to enhance communication between payors and medical providers in the workers compensation context. The goal of these guidelines is to improve the coordination of medical services to benefit both the employee by restoring their health as quickly as possible and the employer by returning a valuable employee to work without the need to defend a costly personal injury civil suit. In the introduction to these new guidelines the Commission explains that the major impediment to the delivery of prompt medical services is the lack of communication between the payors and providers. This lack of communication requires a voluminous number of largely unnecessary hearings wasting time and resources of the Commission as well as claimants and respondents. As such, these new guidelines target the “breakdown in communication” between health care providers and respondents with the goal of establishing a cooperative system to enable injured workers to promptly obtain necessary medical services.

In terms of payor responsibilities in these guidelines, the unmistakable goal is consistency in how claims are handled. Regarding accepted claims where all parties acknowledge an injury occurred in the course of employment, the new guidelines first mandate that voluntary agreements be issued on all accepted lost-time cases. Second, in accepted cases no “pre-approval” can be required by payors for basic medical services such as routine office visits and physical therapy for the accepted body part. Third, in these cases the guidelines advise that all forms of communication between health care providers and payors; telephone calls, facsimiles, e-mails, etc. should be returned in two business days. This rule is intended to include payors’ requests for medical records. While this rule will frankly be difficult to enforce, it is referenced on numerous occasions throughout the new guidelines.

Keeping in mind that prompt communication is required; the guidelines remind payors and their representatives that they are only permitted to communicate directly with treating physicians in writing with notification to all parties. Claimants and their counsel are conversely prohibited from speaking with a Respondent’s examining physician. Finally, in the event that a Commissioner’s Exam occurs, neither party can communicate with the examining physician except through the Commissioner who ordered the exam itself.

Regarding extensions of treatment requested by claimants, in accepted cases, the guidelines require that payors decide to approve or deny further diagnostics and/or treatment plans and communicate that decision to both the claimant and the authorized physician within five business days from the date of the claimant’s request. Due to the cost of such studies and/or treatments, written authorization is required for the following: EMG, CT scan/MRI, Bone Scan, Epidural steroid injection, Additional physical therapy and/or chiropractic treatment beyond the Commission’s Medical Protocols, surgery, diagnostic arthroscopy, pain management, physical rehabilitation, referrals for second opinions and functional capacity evaluations.

Should a payor deny any of the above treatment/diagnostic studies, or contest a claim in general, a Form 43 should be filed and the payor should consider the need to refer to peer or utilization review or schedule a Respondent’s Medical Exam with a provider in a similar medical specialty. The “Respondent’s Medical Exam” (previously referred to as an Independent Medical Exam) if pursued, must be scheduled within twelve calendar days of the payor’s receipt of the claimant’s medical reports. The RME must then be held within sixty calendar days after it is scheduled. In terms of the medical provider responsibilities when an “RME” occurs, the examination report must be issued within twenty-one days of the exam. Again, while difficult to enforce, the objective behind these guidelines is simply to expedite the communication between payors and providers.

In regards to contested claims, it is imperative that payors serve a Form 43 on the Commissioner and the claimant within twenty-eight days of receipt of the written notice of the claim. However, even in contested cases the guidelines encourage payors to authorize evaluations or even indemnity benefits without prejudice pending pursuit of an RME.

In the event that a hearing is necessary to decide a Form 43, the guidelines require that the payor’s representative at the hearing have authority to potentially resolve the noticed issue. Conn. Admin. Reg. § 31-279-5. Further, if the same issue remains unresolved and the matter proceeds to a preformal hearing, an adjustor must be available by telephone to assist in resolution. If no authority is provided by the time a matter reaches the preformal stage, the guidelines permit sanctions/penalties at the presiding Commissioner’s discretion.

As medical providers have a pivotal role in the handling of workers compensation claims the guidelines set forth an array of responsibilities on their end as well. In accepted cases, medical providers should not seek pre-approval for rendering routine medical services unless it has been more than one year since the claimant’s prior treatment. After rendering treatment in these cases, providers must furnish reports to the payor and the claimant within thirty days of the treatment’s completion. Connecticut General Statutes § 31-294f (b). The requisite content of these reports is specified in the guidelines and includes the following: the injury history and causal relationship to work (if applicable), the claimant’s current complaints and the physical findings of the exam, the diagnosis and treatment plan, and the claimant’s present work capacity and restrictions if any. If the treating physician desires to refer a claimant to a specialist and/or for a second opinion, the request must be made in writing to the payor and include a medical basis for the same. Finally, medical providers are instructed to maintain a summary sheet in each respective claimant’s file including: employer identification, claim number, adjuster name and contact information, the medical care plan applicable and its requirements.

In terms of medical providers’ responsibilities with contested claims, the guidelines advise that payors may contest claims on the basis that they are untimely, non-compensable, not the cause of injury due to a subsequent intervening event, or because the treatment requested is not considered reasonable and/or necessary (i.e. palliative). When the claim itself or specific treatment for a claim is denied the provider may need to justify treatment recommended or be willing to testify at a hearing regarding their findings. In terms of payment for treatment in contested cases, if the claimant is covered by a group health insurance policy, the insurer must pay for the claimant’s treatment. C.G.S. § 31-299a. In the absence of group health, the guidelines emphasize that attorneys are prohibited from paying for treatment but that a provider has the right to request a Commission hearing to discuss any bills outstanding.

As the additional obligations placed on medical providers in these guidelines may be met with some resistance, the penalties found in the pre-existing General Statutes Administrative Regulations can be exercised on those physicians who do not comply. Specifically, physicians who fail to comply with the guidelines established by the Commission can be removed from the approved list of physicians to provide treatment in workers compensation cases. C.G.S. § 31-280 (b)(10); Conn. Admin. Reg. § 31-279-9 (g).

Finally, though at first glance they appear minimal, the guidelines do establish obligations on injured workers as well. In accepted cases claimants must immediately notify their employer of the injury and attend all scheduled appointments to obtain written updates on work status. If further treatment beyond initial exams is required, claimants can select a medical provider from the employer’s approved workers compensation network or within the state of Connecticut if none exists. If at any point a payor desires to pursue an RME, or in the event that the Commissioner orders an examination, the claimant must attend and bring any relevant radiographic studies. The guidelines further recommend that claimants review all medical reports to ensure their accuracy.

In contested cases claimants are instructed to contact their employer to attempt to resolve the issue absent a hearing and provide any further information requested. In the event resolution is not possible, the claimant should request a hearing if he or she elects to pursue a claim. Group health insurance, Medicare, Medicaid and Veteran’s benefits are available to pay for treatment when claims are contested but the guidelines advise that claimants should keep a detailed record of any out of pocket expenses incurred.

While these guidelines appear quite broad, the Commission’s goal in enacting them is quite simple; to expedite the claims process and avoid the need for unnecessary hearings. Although the obligations imposed on payors and medical providers in particular appear extensive, no new penalties were established for those who do not comply. Accordingly, only time will tell if the guidelines can accomplish their intended purpose.

Authors: Collette S. Griffin, Esq., Howd & Ludorf, LLC, Hartford, CT represents employers, self-insureds and insurance carriers in workers compensation matters. Contact Info: 860-249-1361; www.hl-law.com

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