Reopening Petitions & Independent Medical Reviews Maggie - - PowerPoint PPT Presentation

Reopening Petitions & Independent Medical Reviews

Maggie Cook-Shimanek, MD, MPH March 15, 2018

Reopening Petitions - Outline

• Brief origin and overview of petition process
• Purpose of reopening medical benefits
• Where to find the appropriate forms
• Petition data to date

http://erd.dli.mt.gov/work-comp-claims/medical-regulations/re-opening-of-work-comp-closed-medical-benefits

BRIEF ORIGIN

Purpose of Reopening Benefits

• ALLOWS WORKER TO STAY AT WORK
• ALLOWS WORKER TO RETURN TO WORK

http://erd.dli.mt.gov/work-comp-claims/medical-regulations/re-opening-of-work-comp-closed-medical-benefits

ADMINISTRATIVE PROCESS

PETITION TO REOPEN CLOSED MEDICAL BENEFITS

Injured worker/ representative initiates, completes, and submits the petition to the Department OR Notify the Employment Relations Division of intent to petition

ADMINISTRATIVE PROCESS

JOINT AGREEMENT AND PETITION TO REOPEN CLOSED MEDICAL BENEFITS

Injured worker/ representative OR insurer initiates, completes, and submits the petition to the Department Both injured worker and insurer sign and date petition

ADMINISTRATIVE PROCESS

Validating Petitions

Eligible for medical review if…

• Accepted claim – not under 608, 615
• Falls within the 90 day window before medical

benefits terminate

• Not five years past the medical benefits

termination

• Medical benefits are not settled or closed by

court order

• Not a permanent total disability or prosthesis

ADMINISTRATIVE PROCESS

14 Calendar days allowed for medical records

ADMINISTRATIVE PROCESS

UPON INSURER RECEIPT OF NOTIFICATION LETTER…

Notify Department immediately if not an accepted claim Indicate choice of review

• Medical Director
• Panel Review

Defaults to panel review if there isn’t consensus

Medical Director Only Review the medical records Medical Director opines on whether benefits should be reopened Based on the Medical Director opinion Panel Review Medical director and two other physicians Review the medical records Each reviewer opines on whether benefits should be reopened Based on the consensus of the panel

ADMINISTRATIVE PROCESS

Odds & Ends

• Medical benefits can only be reopened through the petition

process

– Do not petition for mediation to reopen closed medical benefits – Either party can petition for mediation after the petition process

• Records ≥ 5,000 pages

– FOR JOINT PETITIONS ONLY – may submit < 5 years – Submit shorter time frame, allowing reviewer to understand treatment

• Insurer provides a letter indicating the time frame
• Insurer may not select medical records for submission
• Insurer may be required to submit all records at any future review

ADMINISTRATIVE PROCESS

Possible Outcomes of Petition Process

Do not reopen medical benefits Reopen medical benefits with a two year review Open medical benefits for another two years Close

MEDICAL PROCESS

At The Time Of The 2 Year Review…

INJURED WORKER NOT AT MMI

Plan for further diagnostic evaluation or definitive procedure

MEDICAL PROCESS

http://www.mtguidelines.com/MedPro/BrowseChapters.aspx?cps=MT

Body part/condition specific Guideline applies

http://www.mtguidelines.com/MedPro/BrowseChapters.aspx?cps=MT

MEDICAL PROCESS

Plan for conservative treatment (e.g. medications, episodic PT/chiropractic, psychosocial counseling, etc.)

INJURED WORKER IS AT MMI

Chronic Pain Disorder Guideline applies

Standard of Proof Percentage

Substantial, credible evidence More than mere speculation or possibility, but < 51% Preponderance of Evidence 51% reasonable certainty Clear and convincing 75% reasonable certainty Beyond a reasonable doubt 99% reasonable certainty

Adapted from Jason Swan's “Five-Year Closure” presentation

MEDICAL PROCESS

149 Petitions Received

120 Petitions Reviewed

• 86 (71.7%) Reopened
• 34 (28.3%) Remained Closed

15 Determination Pending 12 Dismissed, Outside 90 Days prior to closure 2 others (received, suspended)

Medical Director Only* Panel Review Reopened 55 30 85+ Remain closed 13 21 34 Total 68+ 51 81% reopened 19% remain closed 59% reopened 41% remain closed

Petitions as of 03/05/18

PETITIONS TO DATE

*Includes joint petitions

+Other=1

Summary

• A worker can petition to reopen medical

benefits after 60 months

• Forms are available on the DLI website
• Medical reviewer opines if the worker needs

medical treatment to return to or stay at work

QUESTIONS?

QUESTIONS?

Independent Medical Review IMR

IMR - Outline

• Circumstances where an IMR is appropriate
• Process for submitting an IMR
• Medical Director review process

Indications

• “Informal alternative dispute resolution process”
• Requires denial of prior authorization by the insurer
• Occurs in cases where

– Treatments/procedure is not specifically addressed/ recommended by the Guidelines – The patient is post-MMI – Proposed treatment goes beyond the duration/frequency

• utlined in the Guidelines

– Guideline requires prior authorization before proceeding

http://erd.dli.mt.gov/work-comp-claims/medical-regulations/utilization-and-treatment-guidelines/independent-medical-review-process

INDICATIONS

http://erd.dli.mt.gov/work-comp-claims/medical-regulations/utilization-and-treatment- guidelines/independent-medical-review-process

ADMINISTRATIVE PROCESS

Independent Medical Review

ITEMS TO INCLUDE

Medical records Prior authorization request and denial Citations and/or supporting literature, other guideline sources, etc.

http://erd.dli.mt.gov/work-comp-claims/medical-regulations/utilization-and- treatment-guidelines/independent-medical-review-process

ADMINISTRATIVE PROCESS

Within 5 days of receipt, the Medical Director may request additional medical records or time for review Within 14 days of receipt, the Medical Director will issue a written recommendation If there is no recommendation within 14 days, the request for review is deemed denied and parties may proceed to mediation

ADMINISTRATIVE PROCESS

Within 5 days of receipt of the recommendation, the insurer will notify the interested party, if the treatment or procedure is authorized If the insurer does not authorize treatment after issuance, the interested party may file for mediation with the department (MCA 39-71-2401)

ADMINISTRATIVE PROCESS

QUESTIONS?

QUESTIONS?

Resources

• Montana Utilization and Treatment Guidelines

– http://www.mtguidelines.com/MedPro/BrowseChapters.aspx?c ps=MT

• Petition to reopen medical benefits

– http://erd.dli.mt.gov/work-comp-claims/medical-regulations/re-

• pening-of-work-comp-closed-medical-benefits
• IMR Requests

– http://erd.dli.mt.gov/work-comp-claims/medical- regulations/utilization-and-treatment-guidelines/independent- medical-review-process

• Montana Code Annotated

– http://leg.mt.gov/bills/mca/index.html