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
BRIEF ORIGIN http://erd.dli.mt.gov/work-comp-claims/medical-regulations/re-opening-of-work-comp-closed-medical-benefits
Purpose of Reopening Benefits • ALLOWS WORKER TO STAY AT WORK • ALLOWS WORKER TO RETURN TO WORK
ADMINISTRATIVE PROCESS http://erd.dli.mt.gov/work-comp-claims/medical-regulations/re-opening-of-work-comp-closed-medical-benefits
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 Medical Director Only NOTIFICATION Review the medical records LETTER… Medical Director opines on whether benefits should be reopened Notify Department Based on the Medical Director opinion immediately if not an accepted claim Panel Review Indicate choice of review • Medical Director Medical director and two other physicians • Panel Review Review the medical records Defaults to panel review Each reviewer opines on whether benefits should be reopened if there isn’t consensus 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 Reopen medical Do not reopen benefits with a two medical benefits year review At The Time Of The 2 Year Review… Open medical benefits for Close another two years MEDICAL PROCESS
INJURED WORKER NOT AT MMI Plan for further diagnostic evaluation or definitive procedure Body part/condition specific Guideline applies MEDICAL PROCESS http://www.mtguidelines.com/MedPro/BrowseChapters.aspx?cps=MT
INJURED WORKER IS AT MMI Plan for conservative treatment (e.g. medications, episodic PT/chiropractic, psychosocial counseling, etc.) Chronic Pain Disorder Guideline applies MEDICAL PROCESS http://www.mtguidelines.com/MedPro/BrowseChapters.aspx?cps=MT
Standard of Proof Percentage More than mere speculation or Substantial, credible evidence possibility, but < 51% Preponderance of Evidence 51% reasonable certainty Clear and convincing 75% reasonable certainty Beyond a reasonable doubt 99% reasonable certainty MEDICAL PROCESS Adapted from Jason Swan's “Five-Year Closure” presentation
Petitions as of 03/05/18 149 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 85 + Reopened 55 30 Remain closed 13 21 34 68 + Total 51 81% reopened 59% reopened 19% remain closed 41% remain closed *Includes joint petitions PETITIONS TO DATE + 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 outlined in the Guidelines – Guideline requires prior authorization before proceeding INDICATIONS http://erd.dli.mt.gov/work-comp-claims/medical-regulations/utilization-and-treatment-guidelines/independent-medical-review-process
http://erd.dli.mt.gov/work-comp-claims/medical-regulations/utilization-and-treatment- ADMINISTRATIVE PROCESS guidelines/independent-medical-review-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- ADMINISTRATIVE PROCESS treatment-guidelines/independent-medical-review-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- opening-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
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