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Medical Issues in an Ohio Workers Comp Case
There are two (2) general forms of benefits paid in workers' compensation claims: (1) compensation (also called "indemnity") and (2) medical benefits. At some point in the life of a workers' compensation claim, there will be a dispute over medical benefits. This usually arises when an attending physician files a C-9 request, or when a physician hired by the employer or Bureau of Workers' Compensation opines the injured worker no longer needs any treatment for the allowed conditions in the claim.
Form of Request
Typically, a physician makes a request for treatment on a C-9 form. Authorizations for treatment in state fund claims are made by managed care organizations ("MCO"). The MCO processes requests from the injured worker's attending physicians and medical providers for medical services, such as requests for treatment, diagnostic studies (x-rays, MRIs, CT Scans, etc.), physical therapy, consultation exams, medical appliances, and other treatment issues.
If the MCO disapproves or modifies the C-9 request, the injured worker and/or the attending physician may appeal. If an appeal is filed, an alternative dispute resolution ("ADR") process begins. This process consists of medical "peer review" and additional decision-making by the MCO. Ultimately, if the injured worker is still dissatisfied with the MCO's decision, the BWC reviews the matter and issues an Order, which the parties may appeal to the Industrial Commission of Ohio. Employers may also appeal decisions of the MCO if they disagree with an approval of a C-9 request.
For self-insured denials or modifications of C-9 requests, the injured worker should file an administrative motion with the BWC and request the Industrial Commission of Ohio schedule a hearing.
The Miller Criteria
The Supreme Court of Ohio in the case of State ex rel. Miller v. Indus. Comm. (1994), 71 Ohio St.3d 229, set forth a three-part test to determine whether a request for treatment, etc., should be authorized in a workers' compensation claim:
1. Are the medical services reasonably related to the industrial injury, i.e. the allowed condition(s) in the claim?
2. Are the services reasonably necessary for treatment of the allowed condition(s)? and
3. Is the cost of such service medically reasonable?
If the medical evidence supports a "yes" answer to each of these questions, then the treatment request should be approved. Unfortunately, there is often conflicting medical evidence (whether from the BWC or the employer's physician) and a hearing before the Industrial Commission invariably becomes necessary.
Sometimes, the physicians hired by the MCO or self-insured employer will state that the medical service is not reasonably related to the work injury. For instance, the injured workers’ attending physician may request an injection, but the MCO or self-insured doctor will state that an injection is not appropriate for the particular injury (medical condition) that is allowed in the claim. Recall that BWC claims are allowed for specific medical conditions (injuries), such as a herniated disc, rotator cuff tear, or tricompartmental arthritis. If the attending physician’s request for services is not reasonably related to the allowed conditions, then the MCO or self-insured employer will deny the request.
Similarly, if the medical services being requested have been rendered in the past, and the injured worker did not have a positive or lasting outcome, the MCO or self-insured employer may deny an additional request for the same services. The BWC and Industrial Commission of Ohio usually rely upon the Official Disability Guidelines (ODG), a set of general “rules” for treatment protocols. For instance, an attending chiropractic physician may keep requesting period after period of chiropractic adjustments in a workers’ compensation claim. The ODG has recommendations for how many periods or treatment visits are appropriate for an allowed condition. If the physician is requesting treatment that exceeds ODG, then the MCO or self-insured employer will state the services are not reasonably necessary.
Finally, the cost of medical services must be reasonable. This is largely a question of what the medical provider’s proposed bill will be in relation to other potential medical services that can be provided which may be less expensive.
At Zamora & Hogan Co., L.P.A., we argue medical issues before the Industrial Commission of Ohio nearly every day. A great volume of hearings we handle involve alternative dispute resolution (ADR) issues. These issues can also impact compensation in a claim; so if a treating physician is asking for treatment, we take those issues very seriously.