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Overcoming Medical Barriers

A resource for vocational counselors and claim managers

July 9, 2009.

Purpose

  • Clarify roles and responsibilities.
  • Encourage collaboration and the development of action plans to address issues.

Issues

1. Referral is not appropriate
Example
There are known medical issues that will preclude participation in vocational services.
Possible VRC actions Possible CM actions
After review, Use ADMA – VRC declines referral. Cite rationale on VCLOS cover sheet.
  • Review VRC rationale for not accepting referral and resolve issues prior to making a new referral.
  • Review VRC rationale for not accepting referral and close voc referral.
  • Resolve issues prior to making a new referral.

2. No current APF/medical
Example
The most recent APF is outdated and worker is complaining of pain.
Possible VRC actions Possible CM actions
  • Request an updated APF via the CAC/EVOC.
  • Meet/write/consult with AP.
  • Review file and identify medical issues that need resolved.
  • Determine whether an APF is needed or whether a letter or telephone call is required.

3. Worker is not released to work full-time but work pattern is full-time
Example
APF or other medical information suggests worker's restrictions have changed to part-time.
Possible VRC actions Possible CM actions
  • Meet/write/consult with AP.
  • Consider recommending work conditioning, work hardening, or graduated return to work.
  • Discuss LEP with employer, worker, and AP.
Facilitate authorization of requested services, if appropriate.

4. Pain clinic is recommended
Example
Pain clinic is recommended at the time of referral or during an open referral.
Possible VRC actions Possible CM actions
Follow worker through pain clinic according to MARF guidelines.
  • AWA referral should be used if voc is part of pain clinic.
  • Review and if appropriate authorize requested services.

5. Worker gets a new AP
Example
New AP may need to be brought up to speed and may have new treatment recommendations.
Possible VRC actions Possible CM actions
  • Meet/write/consult with new AP.
  • Request an updated APF via the CAC.
  • Request an exception to fee cap if needed.
  • Provide new AP with relevant claim information. Request narrative report with APF.
  • Review vocational progress via progress reports and respond to requests for department action.

6. AP is hesitant about capacities
Example
Ongoing diagnostic testing – referring to specialists, active treatment, etc.
Possible VRC actions Possible CM actions
  • Meet/write/consult with AP.
  • Consider recommending PBPCE.
  • Collaborate with claim manager on action plan.
  • Request updated APF via CAC/EVOC.
  • Consider recommending work conditioning, work hardening, or graduated return to work.
  • Work with VRC to develop an action plan.
  • Facilitate authorization of requested services, if appropriate.
  • Determine if APF is needed.
  • Ask AP if want to refer for consult to determine capacities.

7. AP will not respond to VRC requests for information
Example
  • AP will not respond to written request.
  • Out of state AP doesn’t understand WA II.
  • AP will not respond to submitted JAs.
Possible VRC actions Possible CM actions
  • Meet/write/consult with AP.
  • Document efforts to obtain response.
  • Collaborate with claim manager on action plan.
  • Work with VRC to develop an action plan.
  • Call AP and request cooperation with VRC requests.
  • Ask AP if want to refer for consult to determine capacities.

8. AP is requesting IME to review JAs
Example
AP will not respond to VRC request to review JAs.
Possible VRC actions Possible CM actions
Notify CM of request via telephone and progress report – explain impact on referral resolution.
  • Review file and schedule IME, if appropriate.
  • If IME is not warranted, call AP and request JAs be reviewed.
  • Ask AP if wants to refer for consult to determine capacities (PBPCE).

9. AP is requesting treatment authorization
Example
AP will not respond to VRC request for information regarding RTW.
Possible VRC actions Possible CM actions
Notify CM of request via telephone and progress report – explain impact on referral resolution.
  • Review file and authorize APs requested treatment, if appropriate.
  • Call AP to determine if treatment prevents worker from participating in Voc.

10. Worker has an unrelated post- industrial medical condition which impacts voc referral resolution
Example
Auto accident after referral.
Possible VRC actions Possible CM actions
  • Report new medical issue to department.
  • Collaborate with claim manager on action plan.
  • Review new medical to determine impact of unrelated condition on referral resolution.
  • Close referral ADM2 or SNA3 if appropriate.
  • Write AP and determine whether new condition(s) have any bearing on continued eligibility for time loss and vocational services. Determine diagnosis and prognosis, and any impact the effects of the new condition(s) have on the accepted condition(s).
  • Work with VRC to develop an action plan.

11. Medical Information changes
Example
  • AP places new restrictions on worker.
  • New restrictions not compatible with half completed approved voc plan.
  • Medical status changes and AP has not submitted new restrictions.
Possible VRC actions Possible CM actions
  • Collaborate with claim manager on action plan.
  • Consider PBPCE.
  • Request an updated APF via CAC/EVOC.
  • Consider modifying the plan.
  • Ask AP if new restrictions are supported by objective medical information and what was the cause for the change in restrictions.
  • Ask AP to arrange a consult.
  • Work with VRC to develop an action plan.

12. Surgery/recovery: over 90 days
Example
Fusion did not take.
Possible VRC actions Possible CM actions
Close ADM1. Close ADM1. Re-refer when medically appropriate.

13. Worker complains of pain
Example
  • Starts and stops retraining with complaints of pain.
  • Worker is struggling in return to work effort.
  • Worker is in plan threatening to quit due to pain.
  • Sedentary occupational goal approved by AP.
Possible VRC actions Possible CM actions
  • Meet with worker to understand issues. Identify an action plan (e.g., ergo. Chair; modified plan, etc.).
  • Collaborate with claim manager on action plan.
  • Refer to accountability agreement and report non-compliance to Dept.
  • Ask AP if there are any objective findings or rationale for change.
  • Begin non-cooperation process, if appropriate.

14. Running out of money on referral
Example
Fee cap reached as new barriers are encountered.
Possible VRC actions Possible CM actions
  • Follow fee cap guidelines listed in MARFs.
  • Determine if closure is appropriate or if an extension should be requested.
  • Follow guidelines in Management Memo "Voc fee cap reports" to close with ADM7 outcome.
  • Refer to unit VSS if VRC requests a fee cap exception.

15. Surgery/recovery complications: under 90 days?
Example
Post surgical infection of digit.
Possible VRC actions Possible CM actions
Keep working the referral and continue vocational services as soon as released to participate. Monitor worker and VRC activities, and medical reports.

16. New surgery approved (requested by AP and approved by CM)
Example
Hip replacement makes participation in voc questionable.
Possible VRC actions Possible CM actions
  • Review chart notes for additional information.
  • Meet/write/consult with AP to clarify restrictions and identify post-surgery rehab action plan. Communicate plan via progress report.
  • Determine if status will last longer than 90 days, if so, close ADM1.
  • Monitor worker and VRC activities, and medical reports.
  • If worker cannot participate in voc for more than 90 days, close ADM1.

17. Work conditioning/ work hardening delays completion of referral
Example
AP puts worker into a course of work conditioning or work hardening.
Possible VRC actions Possible CM actions
  • Provide JA for occupational goal.
  • Consult with Therapy provider to clarify goals and support progress. Communicate action plan via progress report.
  • Monitor worker and VRC activities, and medical reports.
  • Facilitate authorization of requested services, if appropriate.

18. Worker non coop
Example
  • IW is not actively participating in medical recovery.
  • Unexcused absence from class.
Possible VRC actions Possible CM actions
  • Provide clear expectations to worker, in writing.
  • Collaborate with claim manager on action plan.
  • If necessary, report worker non coop via CAC/EVOC and progress reports.
  • If CM finds worker non coop, follow case to determine if worker decides to cooperate.
  • Work with VRC to develop an action plan.
  • Begin noncooperation process, if appropriate.

19. Conflicting medical information
Example
  • Disagreements among medical providers.
  • AP, as sole medical provider, changes mind without providing objective medical.
  • Approved JA exceeds limitations set elsewhere. For example from an IME.
Possible VRC actions Possible CM actions
  • Collaborate with claim manager on action plan. Make CM aware of conflicting opinions.
  • Make vocational determination according to guidelines for medical preponderance, if the information is available. Note: Consult with VSS if unsure.
  • Work with VRC to develop an action plan.
  • Write to AP, ask for objective basis for disagreement.
  • Write to IME to request clarification.
  • Consider a medical consult or PBPCE.
  • Consider review with ONC/VSS/Therapist, claim lead, PA, etc. for complex claim staffing.

20. AP concurrence with IME undetermined
Example
IME has occurred but there has been no follow up to determine whether AP concurs.
Possible VRC actions Possible CM actions
Notify CM via telephone and progress report – explain impact on referral resolution.
  • Review file to determine if concurrence is needed.
  • If so, write AP and determine concurrence with IME. Ask for objective basis for any disagreement.

21. Need for IME to review JAs
Example
Upcoming (or just completed) IME during a voc referral.
Possible VRC actions Possible CM actions
  • Make sure that CM has copies of relevant JAs.
  • Notify CM of need for request via telephone and progress report – explain impact on referral resolution.
  • Ask IME to review relevant JAs.
  • If IME has already occurred, determine if IME can bill for addendum.

22. IW hasn't seen AP and/or doesn’t have an AP
Example
Worker's previous doctor retired – no referral made.
Possible VRC actions Possible CM actions
Notify CM of situation via telephone and progress report. Identify any barriers that this situation might present.
  • If worker has reached medical fixity and is in training, regular AP visits may not be necessary.
  • If not having an AP presents barriers, write worker and request that he/she see or obtain an AP.

23. LNI asks VRC to reconsider outcome recommendation after VRC has submitted for closure.
Example
VRC has submitted closing report and enters recommended outcome; CM then contacts VRC because new information has been received that may impact the outcome.
Possible VRC actions Possible CM actions
  • If CM request is less than 30 days from outcome recommendation, provide requested information and consider whether closing report and outcome recommendation need to be revised.
  • Request fee cap exception if needed.
  • If request is more than 30 days from outcome recommendation, consult with VSS.
  • CM may request that VRC obtain additional information if VRC outcome is less than 30 days old and CM has not yet closed the referral.
  • Consult with VSS if unsure.

Key
AP Attending medical provider.
VRC Vocational Rehabilitation Counselor.
CM Claim Manager.
APF Activity Prescription Form.
CAC Claim and Account Center.
JA Job analysis.
PBPCE Performance-based Physical Capacity Evaluation.
MARFS Medical Aid Rules and Fee Schedule.

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