Labor Commission of Utah

Worker's Compensation
Handbook for Physicians

Updated May 12, 1998

Prepared by Dr. Boyd C. Holbrook
in cooperation with
the Labor Commission of the State of Utah

This "Workers' Compensation Handbook for Physicians" booklet is designed to assist providers in their relations with the Labor Commission of Utah. The information has been reviewed and approved by the Utah Medical Association's Labor Commission Relations Committee and the Labor Commission of Utah.

TABLE OF CONTENTS

INTRODUCTION
A. The Workers' Compensation Program
B. Administration of the Workers' Compensation Program
C. Eligibility for Workers' Compensation

MEDICAL CARE FOR WORKERS' COMPENSATION
A. Physician Selection
B. Referrals
C. Consultations
D. Special Medical Evaluations (Previously referred to as IME)
E. Dentist
F. Hospital or Surgery Pre-authorization
G. Rehabilitation
H. Prosthesis

COMPENSATION BENEFITS
A. Temporary Total Disability
B. Temporary Partial Disability
C. Permanent Partial Impairment Benefits
D. Permanent Total Disability
E. Death Benefits

PERMANENT PHYSICAL IMPAIRMENT RATING

REQUIRED MEDICAL FILINGS
A. The Physician's Initial Report of Injury/Illness (Form 123)
B. Restorative Services Authorization Form (Form 221)
C. Request/Authorization Form (Form 223)
D. Progress Reports/S.O.A.P. Notes
E. Release to Return-to-Work Form (Form 110)
F. General Recommendations
G. Patient Leaving The State (Form 043 or 044)

NOTE: Forms can be obtained by contacting the Labor Commission (801) 530-6800.

MEDICAL FEES
A. Labor Commission's Relative Value Fee Schedule (RVS)
B. Discounting of the RVS
C. Medical Care Billing

MEDICAL PANELS

OCCUPATIONAL DISEASES

ADJUDICATION PROCESS FOR DISPUTED CLAIMS

RULE R612-2, "WORKERS' COMPENSATION RULES - HEALTH CARE PROVIDERS"

INTRODUCTION

A. The Workers' Compensation Program.

The workers' compensation program is a state program. Each of the 50 states initiated and adopted such programs in the early 1900's. Utah's workers' compensation program became law in 1917. Federal employees are not covered under state workers' compensation programs.

Utah's program provides medical benefits and replacement of lost earnings at 66 per cent of weekly salary while a worker, due to an industrial injury or illness, is temporarily totally disabled. The system is a "no fault" system in that negligence does not have to be established by a worker or employer in order to receive benefits. The system was designed to provide a speedy remedy to an injured worker so that sustenance would continue while medical recovery took place and families would then, not be put in a hardship or onto welfare rolls. The employer enjoys the "exclusive remedy" provision in that an employee who is injured on the job may not sue their employer.

The workers' compensation program in Utah is a mandatory program. Every employer in Utah with even one part-time employee must have coverage, except for some exemptions for agriculture and domestic workers. Employers may insure their workers' compensation liability in one of 3 ways: 1) with a private insurance carrier; 2) with the Workers' Compensation Fund of Utah; or 3) by applying with the Labor Commission for the privilege of self-insuring. The Workers' Compensation Fund of Utah is now a quasi-governmental agency. The Fund is not a part of Labor Commission of Utah. It bears the same relationship to the Commission as do private insurance carriers and the self-insured employers.

B. Administration of the Workers' Compensation Program

The Division of Industrial Accidents, Labor Commission of Utah, has the responsibility of administering the workers' compensation program. The Division's responsibilities are:

Bringing uninsured employers into compliance of providing workers' compensation insurance for their employees;
Monitoring the reporting of injuries by employers and physicians;
Providing information and resolving problems with injured employees, providers, insurance carriers and employers;
Tracking claims to ensure promptness and fairness of payment;
Writing the rules in clarifying the statute governing workers' compensation;
Assisitng injured workers in getting medical bills paid;
Coordinating efforts to return the injured worker to the work force; and
Administering the self-insurance program.

The Labor Commission of Utah is always willing to provide whatever assistance it can. If the provider has questions or problems, he/she should feel free to contact Labor Commission of Utah for information regarding the process or problem. It is essential to bill the correct insurance carrier for payment. The Labor Commission pays no medical bills and does not have sufficient staff to sort through medical bills that are sent to the Commission. Therefore, all medical bills sent to the Commission are discarded. Workers' compensation does not encompass the unlimited field of personal injury or disability and the jurisdiction of the Labor Commission is strictly limited by statute to apply to only work related injuries/illnesses.

C. Eligibility for Workers' Compensation

In order for an employee to be eligible for medical care under the Workers' Compensation Act, four essential elements must exist. They are:

The employer must be subject to the Act;
There must be an employer-employee relationship;
The injury, illness, or death must qualify as compensable under the Act or case law in existence; and
Notice of the industrial injury must have been given to the employer or Labor Commission within six (6) months of the date of injury or knowledge of (diagnosis) an occupational disease. An application for death benefits must be filed within one (1) year after the date of death.

There is no guarantee to the provider that the industrial insurance carrier will assume liability for the bills presented by the provider. In cases where the employer either has no workers' compensation insurance, or if the insurance carrier denies payment, the provider should bill the patient. It is then up to the injured/ill employee to apply for a hearing before Labor Commission to resolve the issue. If the injured employee worked for an uninsured employer who is insolvent or bankrupt, the Uninsured Employers Fund becomes responsible for the medical bills when the injury/illness is compensable. If the Labor Commission rules the injury/illness is not work related, the provider should seek payment from the patient and readjust the bill to the "usual and customary" level. The employee can then present the bill to a group or personal insurance carrier for payment. Since some health insurance policies with a contract with an HMO or a PPO limit the choice of providers, the employee should follow the rules of the health insurance carrier in order to assure payment of the bill. Employees of those employers who specify a company doctor for work-related cases should discuss medical care with their employer before seeking medical treatment.

Questions regarding medical care in specific cases should be discussed promptly with the insurance carrier.

Other questions concerning rules, reporting, fees, or payment disputes should be directed to the Division of Industrial Accidents (530-6800). Most problems are due to misunderstandings, misinterpretations or lack of knowledge or communication. The Division of Industrial Accidents staff is most willing to help all parties in solving problems.

MEDICAL CARE FOR WORKERS' COMPENSATION

An injured employee is entitled, without personal expense, to medical care treatment and hospitalization reasonably necessary, up to the limits prescribed by the law. The provider should always bear in mind that the carrier must make his/her decision based on the information provided by the provider. If the provider has not sufficiently documented the treatment given and the reasons for that treatment, the adjuster may consider such treatment unreasonable or unnecessary.

It is the prerogative of the attending physician to determine the type, duration and frequency of treatment, including hospitalization and nursing services. Such services must be provided in accordance with recognized professional standards for the type of injuries incurred. Services in addition to those prescribed or ordered by the attending physician must be paid for by the patient.

A. Physician Selection

The employer has the right to select an attending physician for medical care related to an industrial injury or illness. If an employer, or the employer's insurance carrier, has designated a physician or clinic for medical care for work-related injuries/illnesses, the employee must first seek treatment through the employer-designated medical provider. If the employer or the employer's insurance carrier does not designate a medical provider, the employee is free to select a physician. Once the injured employee has been seen by the employer's-designated medical provider the employee can make one change of physicians without the approval of the employer or its insurance carrier with prompt notification of the change to the insurance carrier.

The Utah Legislature passed a Managed Health Care Bill in 1992 for workers' compensation which took effect January 1, 1993. The Managed Health Care Bill allows insurance companies and self-insured employers to develop a preferred-provider program which requires the employee to utilize the preferred-provider physicians and medical care facilities. Failure to initially use the preferred physician by the industrially injured/ill employee, who has been informed of the program, can result in the employee being obligated for any charges in excess of the preferred-provider allowances.

The bill also authorized peer review, utilization review, use of case management, and bill audits. It, therefore, becomes very important in all but non-emergency cases, that before providing any extensive services, a provider check with the insurance carrier for those procedures requiring pre-authorization.

The confidence of the patient in the ability of his/her physician is an important element in the treatment of an injury/illness. When an injured/ill employee is referred to a physician unknown to him/her, it is the duty and responsibility of the physician to dispel any doubt or uncertainty by a quick response to the needs of the patient and by obtaining the patient's confidence and cooperation. Most patients, whether they state it or not, rely upon the provider to guide them through this difficult time and deal with a type of insurance that may be entirely new to them.

There are some rules in place to prevent the patient from "doctor shopping" (changing doctors time and time again until the patient obtains a diagnosis that he/she agrees with or running up unnecessary charges for duplicative services). The insurance carrier or self-insured employer has control over changes of doctor with some exceptions

Emergency Room Care - Not all industrially-injured patients who present themselves to the emergency room are in need of "emergency treatment." They should be advised that, if the employer has a designated physician, they could encounter problems if they have not seen that physician first, even if it means a wait until the next day. If the patient is made aware of this, the patient may still choose to be, and should be, treated. Once treated, however, they should make arrangements to be seen by the employer's designated physician. Of course, the patient who is brought in by ambulance must be treated in the emergency room. If the choice for initial care is the emergency room, the injured employee may change the care to a private physician with prompt notification provided to the insurance carrier. ONCE THE PATIENT HAS CHANGED HIS/HER PHYSICIAN TO A PRIVATE PHYSICIAN, HE/SHE MAY NOT RETURN FOR ADDITIONAL EMERGENCY ROOM TREATMENT, EXCEPT AT THE DIRECTION OF THE TREATING PHYSICIAN OR IN INSTANCES WHERE LIFE OR LIMB IS THREATENED.

The employee may make one change of doctors, not counting the change from the emergency room, unless the emergency room is named as the employer's physician, without requesting permission of the insurance carrier, provided the carrier is promptly notified of the change of doctors.

The insurance carrier is to provide the industrially-injured/ill patient with a copy of the change of doctor rules. However, the physician is often the first party to be aware of the injury/illness, and therefore, a copy of the change of doctor rules has been included at the end of this booklet which may be helpful to the patient, if made available by the physician.

There are several reasons for controlling a change of doctors. Certainly good medical management would dictate that the patient not be seen by one physician after another, each in turn not being apprised of the other's treatment. Cost containment is another factor. There is no reason for the same x-rays, tests, and diagnostic examinations to be taken by a series of doctors. If a change of doctor is controlled, medical records, diagnostic reports, and x-rays can be transferred from one physician to another, each benefiting from the groundwork done by the previous physician, and the carrier will not have to pay for the same test or x-ray over and over again. Thirdly, there is the question of medication. There are some employees who would use the industrial system to gain access to any number of treating physicians for the purpose of having addictive drugs prescribed. While each physician seeing the patient may be very conservative in providing such, in the aggregate, they may all add up to a disaster.

The patient can be under the care of only one physician, designated as the Treating Physician. Other specialities may assist or participate in the management, if required by the case. while the patient continues under the management of the Treating Physician. No care should be duplicated.

No industrial patient is to be simultaneously treated by more than one physician without prior approval or one of the following circumstances being present:

Emergency care is such that several physicians' care is required to deal with multiple injuries;
Injuries received require multiple areas of medical specialty, such as:

an eye injury and a broken limb;
injuries to the teeth and lacerations of the trunk; or
brain injuries and internal injuries.

Surgery or routine care require the use of a radiologist, laboratory services, and/or anesthesiologist, as outlined in the currently-used coding procedures. A physician who feels that simultaneous treatment by two physicians is needed should contract the carrier to discuss the matter.

B. Referrals

Referrals to other physicians by the Treating Physician or carrier are not considered a change of doctors for the employee. The referral should be done in writing, with a report to the insurance carrier stating the reason for it. Medical records, diagnostic reports, and x-rays should be transferred with the patient in order to avoid duplication of services. Referrals should not be made to a physician or medical facility outside the state of Utah without prior approval by the insurance carrier, unless the employee is moving out of state. If the injured employee is moving out of state, the employee must complete forms and file them with Labor Commission of Utah. The Treating Physician will be asked to complete a report documenting the employee's condition at the last examination.
It should be clearly indicated if it is to be a consultation, second opinion, referral for treatment of associated problems outside the skill of the treating physician, for an impairment rating, or for some other purpose.
Patients thus seen should generally not have any treatments initiated unless the referral is clearly for that purpose in the minds of the Treating Physician and the insurance carrier. The case may be transferred from one physician to a physician of more expertise in the problem by the attending physician. The insurance carrier should be notified. Physicians to whom a patient is referred should make every effort to obtain the necessary results of prior studies of all kinds to minimize costly duplication. The length, extent, and complexity of the report should be consistent with the needs indicated in the request. The report should not be more lengthy or complex than required to convey the necessary information accurately.
If a request so specifies, the physician can become the Treating Physician. Another physician may be requested to perform certain studies or procedures without a transfer or becoming the Treating Physician.
Physicians, surgeons, and practitioners are prohibited from performing work for which they are not qualified. Payment will not be allowed for any services. When the nature or complexity of the case so indicates, transfer to appropriate specialists at the earliest possible time should be carried out.
In all cases where there is a serious eye injury or any likelihood of complications arising or permanent visual impairment resulting, the case must be referred immediately to a specialist.

C. Consultations

Consultation can be called on at any time and appropriate usage is encouraged. Generally, the Treating Physician should be notified. It is not necessary to obtain permission from the carrier, but the appropriate parties should be notified in writing.
Treatment should be undertaken only under special circumstances and with agreement of the parties concerned advised. It is of paramount importance that there always be a clear identification by all parties as to who is the "Treating Physician." Do not assume the care of the patient without a clear mutual understanding and agreement.
Consultants are duty-bound to file identical reports with the carrier and the attending physician. Reports beyond the "Physicians Initial Report of Injury or Occupational Disease" (Form 123), the final report and billing are not required by the Labor Commission, but are appreciated. Reports of consultants should include the following information:

The date and place of examination.
The patient's history of injury and development to date, including work status since injury and time of examination.
The patient's past history, insofar as the past history will affect the doctor's opinion of the patient's condition.
The examination findings.
X-ray and/or laboratory findings.
Diagnosis and opinion.

Consultation, Usual (Utah RVS Codes 99241-99263)
A consultation is a service provided by a physician whose opinion or advice regarding evaluation as to diagnosis and/or management of a specific problem is requested by another physician or other appropriate source.
Confirmatory Consultations (Utah RVS Codes 99271-99275)
The consulting physician provides evaluation and management services when aware of the confirmatory nature of the opinion sought. Only advice and/or opinion should be rendered. Treatment should not be undertaken.
Carriers and self-insured employers may request the services of a physician to do a medical examination of an industrially-injured patient. The cost incurred therein is to be billed directly to the carrier/employer requesting such service.

D. Special Medical Evaluations (in the past referred to as IME)

The requesting of services by a physician because of the physician's special level of competency. These evaluations are generally not to include more than one visit, unless additional time, or special testing procedures, is needed to complete the evaluation. The Treating Physician should be notified and, generally, treatment by the evaluating physician is not to be under taken.
Fees are to be arranged in advance with the person requesting the services clearly defining the scope of the evaluation and information needed in the written report.

F. Dentist

Except in rendering first-aid in a case of emergency, a licensed dentist must obtain authorization from the carrier or self-insured employer before performing any services.
The dentist must outline the injuries received, the plan for reconstruction and/or treatment, and a listing of the costs for performing those services. The carrier or self-insured employer should promptly respond with either a denial of liability or an acceptance, designating the dollar amount approved. At that point, the dentist must either accept the amount designated by the carrier/employer, reach a compromise agreement with the carrier, or notify the carrier that he/she is not willing to do the work for that amount.
It would then be up to the injured worker to decide whether or not he/she wants to see another dentist or wishes to assume the difference at his/her own expense. If the injured worker does not want to, or cannot assume the difference in cost, it would be the responsibility of the carrier to provide the patient with a dentist who would do the work for the payment indicated.

G. Hospital or Surgery Pre-authorization Procedures

Preauthorization is required for many procedures and shall be made in writing utilizing the form #223 (found in the back of this manual). Within five working days of a request for pre-authorization, the employer/carrier shall notify the physician and employee of approval or denial of the procedure. The employer/carrier shall have five days from receipt of the request to notify the physician and employee of their decision. If the procedure is denied, the carrier representative is to disclose the criteria utilized along with the responsible party denying the request. The provider is then able to resubmit a request to the carrier requesting a physician review. A disposition for this second request is to be concluded within 5 days and is to be forwarded to the Commission. The request can only be denied after a physician-to-physician dialog has occurred. If denial still occurs, the request can be submitted to the Commission for an independent, binding, medical review, arbitration, or adjudication. If the physician proceeds with the requested procedure without pre-authorization, the injured worker may be personally responsible for the bills incurred and may not be reimbursed for the time lost, unless a determination is made in injured worker's favor (See rule R612-2-4). If a determination of liability is made for the injured worker, and preauthorization was not obtained, the physician's reimbursement can be reduced to 50% of the contracted or RVS fee.

Discharge from the hospital, or transfer to a facility of a lesser nature, should be done at the earliest time appropriate to good medical practice. Extended care facilities should be utilized when necessary. In most cases, arrangements should be made with the carrier for home care. Payment for hospital care is limited to the ward rate or comparable. If the patient requests a more private hospital accommodation without medical documentation of need, he/she will be responsible for the difference personally. The physician can also use special hospital units, such as intensive care, to the extent necessary. Special nursing care is rarely required, due to the intensive or critical care units in hospitals, but can be utilized if necessary.

H. Vocational Rehabilitation

The attending physician has the best opportunity and the primary responsibility to aid the injured employee in rehabilitation.

The Injured Workers' Reemployment Act of 1990 mandates that the insurance carrier or self-insured employer provide the Labor Commission of Utah and the injured employee with a reemployment assessment after 90 days of temporary total disability.

All assessments hinge upon the physician's assessment of the functional and physical capacity of the injured employee returning to the work force. A return to light-duty is highly encouraged with the physician assigning physical restrictions as needed. The physician should communicate with the patient's employer on the employee's duties and the ability to return to work in the employee's regular job with some restrictions to work in the employee's regular job or other work with the employer.

In cases of more serious injury where permanent impairment may result, the attending physician should make recommendations to the employee, the insurance carrier, the employer, and the rehabilitation agency involved, as early as possible, with regard to the advisability of a rehabilitation--both physical and occupational--so that the permanent impairment is reduced to a minimum. When it appears that the injured worker will not be able to return to his/her usual occupation, the physician should immediately contact the insurance adjuster, so that training can begin while the employee is still receiving temporary-total and/or permanent-partial impairment benefits, if physically possible. There is no provision in the current workers' compensation for payment of benefits for rehabilitation/training beyond medical stability. The longer a patient is off work, the less likely it is that he/she will ever return to gainful employment.

Any physician wishing to know more about the Reemployment Program should contact the Division of Industrial Accidents at 530-6956.

I. Prosthesis

The insurance carrier is required by law to furnish the injured employee with prosthesis, when the prosthesis is reasonable and necessary. This is a life-long obligation of the insurance carrier if the injury is compensable. The attending physician should assist in the selection of the most suitable device and in the training of its use. The carrier has choice of provider and the option of negotiation rates where feasible.

COMPENSATION BENEFITS

A. Temporary Total Disability

Temporary-total disability benefits are payable to an industrially injured/ill worker when the injury/illness causes loss of work exceeding three (3) days. The first three (3) days are compensable if the worker is totally disabled for more than fourteen (14) days. The three (3) day waiting period need not be concurrent or immediately following the injury.

Employees are eligible for 66-2/3% of their gross weekly wage plus, $5.00 for the spouse and $5.00 for each dependent up to 4 dependents under the age of 18 years, not to exceed 100% of the state's average weekly wage at the time of injury and not less than a minimum of $45.00 per week.

Temporary total disability will continue until the injured worker has reached maximum medical improvement, (up to the maximum benefit entitlement) in the opinion of the physician, or until the physician has released the injured worker to return to work. It is not necessary that the injured worker is capable of returning to his/her prior job. When the patient is capable of performing any remunerative employment, the attending physician is to notify the insurance carrier or self-insured employer within 5 calendar days. The Commission provides "Release to Return to Work" forms, but the physician can indicate the release to return to work on the progress notes sent to the carrier, in letter form or by providing a copy of office notes.

The insurance carrier/self-insured employer has need of knowing the length of time the physician anticipates the injured worker will need off from work for medical reasons for workers compensation disability. The treating physician's reporting of progress and/or continued disability to work is extremely important. If the physician fails to make progress reports, the employee's compensation will, in all likelihood, be stopped. (Also sending the written progress notes reduces phone calls from adjusters to the physician.)

B. Temporary Partial Disability

When a worker is sufficiently recovered so as to be able to do part-time or light duty work (on a temporary basis, with the expectation that he/she will return to regular full-time employment). In these cases, the physicians should clearly state in their reports which duties the injured worker customarily performed in his/her employment that should be avoided and delineate any restrictions.

C. Permanent Partial Impariment Benefits

Permanent partial impairment benefits are paid due to permanent loss of body function and are divided into two types:

Schedules injuries: Those injuries to the lower or upper extremities, ears and eyes that can be objectively rated based upon comparison between member or organ. "Utah's 1997 Impairment Guides," or the American Medical Association's Guides to the Evaluation of Permanent Impairment, Fourth Edition, should be referred to in making these ratings.
Non-scheduled injuries: There are some portions of the body where comparisons cannot be made. Generally speaking, these would include injuries to the torso and head. Many of the ratings of the nervous system would likewise not lend themselves to schedules and thus the condition of the person expressed as a percentage of loss of body function of the "whole person" ratings are then applied by the carriers to the 312 week maximum in order to obtain a correlating dollar value.

Impairment ratings must be accompanied by a report of physical findings and should as be specific as possible. If a finger has been injured, the impairment rating of the finger, rather than the hand, upper extremity or whole person, must be stated, since the Labor Commission will require that the carrier draw up a compensation agreement using the most specific impairment rating.
The following charts should illustrate how much difference can be encountered in compensation depending upon the portion of the body the rating is based.
Example #1
35% impairment of the index finger = 14.70 weeks
9% impairment of the hand = 15.12 weeks
8% impairment of the upper extremity = 14.96 weeks
5% impairment of the whole person = 15.60 weeks
Example #2
3% impairment of the index finger = 1.26 weeks
1% impairment of the hand = 1.68 weeks
1% impairment of the upper extremity = 1.87 weeks
1% impairment of the whole person = 3.12 weeks

The rating of the physical impairment should be related to the most distal level in the Schedule that encompasses all of the impairment. This is the figure the rating is made on. It can then progress up the ladder to whole person.

There are specific code numbers and relative values in the RVS that are to be used for impairment rating services. Codes 99461, 99462, 99466, and 99467 are to be used by physicians on the visit when stability is declared. These codes are to be used alone and include the concurrent evaluation and management services on that day.
99461 -- Impairment Rating by the treating physician that includes diagnosis, stability, calculation of impairment, apportionment, and may include if requested, capabilities assessment and future medical treatment; Initial 30 minutes, 60.00 units.
99462 -- Each additional 30 minutes 50.00 Units
Billing for Impairment Ratings done by Someone Other than the Treating Physician, i.e. a Rating Physician
99466 -- Impairment rating by a physician, other than the treating physician, that includes diagnosis, stability, calculation of impairment, apportionment, and may include, if requested, a capability assessment and future medical treatment; Initial 30 minutes -75.00 Units
99467 -- Each additional 30 minutes - 50.00 Units
The industrially injured patient may request a rating from another physician, if the treating physician either will not or cannot rate the patient's permanent impairment. If, however, the physician states that no impairment exists, that is a 0 % rating. If the patient does not agree, he/she must pay to see another physician for a second opinion regarding an impairment rating.

D. Permanent Total Disability

Certain injuries or losses automatically fall into this category. The loss of two hands, two feet, two arms, two legs, the eyesight in both eyes, or a combination thereof, makes a worker eligible for permanent total disability benefits. Others may qualify for permanent total disability benefits either due to physical impairment or a combination of physical impairment and other disability factors, such as age and education. Each case is evaluated individually, according to the guidelines set by the Workers Compensation Act.

E. Death Benefits

The following death benefits are provided for under the Workers' Compensation Act:

Compensation - Compensation benefits are paid to the dependents of the deceased. Normally benefits are paid for 6 years after the date of death (this can be extended by an administrative law judge for dependent spouses and children under 18 years of age). The dependents have one year after the date of death in which to apply for death benefits.
Burial expenses - These benefits change from time-to-time. The average burial cost is set by rule by the Commission.

PERMANENT PHYSICAL IMPAIRMENT RATING

The attending physician should rate permanent physical impairment when he/she believes that the condition of the patient has reached essentially a permanent and stationary condition and when, for all practical purposes, the patient has reached maximum medical improvement. In the event the physician either wishes not to, or may not feel qualified, to give a permanent physical rating, the patient should be referred to a qualified physician for rating purposes.
The rating of permanent physical impairment is a function of the physician. The residuals following an industrial injury or occupational disease are rated as to the physical impairment based upon the specific loss of function of the part of the body involved or the body as a whole. This is done without an attempt to measure and without consideration of a relationship to the social aspects of the disorder or the employee. In order to maintain as much consistency in rating as possible, the Labor Commission of Utah currently requires the use of the "Utah's 1997 Impairment Guides" for all ratings of impairment given after May 1, 1997 as per Rule R612-6. The AMA Fourth Edition Guides to Impairments are to be used in determining impairment ratings only if the rating cannot be found in the "Utah's 1997 Impairment Guides." If the examiner does give a rating that is not in conformity with this Utah Guide, the report must include the basis for this judgment clearly stated in the report to appraise those persons acting on this information, so they will have a more clear understanding of the pathological condition being considered. This should rarely occur.
The Workers' Compensation Act specifies specific weeks of compensation for specific anatomical losses. For this reason, the rating physician should rate the body part affected that will encompass all of the impairment. If more than one extremity or organ system or the spine is involved, it is necessary to give the rating in percentage of loss of whole body function. This is done by using the proper tables to arrive at each loss in terms of the body as a whole and then these are combined using the Combined Values Chart. (Please refer to "Utah's 1997 Impairment Guides.")
A physician needs to study the Utah Guides and be knowledgeable as to the proper methods of assignment of impairment and the utilization of the Tables included. If a physician does not know how to properly assess permanent impairment, it is much better that no opinion be given because this frequently leads to significant problems.
The report need only include the pertinent facts of the case -- stabilization, the examination findings on which the rating is based, and the rating estimate. Please refer to "Utah's 1997 Impairment Guides" for full information.

REQUIRED MEDICAL FILINGS

The character of the workers' compensation system gives rise to the necessity for medical reports. The system cannot operate without them. Prompt and complete reports enable carriers to pay benefits speedily and without interruption when due. Conversely, if the carrier does not receive prompt and periodic reports, compensation can be delayed or interrupted. Such economic loss on top of the physical, and often emotional trauma already incurred, can result in extensive personal and financial problems for the patient and can negatively impact the healing and rehabilitation process.

The following are required reports from physicians:

The "Physician's Initial Report of Injury or Occupational Disease" (Form 123)
This is the initial medical report filed. This is a four-part form to be distributed to the following: The Labor Commission of Utah, the insurance carrier, the injured worker, and a copy for the physician's record. It is to be filed within one week of the initial visit. It is of special importance that the employee's description of the accident/illness be recorded accurately and completely. In fact, the employee could complete that portion personally. All complaints should be documented, so as to make those injuries part of the record. Examinations and the findings therefrom, as well as the specific treatment provided, should be complete to substantiate the level of service billed for by the physician. No payment will be made to the injured employee until a medical report stating definite compensable loss is received. This form is often used by the insurance carrier to set up reserves adequate to cover the complete treatment of the case. Therefore, as much pertinent information as possible should be given. However, it is not intended that the opinion provided by the physician on this form be set in concrete. A statement that permanent impairment is unlikely can be revised at any time that such impairment becomes evident. Likewise, periods of temporary total disability can be extended or shortened, and subsequently discovered preexisting problems reported at any time. Note: Most carriers and physicians now have fax machines. Physicians are encouraged to fax reports to the carriers.
Restorative Services Authorization Form (Form 221)
Rule R612-2-3(b), effective on October 31, 1995, and updated June 1, 1998, requires that all providers who bill under the Restorative Services Section of the RVS, submit the Restorative Services Authorization Form (Form 221), in addition to the Physician's Initial Report Form (Form 123) and S.O.A.P. notes. The rule and form are in the back of this handbook.
Request/Authorization Form (Form 223)
This is a new form designed to accommodate the new "utilization review standard" rule for a medical provider to request authorization for payment of a medical procedure. The request form needs to be submitted to the insurance carrier for procedures other than office visits, standard x-rays, and emergency care. The form does not apply to restorative services, except when a request for additional treatments have been denied and the physician desires a review by another physician.
Progress Reports/S.O.A.P. Notes
Some individual carriers may have forms they prefer to use in their cases. If so, they are responsible for providing them to the physician. The Commission does not have a form for this purpose and accepts typewritten narratives in letter, or progress notes form, or photocopies of case notes or progress notes. What is important is not the form, but the content. LEGIBILITY IS OF PRIME IMPORTANCE, HOWEVER. The carrier should be updated as to progress, improvement, complications, expected release dates, considered treatment, etc. as the patient is treated. These should be provided by the physician automatically and should not require repeated requests by the carrier. Failure to provide these progress notes can result in the patient's benefits being stopped and the physician's bill not being paid.
In addition, it should be reported to the carrier when patients are sent to consulting physicians. The reports of the consulting physicians also need to be sent to the carrier/employer. Referrals, when made, should be documented in writing and medical records, reports, and x-rays should be transferred to the new treating physician.
Release to Return to Work Form (Form 110)
This form, which is provided by the Labor Commission, is completed by the physician at the time the physician releases an employee to return to work (with either a full release or a light-duty status). This form must be transmitted to the carrier/employer within five calendar days (not working days) of such visit. If the physician cannot meet that deadline, he should place a call to the carrier and either inform the adjuster that the employee has been released to return to work or leave a message to that effect. The physician may note the release to return to work in a progress note, but this must be sent to the insurance carrier immediately.
When services are rendered by more than one physician, or by a physician and a therapist, each must separately report, fully describing the conditions found and the treatment given.
General Recommendations:It should be mentioned that occasionally the attending physician may observe in a patient a reluctance or refusal to cooperate with physicians in their efforts to effect a speedy and complete recovery from the injury. Proper administration of the statute compels physicians to make special, detailed reports in case of uncooperative patients. It is the carrier/employer duty to provide such medical treatment as needed to return the injured employee, as nearly as possible to the same condition as experienced prior to the industrial injury. If lack of cooperation on the part of the patient results in longer or more expensive treatment, such should be reported promptly. In such case, the physician should indicate what additional treatment is necessitated by the patient's lack of cooperation or failure to follow directions.
Patient Leaving the State (Form 043 and 044)
For the protection of the patient and for the knowledgeable management of the case by the carrier, the employee must file an "Employee's Notification of Intent to Leave Locality" with the Labor Commission of Utah and supply the physician with an "Attending Physician's Statement" form to complete for the Labor Commission. This statement includes the attending physician's certification that such a move is medically acceptable and includes the physician's assessment of the patient's condition upon last examination. Upon receipt of both forms, the Commission mails copies of the forms to all parties, including the new treating physician, if known.

MEDICAL FEES

A. The Labor Commission's relative Value Fee Schedule (RVS)

Fees in all cases must conform to the most recent Utah Labor Commission Relative Value Schedule (RVS fee schedule). Providers are paid for services to injured employees by the carrier or self-insured employer according to the (RVS) set by Labor Commission of Utah. The Commission has statutory authority to fix fees for medical treatment for industrial injuries and, for this reason, cannot legally accept a "customary charge" concept. Services by licensed practitioners are subject to the RVS and the associated rules and regulations adopted by Labor Commission of Utah. The RVS establishes maximum fees determined to be fair compensation to attending physicians and other providers for services.

The RVS schedule is an attempt to set reasonable fees, including usual periods of follow up care, and gives due consideration to the fact that, in general, some cases are more difficult and, some more simplified, and that a specific fee will cover the normal complexity. Fees in excess of scheduled amounts may be in order. However, in extremely complicated or unusual cases, if an additional fee is requested, this should be clearly explained at time the bill is submitted or arrangements made with the carrier, in advance, where possible. Failure to do so may result in lesser payment.

B. Discounting of the RVS

Discounting of the RVS fees is only allowed when providers have specifically agreed in writing with a payor to have discounts applied to their treatment of injured workers. [See Rule R612-2-5]

C. Medical Care Billing

When there is a disagreement as to the fees to be paid, the balance unpaid by the carrier/self-insured employer may not be billed to the patient. Section 34A-2-401, Utah Code Annotated, limits the settlement for such matters to be between the carrier/employer and the health care provider, with no assessment against the employee. It is hoped that providers will not consider the Labor Commission fees too low, and thus, refuse to treat industrially injured/ill patients. If the provider believes modifications to the RVS fee schedule are necessary, written recommendations are welcomed and should be made to the Labor Commission of Utah.
Physicians can eliminate many questions as to the RVS and avoid delay in payment by keeping the carrier informed as to the patient's condition and progress and by providing advance notification of planned hospitalization, surgery, or diagnostic testing.
Fees will not be approved for services by more than one attending physician over the same period of time, except for services of consultants, anesthetists, and assistants, provided such individuals are qualified and it is shown that such services were necessary. The case may require concurrent care by other specialists.
In a flat-fee case, the carrier is ordinarily liable only for the scheduled fee, even when the case is transferred to another physician. However, exceptions to the rule include:

First aid or emergency treatment; The first attendant is entitled to reasonable numberation.
Reasonable payment will also be made, other than proration of the flat fee, when the physician conscientiously and sincerely, using recognized medical procedures for which he is qualified, fails to cure or correct the injury or deformity of the employee.

Medical bills should be furnished on the prescribed forms and itemized - particularly showing the dates, nature, and extent of treatment, whether for examination, dressings or operations. Separate bills must be presented by each physician, consultant, anesthetist, and assistant in order to show the payment was made to the person who rendered services. When assistants are used in surgery, bills will be paid according to the RVS in current use by The Labor Commission of Utah.
Bills for fees should be sent with the final report. Reimbursement cannot be expected until necessary reports have been filed. The operative report and x-ray readings should be automatically submitted along with the billings. This will alleviate the problem of adjusters constantly calling doctors and their staffs for the needed information. Bills should be filed with the carrier/employer only - never the Commission!
It is expected that providers in most cases will be able to resolve fee problems with the carrier. It is hoped that only in unusual cases will the assistance of Labor Commission, or the Utah Medical Association, be required. It would be expected that the carrier pay all undisputed claims, reserving payment on only that part of the bill in dispute. The carrier should give the provider an explanation for any reduction or rejection of charges and, likewise, the provider should make a concerted effort to bill according to the industrial schedules, so as not to create the necessity for reducing and explaining bills continually. The provider should expect that if he/she does not make an effort to bill according to the current RVS fee schedule that the carriers/employers cannot afford the time to make such explanations on a routine basis.
As of July 1, 1997, a provider may not take an injured worker to court to collect an unpaid medical bill. The issue must be brought before the Labor Commission.

MEDICAL PANELS

The Labor Commission may request a physician to perform an examination of an industrial patient, and his/her medical records, and provide a written report to the law judge adjudicating that patient's claim. Such examinations are done at the expense of Labor Commission and are known as "medical panels."
Medical Panel members are selected by the Commission. The panel can consist of one or more physicians. The Commission has used panels of orthopedists, internists, otologists, ophthalmologists, tumor specialists, and dermatologists. A panel may not include a physician who has provided treatment to, or had correspondence regarding the patient being examined, but the treating physician is frequently consulted by the panel.
The Commission pays the member(s) of the panel a fee. The Commission also pays all costs of investigation such as x-ray studies, autopsies, biopsies, laboratory, etc.
Only the panel members and the injured worker are in attendance at panel meetings. No attorneys are permitted. No member of the Commission will attend.
The billings for such service should be sent with the reports so that payment can be approved by the law judge and payment made by the Commission. The panel member arranging for the tests, x-rays, etc., should make it clear to the provider of the service that the bills for such are to be sent to the Labor Commission's Division of Adjudication and identified by the name of the employee, the date of injury, and the name of the employer. Such bills must also list the federal provider number for payment to be made. The Commission authorizes the level of fees for medical panel members.

OCCUPATIONAL DISEASES

Occupational diseases are compensable if the occupational disease arose out of and in the course of employment and is medically caused or aggravated by that employment. The physician should file the initial report of the disease with the Labor Commission and the insurance carrier at the time the diagnosis is made.

No disease or injury to health shall be found compensable where it is of a character to which the general public is commonly exposed.

Medical care is provided by carriers in the same manner as for traumatic injuries.

ADJUDICATION PROCESS FOR DISPUTED CLAIMS

Upon the filing of an "Application for Hearing" (Form 001) for injury by accident, occupational disease, or for death, arising out of, or in the course of, employment, the Labor Commission forwards a copy of such claim to the insurance carrier writing the workers' compensation insurance coverage for the period of time in which the Applicant alleges injury.
The carrier is instructed to answer each allegation presented on the form and file their answer with Labor Commission within thirty (30) days.
If the carrier files a denial of liability, the matter is set for hearing before a Administrative Law Judge of the Commission, who takes testimony from both sides.
If the Administrative Law Judge feels that the record is insufficient as to medical aspects, the case may be referred to a Medical Panel for evaluation. The Medical Panel makes such a study, takes such x-rays, and performs such tests (including postmortem examinations upon the authorization of the Labor Commission) as it may determine and, thereafter, makes a report in writing to the Commission on a form prescribed by the Commission, and makes such additional findings as the Commission may require.
The Commission, upon receipt of the Medical Panel report, mails copies of such report to all parties.
Those parties have thirty (30) days in which to file any objections to the report.
If objections are filed, the Administrative Law Judge will ascertain whether or not medical testimony is proffered. If such is proffered, a hearing may be scheduled to take such testimony and to allow for the cross-examination of the Medical Panel chairman. It is the responsibility of a member of the Medical Panel, usually the chairman, to be present at these hearings.
Once the report is accepted, the Administrative Law Judge will enter a Findings of Fact, Conclusion of Law, and an Order in the matter. Parties then have thirty (30) days in which to file an objection to that Order.
If objections are received, the Administrative Law Judge, if in agreement, can enter an Amended Order. If the Order is not amended, the entire file and transcript in the case is reviewed by an Appeals Board at the Commission. They subsequently file an Order as to their findings. If objections are received to that Order, either the Commission may amend its Order, or the matter can be filed with the Utah Court of Appeals.

A. Conflicts

Conflicts may relate to medical or non-medical matters.

Non-medical conflicts may revolve around questions of employer-employee relationship, compensability of the alleged accident, levels of benefits, etc. The physician need not be concerned with such questions.

Conflicts that may ultimately involve the physician would revolve around the following:

Was the patient disabled from work?
When was the patient able to return to work?
Was the alleged accident the cause of the problems being treated?
Does the patient have a permanent impairment as a result of the problem and, if so, what is the percetage of that impairment?
If so, how much is due to a prior impairment that was pre-existing, and if so, should any be apportioned.
Were there pre-existing problems? Were they significantly aggravated or changed?

When problems of this nature arise that cannot be resolved mutually by those involved, the injured employee should file an Application for Hearing with the Labor Commission, so that the matter can be adjudicated by an Administrative Law Judge.