FAQs
Question: What is the “treating physician”? How does this role differ from other providers of medical care?
Answer: The treating physician is the physician managing a workers’ compensation claim. Treating physicians must be able to 1) diagnose a medical condition, 2) determine that the condition is related to the work activity, 3) treat the condition 4) state a period of time in which recovery is expected and 5) manage disability arising from the condition.
To be considered a treating physician the provider must be familiar with the workers’ compensation system.
Rule 20 states that a treating physician must be a licensed Medical Doctor, Osteopath, Chiropractor, Dentist or Podiatrist. Many other providers participate in the care of work related conditions but do not fulfill all parts of the role described above.
In most claims there is a single “treating physician” coordinating care.
Question: How do you register to be a provider? What if it’s an emergency care situation?
Answer: You can register to become a vendor by contacting Vendor Registration at 1.866.45BRICK (452.7425) or 304.941.1000 ext. 5227; Kevin Ramey is the Registrar and you can e-mail him at Kevin.Ramey@BrickStreet.com.
In an emergency situation necessary care should be rendered promptly as medically indicated. We will establish vendor status as a priority after the patient is medically stable. Our Vendor Registration staff will assist to insure prompt handling of the case and payment for services.
Question: How can I contact Workers’ Comp Insurance (BrickStreet) with a question?
Answer: Access our toll-free number (866.452.7425 or 866.45BRICK) for new claims; For claims filed prior to July 1, 2005, contact Cambridge Integrated Services at 304.925.5580 or toll-free 877.925.5580. The Office of Medical Management number is 304.941.1000 ext. 5172.
Question: What are the duties of a provider? What do I need to document in my office notes?
Answer: Rule 20 provides a synopsis of the duties of a Provider. These directives are found in Statue 85- 20–68, and in the Treatment Guidelines (85-20–24 through 69).
What Treating Physicians MUST Do
According to Rule 20 |
- Treat and be responsible for the injured worker’s health care
- Utilize cost effective medical treatments
- Request an Independent Medical Exam when the patient has reached maximal medical improvement
- They may opt to provide a treating physician impairment rating for their patient
- Provide a treatment plan
- Update the diagnosis
- Assist in changes of treating physician
- File initial report of injury
- Immediately report injuries that they believe to be work related
- Provide chart notes
- Update the work status every 90 days to determine whether the injured worker can be returned to work
- Assist in identifying the patient’s abilities and limits in returning to work
- Comply with the treating and reporting requirements of Rule 20
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FOLLOW TREATMENT GUIDELINES (which is the bulk of the content of Rule 20)
Question: Do x-rays or other imaging require prior authorization?
Answer: Initial X-rays and other imagining do NOT require prior authorization, but repeat or subsequent studies do require prior authorization.
Question: Do consultations require prior authorization?
Answer: The first consultation requested of a specialty does NOT require prior authorization, but repeat or subsequent consultations do require prior authorization.
Question: Where are rules and guidelines published?
Answer: The official version of all workers' compensation rules are maintained by the West Virginia Secretary of State and may be accessed through that office or through its web site.
Question: What is Rule 20?
Answer: Rule 20 refers to The Medical Management of Claims Rule (85-20) which was mandated by Senate Bill 2013. It includes treatment guidelines for most of the common medical conditions encountered in the workers’ compensation setting. In addition it includes a section on Permanent Partial Disability awards (section VII) which sets the rules by which PPD awards are determined.
This rule is frequently referenced in regard to medical treatment decisions. It includes sections on physical medicine, work conditioning and work hardening programs. There are guidelines for the use of opiate pain medicines, functional restoration programs, psychiatric evaluations and treatment. The requirements for evaluation and treatment of hearing loss and occupational pneumoconiosis are also found in this document.
Rule 20 contains guidelines that were developed by numerous subcommittees at Workers’ Compensation with input from more than 100 expert physicians.
Question: What is Preferred Drug List and how does it work?
Answer: The Preferred Drug List (PDL) is a list of medications which do not require prior authorization for payment. The list includes many common medications that are available in generic form. All medications that are not on the PDL require prior authorization except in emergencies or in the first two weeks following an injury.
Question: What are IMEs, and what are these abbreviations (PPDs, PTDs)?
Answer: The Independent Medical Evaluation, preformed by a qualified clinician, sets out to evaluate and report on impairment or impairments of any human organ or body part. At BrickStreet, IMEs are used for several purposes, the most common reason being an “impairment rating”. However, BrickStreet also utilizes IMEs:
To evaluate treatment and offer redirection
To determine MMI
To evaluate for causality and compensability
To provide detailed documentation when needed |
If the purpose of an IME is to provide an impairment rating, that rating may be for a Permanent Partial Disability rating, or a Permanent Total Disability rating.
Most IMEs are for PPD ratings, in which a body part such as an arm or a leg or a back has been injured at work AND that injury is stable, and that individual is seeking a permanent award for sustaining the injury in the workplace. This person is not considered unable to work, but is identified as having some permanently impaired function of that body part.
A PTD rating is provided for an injured worker who may be completely disabled from an injury or a series of injuries sustained at work.