Adjusting to the New Normal – Washington Claims Processing and COVID-19

As the impact of COVID-19 continues to reverberate through Washington, it has created numerous challenges for employers and claims managers who are working hard to process claims properly and as efficiently as possible. Within this ever-evolving situation in mind, this post discusses some of the common issues that have arisen to date and offers suggestions for how to navigate claims processing.

Treatment Plans and Time Loss Certification

With treating providers cancelling or postponing many non-emergency appointments, it has made it challenging for workers to submit proper time loss certification in a timely manner. To address this issue, Department’s Guidelines suggest workers schedule appointments via video or telephone to document ongoing eligibility for treatment and/or time loss benefits.

For claims managers, this means increased communication with workers may be necessary to find out why time loss certification has not been provided or why a treatment plan has stalled. During these conversations, we also recommend reminding workers they are authorized to schedule a video or telephone appointment with a healthcare provider if they are unable to go in person, as some workers may be unaware of this option.

In addition, approval of requests to change attending providers may become necessary in situations where a provider is unable or unwilling to conduct televisits. Even as providers reopen their practice, a backlog of patients will likely lead to further scheduling delays and will require ongoing patience combined with close monitoring by claims managers to ensure workers are complying with treatment plans as best they can.

Light Duty

Adjustments to processes for workers released to temporary light duty or modified duty may be needed for the foreseeable future. Light duty is still an option for qualifying workers as long as a proper light duty job offer is made and the position remains in compliance with COVID-19 related rules and procedures for businesses.

Before submitting a light duty job offer or making adjustments to a current light duty position, it is important to consider whether it is necessary to create updated Job Analysis to accurately reflect an adjusted light duty position. We also recommend reviewing applicable Washington employment laws as part of this process as well. If adjustments to a position have been implemented, we suggest evaluating whether an updated opinion from independent medical examiners and/or treating providers is needed before a valid light duty job offer can be made.

In addition, many businesses have reduced their work force or closed for the time being, affecting workers in temporary light duty positions. If this occurs, and barring certain exceptions, an employer will be responsible for providing time loss benefits for any worker who is eligible. Time loss benefits will be payable until employability related issues are resolved or a new temporary light duty position is available and approved.

IME’s & Requests for Records

The Department has held workers may postpone IME’s, with proper notice in advance of a scheduled appointment, under certain conditions. The Department’s Guidelines suggest these conditions include workers at high risk of illness or where travel is necessary to attend a scheduled examination. With this in mind, if a worker requests to postpone an IME, we recommend evaluating the circumstances related to the location of the examination, access to transportation and a worker’s current health situation, including non-claim related issues, before either allowing or denying the postponement.

The number of available doctors performing IME’s is also limited due to travel concerns and health restrictions. We recommend planning ahead when scheduling IME’s, widening searches to find doctors in locations with limited options, and where necessary, keeping the Department apprised of your efforts.

Many claims managers have also been dealing with unusually long delays receiving responses to requests for workers records from medical clinics and other health care providers. Whether this is due to a temporary clinic closure, understaffing or backlog of requests, we recommend keeping this in mind when scheduling IMEs and complying with Department deadlines. Submitting requests early and communicating with Department adjudicators are two options for managing this issue.

As this public health situation evolves, the Department continues to review and provide additional guidance related to claim processes and other areas affected by COVID-19. All of us at SBH remain committed to keeping you apprised of industry changes during these unpredictable times. Please do not hesitate to contact me at scohen@sbhlegal.com or 503-595-6111 if you have any questions.