A compensable injury happens when a patient is injured on the job. When the patient’s job causes a disease, disorder, or infection, it is considered an occupational disease. A patient may file a claim for a compensable injury or occupational disease. The insurer has 60 days to accept or deny the claim.
In Oregon, the on-the-job injury is not accepted, rather the medical condition that stems from the injury or disease. This is referred to as the accepted condition. An insurer has to pay only for medical treatment of an accepted condition and any time loss caused by the accepted condition. For example, if the patient has an accepted sprain/strain and you treat for a herniated disk, the insurer will not have to pay you for treating the herniated disk.
When an insurer determines that a claim is not work related, it will issue a written claim denial. On accepted claims, the insurer may deny only certain conditions; this is known as a partial denial. When the insurer issues a claim or partial denial and it is aware that you are the treating provider, it must notify you of the denial. Only a patient can appeal a denial of a claim.
A deferred claim is a claim not yet accepted or denied. While the claim is deferred, medical services should be billed to the insurer, but the insurer does not have to pay until the claim is accepted. See also interim medical benefits.
A new condition is a condition that has not been previously diagnosed. A patient may request, in writing, acceptance of a new condition at any time.
Example: An initial diagnosis of low back sprain/strain results in the acceptance of that condition. After further diagnostic studies, a herniated disk is diagnosed. The patient may now make a claim for a new condition in writing for that herniated disk.
A patient may request, in writing, acceptance of an omitted condition that the patient believes was incorrectly omitted from the Notice of Acceptance. Medical services for omitted conditions are not compensable unless conditions are accepted.
Example: Following a traumatic injury, the attending physician documents a cervical spine fracture and low back sprain/strain. The immediate medical treatment is focused on the cervical fracture, and not much attention is given to the low back. Consequently, the low back sprain/strain is inadvertently omitted from the Notice of Acceptance. However, the low back pain persists, and the patient later files a claim for an omitted condition of low back sprain/strain.
The insurer has 60 days to accept or deny new or omitted conditions. The insurer does not have to pay medical services for new or omitted conditions until conditions are accepted.
Patients may claim new conditions arising as consequences of their accepted conditions. The compensable injury must be the major contributing cause of the consequential condition. Acceptance of the consequential condition on a closed claim results in the reopening of the claim for medical care and other benefits.
Example: A patient could develop a consequential condition when, in the course of recovering from accepted knee conditions, he or she develops a shoulder condition from using crutches. In order for the shoulder condition to be compensable, the knee injury must contribute more than 50 percent to the patient’s need for treatment of the shoulder condition.
A combined condition is a condition where a pre-existing condition combines with a compensable condition to cause disability or prolong treatment.
Example: A patient has arthritis of the knee and then sustains a job-related injury to the same knee. The acute condition is diagnosed as a sprain. Both conditions contribute to the patient’s disability. The combined condition is compensable only if the compensable injury (the sprain) contributes more than 50 percent to the patient’s disability or need for treatment.
A closed claim is when the worker has been found medically stationary and the insurer has issued a notice of closure.
Medical provider vs. medical service provider
A medical provider is any type of provider who offers any medical services, such as hospitals, clinics, or prosthetists/orthotists. It also includes medical service providers.
Medical service providers are people duly licensed to practice one or more of the healing arts, such as physicians, physical therapists, or acupuncturists.
Note: Licensed massage therapists are not licensed to practice a healing art and , therefore, are not considered a medical service provider.
Attending physician or authorized nurse practitioner
An attending physician or authorized nurse practitioner is primarily responsible for the patient’s care, authorizes time loss, and prescribes and monitors ancillary care and specialized care. Under Oregon law, the patient may choose the first attending physician or authorized nurse practitioner and then, after that, may change attending physicians only two times by choice. Additional changes require pre-approval from the insurer or the Workers’ Compensation Division. Generally, changes outside the patient‘s control do not count toward the three choices.
If you assume responsibility from another attending physician for treating a workers’ compensation patient, the patient must complete Form 827 to clearly indicate that the patient has transferred ongoing treatment for the on-the-job injury to you.
The following situations are not changes of attending physician:
- Emergency or “on call” treatment
- Examinations at the request of the insurer
- Referrals for specialized treatment or consultations
- Referrals to radiologists or pathologists for diagnostic studies
If you are seeing the patient solely for a consultation or as a specialist physician, it is not considered a change of physician and the patient should not complete Form 827.
You may not authorize the worker’s temporary disability benefits (time loss) unless you are the worker’s attending physician.
Disputed claim settlements (DCS)
If a patient and the insurer disagree about whether the patient has a valid workers’ compensation claim or condition, the patient and the insurer may resolve the disagreement with a disputed-claim settlement. If such a settlement is reached, the claim will remain denied, and, for a sum of money, the patient will give up all rights to future benefits for the denied medical conditions of the claim.
Oregon law requires that, under a DCS, health care providers be reimbursed for medical services at half the amount allowed by the fee schedule, and total reimbursement to health care providers cannot exceed 40 percent of the total settlement without the patient’s approval. However, the patient may choose to directly reimburse health care providers from the settlement proceeds at 100 percent of the Oregon workers’ compensation fee schedule amount. Generally, only those bills that have been received by the insurer are included in the DCS.
When a patient’s claim is settled by a DCS, you can submit the unpaid portion of your bills to the patient’s health insurer. If there is no health insurer, you may directly bill the patient. However, if the patient chooses to directly reimburse health care providers from the settlement proceeds at the Oregon workers’ compensation fee schedule amount, the provider must accept this as payment in full (ORS 656.313).
Claims disposition agreements (CDA)
A CDA is a compromise and release of all benefits, except medical benefits, on an accepted claim for a cash amount and will not affect medical reimbursement.
Workers’ compensation terms and abbreviations