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Physical therapists

An attending physician or specialist physician (an authorized nurse practitioner for a limited time) must prescribe all treatment.

On the first visit, you must notify the patient, preferably in writing, that he or she may have to pay for medical services that are not covered. This may include:

  • If the patient seeks treatment for conditions that are not related to the accepted compensable injury or illness. You can contact the insurer to find out what the accepted conditions are.
  • If the patient has been enrolled in an MCO and seeks treatment from you and you are not a panel provider for that MCO.
  • If the patient seeks treatment after having been notified that the treatment is experimental, outmoded, unscientific, or unproven.

See sample notification. 

Chart notes
It is crucial that your chart notes are clear and comprehensive. You must submit a legend when submitting coded or semi-coded chart notes.

MCO
At any time, insurers may enroll patients into a managed care organization (MCO). If you treat an MCO-enrolled patient and you are not on that MCO’s panel, the insurer will not have to pay. You should ask the patient if he or she is enrolled in an MCO. You may also want to contact the insurer to find out whether or not the patient is enrolled in an MCO.​​

You must have a treatment plan before you begin treating the patient. The treatment plan must contain the following four elements:

  • Objectives (e.g., decreased pain, increased range of motion)
  • Modalities (e.g., ultrasound, chiropractic manipulation)
  • Frequency of treatment (e.g., once per week)
  • Duration (e.g., four weeks)

You must send the treatment plan within seven days to the insurer and the physician or authorized nurse practitioner.

Tip: Fax the treatment plan to the insurer and keep a copy of the confirmation page in the patient’s file.

If you continue treatment beyond the duration outlined in the treatment plan, you must have a new referral from the attending physician to continue treatment. You also must send a new treatment plan to the insurer and physician or authorized nurse practitioner within seven days.

Note: The insurer does not have to pay you if you treat the patient without a treatment plan or you fail to send it to the insurer within seven days.

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The attending physician is primarily responsible for treatment and authorizing time loss for a workers’ compensation patient. Generally, a medical doctor, osteopathic physician, podiatric physician and surgeon, or oral or maxillofacial surgeon qualifies as an attending physician. An authorized nurse practitioner may assume a similar role for a limited time.

(A chiropractic physician, naturopathic physician, and physician assistant also may qualify as an attending physician, but only for a limited period.) See Type B.

The Oregon workers’ compensation system places considerable responsibility on the attending physician for:

  • Directing and managing treatment of patients
  • Authorizing time loss
  • Determining the patient’s physical ability to stay at work and return to work
  • Deciding when the patient becomes medically stationary
  • Making impairment findings
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At every visit, ask the patient if he or she is enrolled in an MCO. You may contact the insurer to find out if the patient is enrolled in an MCO. If you treat an MCO-enrolled patient and you or the referring physician is not on that MCO’s panel, the insurer will not have to pay you.

Your rights and duties as an MCO-panel provider may differ from those described in this guide. Many MCOs require pre-certification of medical services for enrolled patients. Therefore, if you are an MCO panel provider, you should refer to your MCO provider participation agreements or contracts for specific requirements in addition to this guide.​​

Here is some useful information for an efficient billing process:

  • An employer may not pay you directly unless the employer is self-insured. Therefore, you must always bill the workers’ compensation insurer and not the employer.
  • Send your bills to the insurer on a CMS 1500 form no later than 60 days after the date of service – even if the worker’s claim has not yet been accepted.
  • Charge the usual fees that you charge to the general public.
  • Use CPT® and Oregon-specific codes. If there is no CPT® or Oregon-specific code, use the appropriate HCPCS code. If there is no specific code, use an unlisted code at the end of each CPT® section.
  • All your billings must include legible chart notes describing the services provided and identify the person performing the service.
  • You may not charge a fee for providing the chart notes with your bills. However, if the insurer requests additional copies, you may bill for the copies using Oregon specific code R0001 or, if electronically, R0002.
  • If you are asked to prepare a report or review records other than your own, use CPT® code 99080 and indicate the actual time spent. If the request comes from the insurer, the insurer must pay you, even if the claim is denied.
  • Before the claim is accepted or denied and if the patient has private health insurance, you should bill as described under interim medical benefits.

Tip: You may bill electronically. See the electronic medical billing rules OAR 436-008 or contact the insurer.

Interim medical benefits
The Oregon Workers’ Compensation Division has published administrative rules implementing House Bill 4104 affecting interim medical benefits. Effective Jan. 1, 2015, the following applies to interim medical benefits:

  • Interim medical benefits apply only when a patient initially files for workers’ compensation benefits and has a health benefit plan. Interim medical benefits cover services from the start of the claim to the date the insurer accepts or denies the claim.
  • Interim medical benefits do not include treatments listed under OAR 436-009-0010(12).
  • The provider must bill the workers’ compensation insurer within 60 days and the health benefit plan according to the plan’s requirements.
  • The provider should submit a pre-authorization request to the health benefit plan according to the plan’s requirements before claim acceptance or denial.
  • The provider may not collect any health benefit plan co-pay, co-insurance, or deductible from the patient during the interim period.
  • If the insurer accepts the claim, the workers’ compensation insurer must pay providers for services according to the medical fee and payment rules (OAR 436-009). When the provider receives the insurer’s payment, the provider must reimburse the patient and the health benefit plan for any medical expenses, co-pays, co-insurance, or deductibles paid by the patient or the health benefit plan.
  • If the insurer denies the claim, the workers’ compensation insurer must notify the medical provider that the claim has been denied. The provider must forward a copy of the workers’ compensation denial letter to the health benefit plan.

Finding the workers’ compensation insurer
If your patient does not know who the insurer is, call the WCD Employer Index at 503-947-7814 or visit the WCD Employer Proof of Coverage search page. ​​

Once the claim is accepted, the insurer must issue payment within 45 days of receiving your bills and chart notes. If you do not receive payment within 45 days or you disagree with the payment amount, first contact the insurer to try to resolve the issue (See Payment disputes). If the insurer fails to pay timely, you may charge a reasonable monthly service fee for the period that the payment was delayed, but only if you charge such a fee to the general public. Tip: When the insurer does not issue a notice of acceptance or denial within 60 days of employer notice then the workers’ compensation claim is considered denied (de facto denial). The patient may appeal the de facto denial with the Oregon Workers’ Compensation Board.

Tip: When the insurer does not issue a notice of acceptance or denial within 60 days of employer notice then the workers’ compensation claim is considered denied (de facto denial). The patient may appeal the de facto denial with the Oregon Workers’ Compensation Board.

An employer may not pay you directly unless the employer is self-insured. Therefore, you must always bill the workers’ compensation insurer and not the employer.

Unless you have an MCO contract or a fee discount agreement, you should get paid the amount you billed or the amount of the Oregon workers’ compensation fee schedule, whichever is less.

Insurers do not have to pay providers for the following:

  • Treating conditions that are not accepted by the insurer
  • Providing chart notes with the original bill
  • Preparing a written treatment plan
  • Supplying progress notes that document the services billed
  • Completing a work release form or completion of a PCE form, when no tests are performed
  • A missed appointment “no show”
  • Dietary supplements

Note: There are excluded treatments that insurers don’t have to pay for. See OAR 436-009-0010(12).

If an insurer reduces a fee stating that the service is included in another service billed (bundling), you may want to verify that either the CPT® or the Division 009 rules allow that specific bundling.

Note: WCD has not adopted the National Correct Coding Initiative (NCCI) edits, and the insurer should not apply any NCCI edits.

Payment disputes
Some insurers may ask you to file an appeal to answer your payment question or resolve your dispute; however, you are not required to file an appeal with the insurer. If you are unable to informally resolve your payment issue with the insurer, you may request dispute resolution with WCD.

However, you must request dispute resolution with WCD within 90 days of the mailing date of the most recent explanation of benefits or a similar notification.

Note: Even if you are working with the insurer to resolve your issue during the 90 days, don’t let the 90-day time frame pass before requesting dispute resolution with WCD.

To request dispute resolution, use a copy of Form 2842, “Request for Dispute Resolution of Medical Issues and Medical Fees.” To identify specific services in dispute, you may use worksheet 2842a, “Medical Fee Dispute Resolution Request and Worksheet,” in addition to Form 2842.

Alternatively, if you have an EOB, you can request dispute resolution by doing all of the following:

  • Signing and dating the EOB
  • Attaching copies of chart notes, original bills, or additional supporting documentation
  • Providing a cover letter outlining the steps you have taken to try to resolve the dispute and describing the specific issue in dispute
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The fee schedules are located in the Division 009 rules, specifically:

  • Physician fee schedule in OAR 436-009-0040
  • Ambulatory surgery center in OAR 436-009-0023
  • Hospital fee schedule in OAR 436-009-0020
  • Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) fee schedule in OAR 436-009-0080
  • Pharmaceutical fee schedule in OAR 436-009-0090

Fee schedule amounts:
The Oregon Workers’ Compensation Division publishes the following fee schedules:

  • Physician fee schedule (Appendix B or calculator)
  • Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) fee schedule (Appendix E)
  • Ambulatory surgery center fee schedule (Appendices C and D)

The insurer must pay you the billed amount or the fee schedule amount, whichever is less. If there is no fee schedule amount published for a certain service, with some exceptions (e.g., dental), the insurer must pay you at 80 percent of the amount billed.

Discounts and contracts:
Insurers are only allowed to apply a discount to the fee schedule amounts if the service is covered by an MCO contract or you and the insurer have a fee discount agreement registered with the division.

If the insurer has multiple contracts with a provider and one of the contracts is through an MCO for services provided to an enrolled worker, the insurer may only apply the discount under the MCO’s contract.​​

The following medical treatments (or treatment of side effects) are not compensable and insurers do not have to pay for:

  • DMSO (dimethyl sulfoxide), except for treatment of compensable interstitial cystitis
  • IDET (intradiscal electrothermal therapy)
  • Surface EMG (electromyography) tests
  • Rolfing
  • Prolotherapy
  • Platelet rich plasma (PRP) injections
  • Thermography
  • Lumbar artificial disc replacement [with certain exceptions 436-009-0010(12)]
  • Cervical artificial disc replacement [with certain exceptions 436-009-0010(12)]
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The patient may choose an interpreter; however, you may disapprove the patient’s choice if the interpreter does not improve communication with the patient.

You may not bill for interpreter services if one of your employees provides those services.​​

Once a patient reaches maximum recovery, the patient becomes medically stationary, meaning no further material improvement would reasonably be expected from medical treatment or the passage of time.

When the patient is medically stationary the patient’s attending physician should conduct a closing evaluation to measure impairment. If the attending physician does not want to conduct the closing evaluation, he or she may refer the patient to another provider.

Closing reports must be submitted to the insurer within 14 days of the date the patient is declared medically stationary.

Note: Bulletin 239 outlines the requirements for performing a closing evaluation.

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After the patient is declared medically stationary, the attending physician may prescribe curative care or palliative care that is provided by ancillary care providers such as physical therapists, massage therapists, or chiropractic physicians.

Curative care is care provided to a patient to stabilize a temporary and acute waxing and waning of symptoms. Treatment plan require¬ments are the same as described here (link to treatment plan). The attending physician does not need to request approval from the insurer for curative care.

Palliative care is treatment aimed at reducing or moderating temporarily the intensity of an otherwise stable medical condition and is necessary to enable the patient to continue current employment or a vocational training program. This means the patient must be employed or in a vocational training program. The palliative care request that the attending physician sends to the insurer contains a treatment plan. Therefore, the ancillary care providers do not need to submit a separate treatment plan when providing palliative care. The attending physician’s palliative care request must contain the following elements:

  • A description of any objective findings.
  • An ICD-10-CM diagnosis.
  • A treatment plan containing the name of the provider who will provide the care, specific treatment modalities, frequency, and duration (not to exceed 180 days) of the care.
  • An explanation of how the requested care is related to the compensable condition.
  • A description of how the requested care will enable the patient to continue current employment or a vocational training program and any possible adverse effects if the care is not approved.

Tip: Ask for a copy of the palliative care request from the attending physician. Make sure the palliative care request contains all the required elements. If not, talk to the attending physician.

The insurer does not have to pay you for the service you provide if the attending physician fails to complete and send the completed palliative care request to the insurer for approval.

Aggravation
To qualify as an aggravation, the patient’s accepted condition must have pathologically worsened. A patient may make a claim for aggravation by filing Form 827 anytime within five years after first closure or, on a nondisabling claim, five years after the date of injury. The attending physician must include medical evidence supported by objective findings of an actual worsening of the accepted claim and file Form 827 on the patient’s behalf. ​​

Submit treatment plan when you are the ancillary care provider within 7 days.

Respond to records request from insurer or director within 14 days.

Complete an insurer-requested PCE or WCE within 20 days.

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When your patient signs Form 801 or Form 827 to file a workers’ compensation claim, he or she authorizes you to release relevant medical records to the insurer, self-insured employer, or the Workers’ Compensation Division. Relevant medical records include records of prior treatment for the same conditions or of injuries to the same area of the body. However, you are not authorized to release information regarding the following without a separate authorization:

  • Federally funded alcohol and drug-abuse treatment programs
  • HIV-related information unless the patient makes a claim for HIV or AIDS or when such information is directly relevant to the claimed condition

The privacy rule of HIPAA allows health care providers to disclose protected health information to regulatory agencies, insurers, and employers as authorized and necessary to comply with the laws relating to workers’ compensation.

Note: Any disclosures to employers are limited to work-related purposes, such as return to work or modified work.

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