Physician associates

As a physician associate, you must certify that you have read and understand certain informational material provided by the Workers' Compensation Division before treating patients with an Oregon workers' compensation claim. Insurers are not required to pay you for any medical services you provided before you certify.

You can find the materials on our website by selecting the appropriate provider type.

As a physician associate you may become a worker's attending physician.

As an attending physician, you are primarily responsible for treatment and authorizing time loss for a workers' compensation patient. Generally, a medical doctor, osteopathic physician, podiatric physician and surgeon, oral or maxillofacial surgeon, physician associate, or nurse practitioner qualifies as an attending physician.

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

Emergency room physicians may authorize time loss only for a maximum of 14 days when they refer the patient to another primary care provider for care.

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

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

The insurer may periodically request progress or narrative reports in addition to chart notes. You must respond within 14 days of receiving the request.

If you are the attending physician and you refer the patient to an ancillary care provider (e.g., physical therapist), the ancillary care provider should send you a treatment plan for signature within seven days. You must sign a copy of the treatment plan and send it to the insurer within 30 days of starting the ancillary treatment.

As the attending physician, you can also refer your patient to a specialist physician for a consultation or specialized treatment, and you will continue to serve as the patient’s attending physician (you are responsible for authorizing any time loss).

Stay at work / Return to work
As the attending physician, you have primary responsibility to determine whether the patient is able to continue regular employment or whether there are any limits on the patient’s ability to perform work activities. If you determine that the patient is unable to continue regular work duties, the Workers’ Compensation Division strongly encourages you to contact the employer or insurer to discuss potential modified work duties the patient is able to perform.

If you place, modify, or lift any work modifications, you must immediately inform the patient and notify the insurer in writing within five consecutive calendar days. Prompt notification to the insurer will reduce insurer inquiries and promote timely payment of benefits to the patient.

When you release a patient to return to work, you must do so in writing and specify work restrictions, if any. You may use Form 3245, “Return-to-Work Status”; however, you are not required to use this form unless the insurer requests it.

Click here for more information about return to work.

Tip: You are allowed to communicate with the employer regarding what type of work the patient is able to perform.

Treatment after the patient is medically stationary
Once the patient becomes medically stationary, you can no longer be the attending physician. However, you may continue to provide compensable medical services if authorized by the attending physician.

The patient may file a workers’ compensation claim two ways:

When the employer completes and submits Form 801, “Report of Job Injury or Illness”
When you complete and submit Form 827, “Worker’s and Health Care Provider’s Report for Workers’ Compensation Claims”

Form 827 - Worker’s and Health Care Provider’s Report for Workers’ Compensation Claims
Have the patient complete and sign the worker portion of this form ONLY if:

You are the very first health care provider the patient sees for their injury. In this case, send Form 827, to the insurer within three days.
If you become the new attending physician and become primarily responsible for treating the patient. In this case send Form 827 to the insurer within five days.
The patient wants to file a new or omitted medical condition. In this case send Form 827 to the insurer within five days.

Give the patient a copy of the completed Form 827. To learn how to use Form 827, check out this short video.

On the first visit, you must notify the patient, preferably in writing, that the patient 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.

Tip: You can order Form 827 here.

Stay at work / Return to work
All parties benefit when the patient stays at work or returns to work as quickly as possible after an on-the-job injury. Physicians who regularly treat workers’ compensation patients have said that setting stay-at-work or return-to-work expectations at the patient’s first visit is a vital part of the treatment program and key to the healing of their on-the-job injury.

Chart notes
It is crucial that your chart notes are clear and fully document a comprehensive diagnostic workup. You must submit a legend when submitting coded or semi-coded chart notes. The insurer uses the information in your chart notes to determine what conditions to accept for the claim. The patient is only entitled to medical services that are related to the accepted conditions.

Tip: It is important that you report a specific diagnosis rather than a symptom.

At every visit, ask the patient if they are 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 are 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.

Tip: Remind your patient at each visit to bring in any paperwork from the insurer or MCO.

Come-along provider

If you are not an MCO-panel provider, but you have a history of treating the patient before the work-related injury or disease, you may continue to treat the patient as a come-along provider. As a come-along provider, you must abide by the MCO’s terms and conditions to remain a come-along provider. To become a come-along provider, have your patient contact the MCO or insurer.

Generally, insurers do not have to issue pre-authorization for any treatment. An exception is for imaging studies other than plain film X-rays. You may contact an insurer in writing for pre-authorization of diagnostic imaging studies other than plain film X-rays. The request must be separate from chart notes and clearly state that it is a request for pre-authorization of diagnostic imaging studies. Pre-authorization is not a guarantee of payment. The insurer must respond to your request in writing whether the service is pre-authorized or not pre-authorized within 14 days of receipt of the request.

Another exception is after a patient becomes medically stationary the attending physician needs to request approval from the insurer for palliative care (e.g., physical therapy).

If a patient is enrolled in a certified managed care organization (MCO), the MCO may require pre-authorization of certain services. Please check with each MCO.

You must notify the insurer in writing of your intent to perform elective surgery at least seven days before the date of the surgery. The insurer must respond within seven days of receiving the notice of intent to perform surgery that the proposed surgery is either approved; not approved and a consultation is requested; or is disapproved. Emergency surgery to preserve life, function, or health is excluded from notification requirements.

Referral to an ancillary care provider
If you refer the patient to an ancillary care provider, such as a physical therapist or acupuncturist, the ancillary care provider must send you a treatment plan containing the following four elements within seven days of beginning treatment:

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)

Once you receive the treatment plan from the ancillary care provider, you must sign and send the plan to the insurer within 30 days of the beginning of the ancillary care.

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

At any time insurers may enroll patients into an MCO. You should ask the patient or the insurer if the patient has become enrolled in an MCO. If you refer an MCO-enrolled patient to an ancillary care provider, that provider must be on that MCO’s panel.

Referral to a specialist physician
As the attending physician, you can refer your patient to a specialist physician for a consultation or specialized treatment, and you will continue to serve as the patient’s attending physician (you are responsible for authorizing any time loss).

A specialist physician provides a consultation or specialized treatment without assuming the role of the attending physician.

Here is useful information for a more 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.
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: When physician associates assist in surgery, they must bill using modifier 81.

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.

Billing the workers’ compensation patient
When you provide medical services to a workers’ compensation patient, you should not bill the patient for any services related to an accepted compensable injury or illness unless:

The patient seeks treatment for conditions not related to the accepted compensable injury or illness
The patient seeks treatment for a service that has not been prescribed by the attending physician or specialist physician
The patient seeks palliative care after it has been disapproved by the insurer or the director
The MCO-enrolled patient seeks treatment from a non-panel provider
The patient seeks excluded treatment after the patient has been notified that such treatment is unscientific, unproven, outmoded, or experimental

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

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

Once the claim is accepted, the insurer must issue payment within 45 days of receiving your bills and chart notes. If the insurer fails to pay timely, you may charge a reasonable monthly service fee for the period 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.

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. If you are unable to resolve the issue with the insurer you can file a dispute with the Workers’ Compensation Division (WCD), but you must do so within 90 days of the mailing date on the explanation of benefits (EOB).

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
Completing forms 827 and 4909
Providing chart notes with the original bill
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 do not 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 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 file a dispute 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.

Tip: 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 file a dispute, 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 file a dispute 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

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 or calculator)
Ambulatory surgery center fee schedule (Appendices C and D or calculator)

Unless otherwise provided by contract or you assist in surgery, a physician associate gets paid according to the table below:

Services billed with:	Appendix B lists:	Payment amount is:
CPT, HCPCS, Oregon specific codes	A dollar amount	The lesser of	85% of the dollar amount listed in Appendix B
CPT, HCPCS, Oregon specific codes	80% of billed amount	68% of the amount billed
Codes not listed in Appendix B	N/A	68% of the amount billed

Unless otherwise provided by contract, a physician associate who assists in surgery must use modifier 81 and gets paid according to the table below.

Procedures:	Appendix B lists:	The payment amount is:
One or more surgical procedures as the surgical assistant	A dollar amount	The lesser of	15% of the surgeon’s fee
	A dollar amount	The lesser of	The billed amount
	80% of billed amount	15% of the surgeon’s fee

Discounts and contracts Insurers are allowed to apply a discount to the fee schedule amounts only 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 apply the discount only under the MCO’s contract.

If you dispense drugs from your office, you are allowed to give the patient only a 10-day initial supply. Your payment will be the same as if dispensed by a pharmacy. See the table in Division 009-0090 rule.

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, unless they are for non-operative:

Knee: Osteoarthritis pain, chondral surface injury and partial thickness meniscal tears after failure of three months of conservative care, which may include a standard course of physical therapy;
Elbow: Lateral and medial epicondylitis after failure of three months of conservative care, which may include a standard course of physical therapy; or
Shoulder: Tendon, bursa, and muscle injuries, including partial tears and small tears, and adhesive capsulitis after failure of three months of conservative care, which may include a standard course of physical therapy.

Thermography
Lumbar artificial disc replacement, unless it is a single-level replacement with an unconstrained or semi-constrained metal on polymer device and:

The single level artificial disc replacement is between L3 and S1
The patient is 16 to 60 years old
The patient underwent a minimum of six months unsuccessful exercise based rehabilitation
The procedure is not found inappropriate under OAR 436-010-0230

Cervical artificial disc replacement, unless the procedure is a single level or a two level contiguous cervical artificial disc replacement with a device that has Food and Drug Administration (FDA) approval for the procedure.

The patient may choose an interpreter; however, you may disapprove the patient’s choice if the interpreter does not improve communication with the patient.

Only a sign language interpreter licensed by the Health Licensing Office may provide signed language interpretation services in a medical setting.

You may not bill for interpreter services if one of your employees provides those services, unless that employee is certified or qualified by the Oregon Health Authority and employed by you solely to provide in-person (face-to-face) interpreter 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 exam to measure impairment.

If you are the attending physician and do not want to conduct the closing exam, you may refer the patient to another provider. Contact the insurer if you want the insurer to schedule the exam. If another physician completes the closing exam, you will be asked to review the report and comment on the findings.

File Form 827 for first report of injury or disease within 3 days.

File Form 827 for change of attending physician within 5 days.

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

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

Sign copy of treatment plan when you are the attending physician within 30 days.

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.

Resources
Workers’ compensation terms for providers

OARs
008 Electronic Medical Billing
009 Oregon Medical Fee and Payment
010 Medical Services
015 Managed Care Organizations

Physician associates

Before treating workers’ compensation patients

Responsibilities as the attending physician

First visit

Managed care organization (MCO)

Pre-authorization

Referrals

Billing

Payment

Fee schedule

Dispensing drugs

Excluded treatment

Interpreter services

Medically stationary and closing exams

Timeline summary

Medical records – what to release