Alta Partners News & Tips

I need to make all practices aware of a VERY IMPORTANT change the Ohio Bureau of Worker's Compensation has made that, if not strictly followed, could result in your practice being decertified by the BWC. Because this applies to ALL practices, we have sent this information to all on our mailing list, whether we do your billing or not. Though the technical BWC language is listed below, the essence is this:

The Ohio BWC will soon announce a timetable that could decertify you as a BWC provider IF, during a rolling 24 month period, you submit a Physician’s Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9 form) or if you submit the medical documentation retroactively more than three times without just cause.

There are exceptions, but the penalty for many providers (decertification) for NOT submitting this information timely is very severe.

Ws advise that you please check your in-house billing procedures and determine if your practice could be at risk and quickly implement a revised set of procedures to eliminate retroactive submissions of the C-9 forms to the BWC.

Managed care organizations (MCOs) will continue to send a letter to the provider each time it does not receive timely medical documentation, when it receives a retroactive C-9 after the treatment or when the MCO provides a service without just cause. Just cause reasons may include, but are not limited to:

*Emergency treatment;
*Provider not aware that services were for a workers’ compensation claim;
*Provider is non BWC-certified and has no established relationship with the injured worker;
*Provider recently became BWC-certified (within last six months);
*Pending additional allowances with BWC or the Industrial Commission of Ohio;
*Pending claim allowance with the BWC or Industrial Commission;
*Treatment provided was within the presumptive authorization guidelines;
*Treatment provided does not require prior authorization;
*Other (provider provided other documented justification for just cause).

The letters MCOs send are educational only, and they cannot use them to monitor occurrences to decertify a provider. At the time of implementation, BWC will review and confirm occurrences, and then send two warning notices to providers prior to proposing decertification if the non-compliant behavior continues.

Please contact our BWC specialist, Jennifer Negulescu, 440-808-3712, if you have any questions or need additional information.

For dates of injury on or after Nov. 1, 2002, BWC has expanded the time frame for presumptive approval to provide services from the first 45 days to the first 60 days following the injury. We’ve also added services and clarified others.

Service	Requirement
Physical medicine services, including chiropractic/osteopathic manipulative treatment and acupuncture	Prior authorization (PA)
Consultations - Psychological/chronic pain program only	PA
Chronic pain program including pre-admission evaluation and treatment	PA
Dental	PA
Diagnostic testing	PA (except basic X-rays which do not require PA)
DME	PA if the purchase price is > $250.00 PA for all DME rental
Home/auto/van modifications	PA required from BWC
Home health agency services	PA
Hospital inpatient treatment, including surgery and outpatient/ASC surgery	PA for surgery from date of injury, if not emergency
In-home physician services	PA after first visit
Injections	PA
Non-emergency ambulance services	PA
Orthotic and prosthetic devices and/or repair	PA >$250
Skilled Nursing Facility (SNF)/Extended Care Facility (ECF)	PA
TENS and NMES units	PA for both rentals and purchases
TENS and NMES monthly supplies	PA for a maximum of six months
Vision and hearing services	PA > $100
Vocational rehabilitation - All vocational rehabilitation services, including remain at work, in or out of plan	Note: PA not required for transitional work on-site therapy services provided by an occupational therapist or physical therapist that fall under the presumptive authorization guidelines. Note: Occupational rehabilitation (work hardening) requires CARF accreditation.

What is documentation, and why is it important?
Medical record documentation is required to record pertinent facts, findings and observations about an individual's health history including past and present illnesses, examinations, tests, treatments and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high quality care. The medical record facilitates:

This would include identifying demographic information for the injured worker to image medical record documentation. An appropriately documented medical record can reduce many of the issues associated with bill processing and may serve as a legal document to verify the care provided, if necessary.

What does BWC want and why?
Because we have an obligation to employers, they may request documentation that shows services are consistent with the coverage provided. For this reason BWC requires information to validate:

General principles of medical record documentation
The principles of documentation listed below are applicable to all types of medical and surgical services in all settings.

Note: For evaluation and management (E/M) services, the nature and amount of physician work and documentation varies by type of service, place of service and the patient's status. The general principles listed above may be modified to account for these variable circumstances in providing E/M services.

Below is the list of MCOs and the Fax number to submit medical documentation and C-9 forms: