Medical Issues in an Ohio Workers Comp Case
Helping Ohio Clients Navigate Worker Compensation Claims
There are two (2) general forms of benefits paid in workers' compensation claims: (1) compensation (also called "indemnity") and (2) medical benefits. At some point in the life of a workers' compensation claim, there will be a dispute over medical benefits. This usually arises when an attending physician files a C-9 request, or when a physician hired by the employer or Bureau of Workers' Compensation opines the injured worker no longer needs any treatment for the allowed conditions in the claim.
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Common Medical Issues in Ohio Workers' Compensation Claims
Workers' compensation claims often involve a variety of medical issues, depending on the type of work and the nature of the injury. Below are some of the most common medical conditions that arise in these cases:
- Musculoskeletal Injuries: These are some of the most frequent injuries in workers' compensation claims. They can include sprains, strains, fractures, and dislocations, often caused by heavy lifting or repetitive physical tasks.
- Repetitive Stress Injuries: Injuries such as carpal tunnel syndrome, tendonitis, and bursitis result from repetitive motion over time. These conditions often affect workers who perform tasks like typing, assembly line work, or frequent lifting.
- Mental Health Issues: Work-related stress, traumatic events, or long-term physical pain can lead to mental health conditions such as depression or anxiety. These conditions can also be eligible for workers' compensation if linked to the workplace injury or environment.
These medical issues significantly impact the claims process. The severity of the injury, its long-term effects, and how well the injury is documented play a critical role in the approval of workers' compensation benefits.
The Role of Medical Providers in Workers' Compensation Cases
Medical providers play a key role in workers' compensation cases by diagnosing injuries and determining the appropriate treatment. Here’s how different providers contribute to the process:
- Attending Physicians: These are the doctors who treat the injured worker. Their medical reports and recommendations are crucial in determining the type and duration of medical treatment needed.
- Specialists: Depending on the injury, specialists may be required to provide detailed care, such as orthopedic surgeons for musculoskeletal injuries or psychologists for mental health issues.
- Independent Medical Examiners (IMEs): In some cases, the insurance company may require an IME to assess the worker’s condition. While these doctors are not treating the worker, their opinions can significantly influence the approval or denial of claims.
The opinions of these medical professionals can determine whether the injury is considered work-related, the extent of the injury, and the necessary treatment.
How to Choose the Right Medical Providers for Your Workers' Compensation Claim
Choosing the right medical provider can make a big difference in the outcome of your workers' compensation claim. Here are some tips to ensure you get the right care:
- Look for Experienced Providers: Choose doctors who are familiar with workers' compensation cases and the documentation requirements. This will ensure that they know how to properly handle your case.
- Ensure Thorough Documentation: The provider should offer detailed medical reports that explain the nature of your injury, its work-related cause, and the recommended treatment plan. This documentation is essential for a successful claim.
- Get Referrals: Your attorney may have suggestions for medical providers who are experienced in handling workers' compensation claims.
Medical Treatment Authorization and Denial Challenges
A common issue in workers' compensation cases is the denial or modification of medical treatment. The Managed Care Organization (MCO) that handles your claim may refuse to authorize treatment for various reasons:
- Lack of Medical Necessity: The MCO may argue that the treatment is not necessary or that a less expensive option could be effective.
- Failure to Follow Proper Procedures: If the attending physician didn’t follow the correct procedures in submitting a request for treatment, the MCO may deny it.
- If your treatment is denied, you have the right to challenge the decision. Here’s how you can do that:
- Appeal the Denial: You can appeal the MCO’s decision through the Alternative Dispute Resolution (ADR) process, which may include a peer review of your medical records.
- Request a Hearing: If the ADR process doesn’t resolve the issue, you can request a hearing with the Bureau of Workers' Compensation (BWC) or the Industrial Commission of Ohio.
Understanding the reasons behind medical denials and knowing how to challenge them can help ensure that you receive the care you need to recover from your workplace injury.
Understanding the C-9 Request Process
Typically, a physician makes a request for treatment on a C-9 form. Authorizations for treatment in state fund claims are made by managed care organizations ("MCO"). The MCO processes requests from the injured worker's attending physicians and medical providers for medical services, such as requests for treatment, diagnostic studies (x-rays, MRIs, CT Scans, etc.), physical therapy, consultation exams, medical appliances, and other treatment issues.
Steps to Take If Your C-9 Request is Denied
If the MCO disapproves or modifies the C-9 request, the injured worker and/or the attending physician may appeal. If an appeal is filed, an alternative dispute resolution ("ADR") process begins. This process consists of medical "peer review" and additional decision-making by the MCO. Ultimately, if the injured worker is still dissatisfied with the MCO's decision, the BWC reviews the matter and issues an Order, which the parties may appeal to the Industrial Commission of Ohio. Employers may also appeal decisions of the MCO if they disagree with an approval of a C-9 request.
For self-insured denials or modifications of C-9 requests, the injured worker should file an administrative motion with the BWC and request the Industrial Commission of Ohio schedule a hearing.
FAQ: Medical Issues in an Ohio Workers' Comp Case
- What should I do if my medical treatment is denied in a workers' compensation claim?
If your medical treatment is denied, you have the right to challenge the decision. You can start by appealing the decision through the Alternative Dispute Resolution (ADR) process. If the ADR process does not resolve the issue, you can request a hearing with the Bureau of Workers' Compensation (BWC) or the Industrial Commission of Ohio. - What is a C-9 form and why is it important?
A C-9 form is used by a physician to request approval for treatment in a workers' compensation claim. The form is submitted to the Managed Care Organization (MCO) for review. If the MCO approves the request, treatment can proceed. If denied, you can appeal the decision. - Can mental health conditions be covered under workers' compensation?
Yes, mental health conditions such as anxiety, depression, or post-traumatic stress disorder (PTSD) may be eligible for workers' compensation if they are directly linked to a workplace injury or event. Documentation from a mental health professional is crucial in these cases.
THE OPINIONS THAT MATTER MOST
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“Up front and honest”
Abbie has been nothing but amazing with my workman's comp claim. She is up front and honest about everything regarding my claim. She is down to earth and very approachable. She made sure they approved and paid for everything within my claim. If I ever needed her again I would absolutely choose her. I will also refer others to her as well.- F. Towns -
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Wish I had contacted Chuck Zamora earlier in the workers comp process. Him and his group were fantastic, can't thank them enough.- Daniel S. -
“Highly recommended”
Mr Chuck helped me with a worker compensation claim,they worked with me throughout the process from day one until the end. He is respectful,knowledgeable on what he does and always open to answer your questions or concerns.....highly recommended- Former Client -
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Mr Zamura was extremely knowledgeable with all phases of my Ohio Police and Fire disability claim. He followed up on all aspects and made sure I was informed and up to date with everything going on. He was prompt at returning calls and emails if needed. His application paperwork was done very thoroughly which helped the process go much easier with the OP&F review board. His staff was great also. I would recommend him to anyone looking into a possible disability claim. I am from Akron and he is in Columbus. I only made 2 trips down to see him face to face. Everything else was done electronically or by phone.- Steve H. -
“A professional with high ethical standards”
I hired Mr Zamora and could not have been happier. He was a professional with high ethical standards and represented me well, gave me excellent legal advice, peace of mind through the process and handled everything efficiently and effectively! I would highly recommend him to any of my fellow police officers or fireman!- Don M. -
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If I had to go through such a situation with BWC I’m forever grateful it was with these people walking through it together...Charles & his secretary Iesha & Danielle. They ALWAYS treated me with kindness, dignity, & respect. They treated my situation as if it just as important to them as it was to me. They ALWAYS made me feel like I was their only one... trust me they have many & for good reasons. It makes my heart happy knowing there are still hardworking wonderful people out there doing what they do & fighting for the right reasons because they genuinely care. I’ll always feel fortunate to have met them. 🙏❤️🙏- Erica -
“If you've been injured at your job then you need Abbie from Zamora & Hogan Co., L.P.A. She is the best!”
- Mostafa O.If you've been injured at your job then you need Abbie from Zamora & Hogan Co., L.P.A. She is the best! She is smart, patient, and hard working. Attorney Abbie Hogan will get you the maximum compensation you deserve.
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The Miller Criteria
The Supreme Court of Ohio in the case of State ex rel. Miller v. Indus. Comm. (1994), 71 Ohio St.3d 229, set forth a three-part test to determine whether a request for treatment, etc., should be authorized in a workers' compensation claim:
- Are the medical services reasonably related to the industrial injury, i.e., the allowed condition(s) in the claim?
- Are the services reasonably necessary for the treatment of the allowed condition(s)? and
- Is the cost of such a service medically reasonable?
If the medical evidence supports a "yes" answer to each of these questions, then the treatment request should be approved. Unfortunately, there is often conflicting medical evidence (whether from the BWC or the employer's physician), and a hearing before the Industrial Commission invariably becomes necessary.
Reasonably Related Work Injury
Sometimes, the physicians hired by the MCO or self-insured employer will state that the medical service is not reasonably related to the work injury. For instance, the injured workers’ attending physician may request an injection, but the MCO or self-insured doctor will state that an injection is not appropriate for the particular injury (medical condition) that is allowed in the claim. Recall that BWC claims are allowed for specific medical conditions (injuries), such as a herniated disc, rotator cuff tear, or tricompartmental arthritis. If the attending physician’s request for services is not reasonably related to the allowed conditions, then the MCO or self-insured employer will deny the request.
Requesting Same Services
Similarly, if the medical services being requested have been rendered in the past, and the injured worker did not have a positive or lasting outcome, the MCO or self-insured employer may deny an additional request for the same services. The BWC and Industrial Commission of Ohio usually rely upon the Official Disability Guidelines (ODG), a set of general “rules” for treatment protocols. For instance, an attending chiropractic physician may keep requesting period after period of chiropractic adjustments in a workers’ compensation claim. The ODG has recommendations for how many periods or treatment visits are appropriate for an allowed condition. If the physician is requesting treatment that exceeds ODG, then the MCO or self-insured employer will state the services are not reasonably necessary.
Finally, the cost of medical services must be reasonable. This is largely a question of what the medical provider’s proposed bill will be in relation to other potential medical services that can be provided which may be less expensive.
Contact Our Attorneys At Zamora & Hogan Co., L.P.A., Today
At Zamora & Hogan Co., L.P.A., we argue medical issues before the Industrial Commission of Ohio nearly every day. A great volume of hearings we handle involves alternative dispute resolution (ADR) issues. These issues can also impact compensation in a claim, so if a treating physician is asking for treatment, we take those issues very seriously.
If you have questions about medical treatment or diagnostic study requests in your workers' compensation claim, please call us at (614) 344-6822 to speak with an attorney from Zamora & Hogan Co., L.P.A.
We are devoted to fighting for the rights of injured workers and their families. We provide personal attention to your claim, answer your questions promptly, and pursue all benefits you are entitled under the law.
