Patient Care Policies

Within workers’ compensation, a major objective is a prompt, accurate diagnosis with timely, safe return to work. While receiving workers’ compensation benefits, the employee needs to be accountable for compliance with scheduled medical appointments and to make an effort to learn about his/her injury and how he/she can help speed recovery and prevent future injuries. Physicians are encouraged to provide patient education to optimize results.

Physicians are expected to see patients promptly and schedule follow-up appointments as soon as possible to help eliminate any unnecessary gaps in medical care that would result in unnecessary delay in timely return to work.

Specialist referral appointments must be arranged the same day or next day so that the employees are seen within 72 hours of referral to your office.

HCS must authorize second opinions.

Prompt care is important. Physicians should see employees within 30 minutes of arrival. Please log the patient’s time of arrival and departure from your office on the chart for each visit.

Emergency cases should be referred immediately to the nearest emergency facility or hospital. Emergency admissions do not require precertification. Your office must notify HCS within 24 hours of an Emergency Room visit or admission.

Medical Care After Office Hours

If an employee requires medical care for a work-related injury or illness after routine office hours, the employee’s supervisor will refer the injured or ill employee to the nearest network urgent care center. The initial treater at the urgent care center will communicate this to HCS by faxing a completed Patient Treatment Plan Form.

If the urgent care center is not open, and treatment of the injury cannot wait until the next business day, the employee’s supervisor or HCS will refer him/her to the nearest Emergency Room.

For patients being treated for work-related injuries and illnesses, referrals must be made only to HCS network hospitals, ambulatory surgical centers, facilities, physicians and other health care professionals, and services. These referrals should be coordinated with the assigned case manager.

In some cases, in accordance with Personal Injury Protection (PIP) regulations, automobile insurers establish voluntary networks for the provision of certain medical services. Voluntary networks offered by insurers include:

• ambulatory surgery centers
• durable medical equipment
• electrodiagnostics
• pharmacy and radiology services.

Individuals who seek care within the insurers' voluntary network are not subject to out-of-network penalties. For workers’ compensation claimants, justification for referral out of network must be discussed with and approved by an HCS case manager. Precertifications may be obtained by calling HCS at 1-800-985-7777 or by calling the applicable case manager.

The HCS network is comprised of initial treater, specialty care physicians and other health care professionals, plus a broad array of facilities. The initial treaters serves as the primary physician delivering medical evaluation and care to the injured or ill claimant. Initial treaters generally specialize in internal medicine, occupational medicine or family practice.

Because the costs associated with lost work time by workers’ compensation claimants are significant, it is important that initial treaters see injured workers the same day of injury, if possible, and without an appointment, if necessary. Modified duty may be available and appropriate.

Walk-ins will occur. HCS encourages supervisors to call in advance of an injured employee’s arrival at an initial treater’s office. If an employee arrives without an appointment, he/she should be seen as soon as possible.

Once it is determined that an injury is work-related, the initial treater provides the necessary and appropriate evaluation and treatment. If referral to an in-network specialist and/or facility is necessary, the initial treater should make the referral as soon as possible to expedite care and avoid unnecessary lost time. As specified later in this manual, precertification is required for some referrals. All precertifications and referrals should be coordinated with the assigned case manager.

If it is determined that an injury was not sustained in either a work-related or automobile accident, the initial treater can either treat the patient, at the patient’s expense, or refer the patient to his/her own personal physician. It should be made clear to the patient that the injury or illness being treated is not covered under a workers’ compensation or an automobile insurance policy. Payment for all medical care and services rendered for such treatment is the responsibility of the patient.

If employers elect, employees may be referred to initial treaters for corporate health care services including Department of Transportation (DOT) exams, blood alcohol testing (BAT), drug screening, pre-placement physicals and preventive care. As these services are outside of workers’ compensation coverage, bills for these services should be sent directly to the employer.

If the physician feels that blood alcohol testing and/or urine drug screening is appropriate for evaluation of particular work-related illnesses and injuries, he/she should contact the applicable case manager prior to performing the examinations.

Participating specialists work in partnership with initial treaters to provide appropriate, quality and cost-effective medical care to patients. Initial treaters may refer patients to specialty services as part of the treatment plan.

Specialists play a critical role by providing efficient care within their areas of expertise and within the scope of the patient’s treatment plan.

Patients being treated under PIP coverage are entitled to seek medical treatment by physicians and other health care professionals of their own choice. However, such patients should be encouraged to use HCS participating physicians and health care professionals. HCS participating physicians have expertise in the treatment of musculoskeletal injuries and the cost of in-network care tends to be lower, creating a financial benefit to patients that enables them to sustain benefits below their PIP coverage ceiling for a longer period.

Please call HCS at 1-800-985-7777 if you have questions about referrals or network participants.

Diagnostic X-rays may be performed in your office if your diagnostic X-ray equipment complies with all New Jersey State Department of Environmental Protection regulations. Evidence of current certification must be presented to HCS upon request. When an initial treater elects to X-ray a patient in his/her office, the initial treater should read the X-ray(s). All radiological interpretations must be in writing, signed, dated and placed into the medical record. A brief report of X-ray findings should accompany the HCS Patient Treatment Plan Form or office notes that are faxed or mailed to the applicable case manager. The case manager may arrange for a second reading by a board-certified radiologist for X-rays taken by the initial treater. An official reading will be promptly forwarded to the initial treater’s office by telephone and then followed by hard copy.

Diagnostic tests, such as EKG, visual/audiological evaluation and pulmonary function, may be performed without precertification for evaluation of a work-related injury or condition. If your office does not have the necessary equipment, please contact the assigned case manager.

If there is need for referral or precertification, call the assigned case manager at 1-800-985-7777 while the patient is in your office. In most cases, precertification will be given immediately. The assigned case manager will select the appropriate specialist or health care professional, coordinate all referrals and schedule all necessary appointments. After normal business hours, leave a voice mail message justifying the need for precertification. A case manager will return your call on the next business day.

At times, the assigned case manager may refer a precertification request to a medical consultant. In such cases, the medical consultant may contact the treating physician directly to discuss the precertification request and related suggestions for an alternative course of treatment. HCS encourages its contracted physicians to take these calls to expedite planning of the most effective course of treatment.

Laboratory testing: All lab services must be sent to an in-network lab. Such services include routine lab tests and blood and urine screenings. HCS’ lab network includes: BioReference Laboratories, LabCorp and Quest Diagnostics.

Prescription drugs: An HCS participating physician should not prescribe or renew any prescription that is not related to the covered injury or illness.

For workers’ compensation and PIP patients, the dispensing of prescription medications by a physician’s office is prohibited.

Physical or occupational therapy is often used in the non-operative and post-operative treatment of workers’ compensation injuries. Current literature would support that therapy treatments with the best outcomes include aggressive individualized treatments, with limited use of modalities that are functionally driven, with the goal of patient self-management.

Because claimants are generally evaluated and treated first by a physician, the number of treatment sessions and the need for additional treatment are determined by the treating physician. This is also important for post-operative therapy treatment, as the surgeon is aware of the tissues that have been injured and surgically treated.

Both the treating physician and the therapist are required to have an understanding of current, evidence-based treatments and the number of treatment sessions that would generally be needed per current national guidelines.

It is imperative to have close communication between the physician and therapist so that common goals of treatment can be determined and communicated in a uniform manner to the injured worker. A lack of expected improvement during therapy should be quickly communicated to the treating physician to determine whether additional examination or a change in the treatment plan is necessary. A team approach that includes the physician, therapist and injured worker, and clearly communicates expectations and goals can result in an efficient and successful return to work.

For workers’ compensation claims, every workday lost is an expense to the employer. To avoid unnecessary cost to the employer or insurer, please see patients promptly.

Appointments for treatment by specialists or diagnostic testing should be made for the same day or next day, and gaps between appointments should be minimized. Every patient should have a follow-up appointment scheduled and/or a referral to a specialist with an appointment scheduled. No patient should be inactive at any time from his/her medical treatment program unless he/she is cleared for return to work and no further treatment is necessary. Please record scheduled appointments in the patient’s record.

To help physicians achieve a safe and rapid return to work for their patients, your assigned case manager will provide you with a return-to-work metric based on nationally accepted guidelines. HCS workers’ compensation clients are focused on this metric.

Modified duty may be available and appropriate. When return to regular job duties is not possible because the employee is unable to perform essential job functions, other options include temporary modified duty, or temporary or permanent assignment to new job duties.

The case manager will supply, when available, a Workers’ Compensation Physical Demands Analysis Form that has been completed by the employer. This form will outline the injured workers’ job duties. Many employers have modified or alternative job assignments of which you and the employee may not be aware.

HCS uses the following forms for communications and medical bill payment:

HCS uses the following forms for communications and medical bill payment:

• Workers’ Compensation Patient Treatment Plan Form
• Workers’ Compensation Physical Demands Analysis Form
• Weekly Physical/Occupational Therapy Plan Form
• Procedure/Surgery And After Care Precertification Form
• Progress & Treatment Status Psychologist/Psychiatrist Report Form

Should a medical condition exist that is not related to an applicable workers’ compensation- or PIP-covered injury, it is advisable that you refer the patient to his/her family physician. Payments for treatments arising from nonwork-related illnesses or injuries are the responsibility of the patient and/or his/her health insurance carrier.

Because of the frequent need to correspond with HCS case managers or assigned client case managers, employees, employers, attorneys and other physicians, it is important that documentation is clear and concise.

• Within one day of the office visit, HCS requires that you fax a patient treatment plan to the injured worker’s case manager. The treatment plan must include the patient’s work status.
• Within three days of the office visit, HCS requires that you submit a dictated note/report of the injured worker’s office visit to the case manager.

Maximum Medical Improvement:

The patient has reached maximal benefit from a curative treatment plan, or further medical treatment will not provide any improvement in the patient’s current condition.

Future need for care:

The patient will need further care and periodic evaluations, or the patient will require specific continuing care to function.

Re-evaluations:

A one-time medical re-evaluation is done by the physician of record to confirm if current symptoms are related to the original injury and to determine if the injured worker will benefit from any additional treatment or remain at maximum medical improvement.

Independent Medical Exam (IME):

In select cases, network physicians will be asked to evaluate injured workers who receive care from other physicians. The assigned case manager will provide the physician with a case overview and medical information to facilitate the process. It is important that findings are accurately documented and final opinions are conclusive.

Second Opinion and Takeover:

This process involves a review of current records by another physician of the same specialty to determine course of treatment and probable takeover of care as directed by the case manager.

Medical authorization:

When seeking authorization, the phrase “I believe this care is medically necessary and appropriate” is preferable. Use the term “palliative” only when the patient is receiving palliative care.

Causal relationship:

Always be specific and decisive by using “direct causation,” “aggravation,” “exacerbation,” or “acceleration” when there is a causal relationship.

Complaints versus findings:

Always differentiate between objective findings and subjective complaints when confirmation cannot be made by examination or tests.

Probability:

The term “probability” should be used in all cases rather than “possibility,” which has no legal meaning. “More likely than not” is also acceptable.

Documenting the initial office visit:

Detailed documentation of the initial office visit is essential.

Please use the following guidelines:

• Accurately record the initial statements and subjective complaints of the injured employee.
• Maintain a written account of the patient’s perception of the injury, regarding the time, date, location, mechanism and related additional observations.
• Note anything unusual, e.g., the patient limps into the office and leaves with a normal gait.
• Avoid assuming that the incident is work-related or sustained in an automobile accident.
• Evaluate how the injury occurred. Ascertain whether a pre-existing condition unrelated to the patient- reported cause may have triggered the injury.
• Include a significant number of facts in your notes.
• Assess and document the depth of the apparent injury, e.g., mild, moderate or severe.

For workers’ compensation claimants, the treating physician is responsible for obtaining precertification for:

• Audiology
• Chiropractic care
• CT scan
• Durable medical equipment over $500
• Electroencephalogram (EEG)
• Extended care and rehabilitation facilities
• Home health care
• Infusion therapy
• MRI
• Needle Electromyography (EMG)
• Non-emergency inpatient and outpatient hospital care
• Non-emergency surgical procedures
• Occupational therapy
• Out-of-network referrals
• Outpatient psychology and psychiatric services, including biofeedback
• Pain management services
• Physical therapy
• Podiatry services
• Second opinions

To obtain a precertification number, call an HCS representative at 1-800-985-7777 or call the assigned case manager for workers’ compensation treatment. The precertification number must be recorded on the Patient Treatment Plan Form.

All initial treaters and specialists are required to comply with HCS policies and procedures contained in this manual.

For PIP services, a Point of Contact Letter is sent to the claimant, his/her legal representative and all treating physicians and health care professionals. This letter outlines in detail the entire precertification process, including information on:

• Assignment of Benefits
• Completing the Review Process
• Decision Point Review
• How to Submit Requests for Decision Point Review and Precertification
• Mandatory Precertification
• Reconsideration Process
• Voluntary Network Services
• Voluntary Precertification

Under New Jersey law, the physician treating PIP claimants is responsible for obtaining precertification for:

• Brain Audio Evoked Potential (BAEP)
• Brain Evoked Potential (BEP)
• Brain Mapping
• Cognitive therapy
• CT/CAT scan
• Durable medical equipment, including orthotics and prosthetics, costing more than $50 or rented longer than 30 days
• Dynatron/Cyber Station/Cybex
• Electroencephalogram (EEG)
• Extended care and rehabilitation facilities
• Home health care
• H-reflex study
• Infusion therapy
• MRI
• Needle Electromyography (EMG)
• Nerve Conduction Velocity (NCV)
• Non-emergency dental restoration
• Non-emergency inpatient and outpatient hospital care
• Non-emergency surgical procedures
• Occupational therapy
• Outpatient psychology and psychiatric services, including biofeedback
• Pain management services except those provided for identified injuries in accordance with Decision Point Review
• Physical therapy
• Restorative therapy, other
• Somatosensory Evoked Potential (SSEP)
• Sonograms/Ultrasounds
• Speech therapy
• Therapeutic or body part manipulation including manipulation under anesthesia
• Thermograph/Thermography
• Videofluroscopy
• Visual Evoked Potential (VEP)

Some services are subject to individual benefit limitations.

Except for emergencies, all hospital inpatient admissions must be precertified. To precertify an admission, please call HCS at 1-800-985-7777 or contact the assigned case manager. The precertification number must be recorded on the Patient Treatment Plan Form.

HCS contracts with hospitals throughout the region. HCS participating physicians are required to have admitting privileges at one or more participating hospitals.

To the extent allowed under applicable law under workers’ compensation, no patient is to be admitted to an out-of- network hospital unless the case is an emergency. Should such a case occur, please notify HCS of the admission within 24 hours of the admission.