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Managed Care & Rehabilitation

FREQUENTLY ASKED QUESTIONS AND ANSWERS ABOUT MANAGED CARE AND REHABILITATION

When am I a “rehabilitation supplier” or “case manager”?

For purposes of Board definition clarity, any case management being provided pursuant to an MCO is regulated by Rule 208, and the person providing the case management is referred to by the Board as a Case Manager.

Any case management that is being provided in all other cases is regulated by Rule 200.1, and the person providing the case management is referred to by the Board as a Rehabilitation Supplier, regardless of how that person identifies his or herself (i.e. case manager, nurse, etc.).

What is the difference among a “voluntary rehabilitation supplier”, “rehabilitation consultant”, and “direct employee” of an employer, insurer or third party administrator (tpa)?

A voluntary rehabilitation supplier is providing services on a post 7/1/1992 date of accident claim that is not designated by the Board as catastrophic, pursuant to Rule 200.1(h).

A rehabilitation consultant is a person employed outside of the employer/insurer/tpa who is hired by the adjuster to provide guidance on the employees medical and/or rehabilitation needs.

A direct employee of an employer/insurer/tpa is someone who receives their paycheck and benefits from that particular party.  This is directly contrasted with the “direct” hiring of a person employed by someone else or self-employed to perform case management services on behalf of the employer/insurer/tpa.

Do case managers have to be registered with the Board?

Case managers employed by a Board Certified MCO, and working with the MCO’s contracted employer, do have to be registered:  He/she must have one of the following credentials: CCM, CRRN, or COHN, COHN-S, LPC, CWAVES, CDMS or CRC, and the MCO must file with the Board the name of the proposed case manager and a copy of their credentials.  In addition, the MCO must attest that all of their case managers have the appropriate credentials. 

Do rehabilitation suppliers have to be registered with the Board?

Yes, if the supplier wants to actively provide case management services as a voluntary rehabilitation supplier on a claim pursuant to Rule 200.1(h).  Registration requirements are provided in Rule 200.1(f).

Do rehabilitation consultants have to register with the Board?

It is not required.  However, a Board registered rehab supplier may serve as a rehabilitation consultant on a claim.   

Do direct employees of the employer/insurer/tpa have to register with the Board to provide case management services?

It is not required, but very often, if qualified, these employees do register as a rehabilitation supplier with the Board.  If so, when working on a claim, they must operate as either a voluntary rehab supplier or as the direct employee and may not change mid-stream.  (See below) 

What can I do as a voluntary rehabilitation supplier?

Voluntary rehabilitation suppliers must first comply with Rule 200.1(h) by obtaining written consent from the injured employee or his/her attorney to provide rehabilitation services.  If the adjuster has specified what the supplier is being hired to do, it is encouraged for the consent to specify same, so all parties understand the supplier’s involvement.  The supplier should then provide whatever services are authorized pursuant to the rest of Rule 200.1.  If the authorization to continue providing case management services is withdrawn by any party at any time, the supplier must immediately cease all further work and close his/her file.

What can I do as a rehabilitation consultant?

The consultant may review records, conduct job analyses, and provide technical assistance to an employer/insurer.   A rehabilitation consultant may not contact the injured employee, his/her attorney or the authorized treating physician either in person, in writing, or by telephone or fax. 

If I am acting as a Rehabilitation Consultant on behalf of the employer/insurer/tpa, may I contact authorized treating physicians on behalf of the adjuster?

You may not speak with, discuss, fax or write to the authorized treating physician.   As a Rehabilitation Consultant you work only with the employer/insurer/tpa who hired you.  Any written job descriptions, recommendations, medical reviews or questionnaires go directly to the claims adjuster.  The claims adjuster may then send this work product out under his/her letterhead.

Can a rehabilitation consultant help with an IME?

A rehabilitation consultant may only help to set up the time and place of an IME and coordinate records transfer. However, any questions asked of the IME physician regarding the injured employee must come from a party to the claim.  The consultant may not have any contact with the IME physicians or office staff to discuss the injured employees’ treatment, outcomes, return-to-work status, or job descriptions.   This includes all methods of contact: telephonic, correspondence, e-mail, fax, or face-to-face interaction. 

As a rehabilitation consultant, if I write a job description, and the claims adjuster submits it to the doctor, may I call the doctor’s office after several weeks to determine if the doctor has reviewed it or signed off on it?

No, you would not be allowed to speak to the doctor or his office regarding the job description.   That provides too much opportunity to discuss the employee’s care with the doctor. If the adjuster has sent a job description to the doctor, the adjuster can call the doctor to determine the status of the job description.

What may a registered rehabilitation supplier or person do regarding case management if a “direct employee” of an employer, insurer or TPA on a claim?

That person has the same standing that an adjuster would (i.e., a party to the claim), and may have contact with the treating physicians.  However, the supplier or person must clearly identify themselves as the employee of the party and not use any titles (i.e. case manager, nurse, etc.).   Furthermore, since that person is viewed as a representative of the party, if he or she makes any representation to an employee, employee’s attorney or treating physicians, it can be held to be binding on the party.  Internal decisions must be made as to authority of this person to commit the party to a position and followed by the direct employee.

If you are working as a voluntary rehabilitation supplier, does the Fee Schedule apply?

In a voluntary rehabilitation claim, the Rehabilitation Fee Schedule applies when the payer wants to use it. Certainly, rehabilitation suppliers should stay within the time allotments allowed per the Fee Schedule (Catastrophic Injury cases are exempt from the time allotments). The payer and the rehabilitation supplier can agree on a higher per hour fee. All rehabilitation suppliers/case managers should realize that the payer might conform rehabilitation charges in any Georgia workers’ compensation case to the Fee Schedule unless otherwise negotiated.

If the employer/insurer does not pay my rehabilitation services bill for 90 days, can it still be reviewed and reduced?

All payments for rehabilitation services are due and payable within thirty (30) days of receipt of the bill. Bills not paid within thirty (30) days from date of receipt by the payer may be subject to penalties as prescribed by the Board.   Within the same thirty (30) days, an employer, insurer, or third party administrator who believe there are any charges not listed in the fee schedule, or any service being disputed, that are not usual, customary, reasonable or necessary, shall in the first instance submit to peer review and thereafter may file a WC-14 to request a mediation or hearing. 

Except for the hourly rate, catastrophic injuries as defined in O.C.G.A. §34-9-200.1(g) are exempt from the fee schedule. O.C.G.A. §34-9-200.1(d) specifies that the reasonableness of fees and necessity of services are subject to review by the State Board of Workers’ Compensation. The Board may require, or any party or supplier may request, a review by a panel of peers to determine whether fees were reasonable. The process for requesting peer-review is detailed in the forward to the Rehabilitation Fee Schedule.

If I receive a psychological evaluation, may I send it to the State Board or quote anything in the evaluation in a letter or report?

According to Board Rule 200.1 (a)(3)(iii): "Rehabilitation reports do not include psychiatric or psychological reports." However, if the psychological evaluation is requested by the employer/insurer or is done in relation to the employee’s injury (i.e., before surgery, a neuro-psychological evaluation for a head injury or ongoing treatment notes) then this information may be attached.

What should a rehabilitation supplier/case manager do when he/she believes a referred claim is catastrophic and the insurer/employer disagrees?

Any rehabilitation supplier/case manager may call the Board’s rehabilitation coordinators to report such a claim. The coordinator will investigate, pull the Board’s file, review the records or request more information, and follow-up with the employer/insurer.  However, under no circumstances should the rehabilitation supplier/case manager continue to work on the file.

How can I obtain a copy of the Rehabilitation Fee Schedule?

You may download the document from our website.  Click here.

How can I obtain a copy of the Rehab Supplier List?

You may download the document from our website.  Click here.