A Practical Approach to South Carolina’s New Rehab Regulations

1. A Practical Approach to South Carolina’s New Rehab Regulations BY Margaret McLarney, RN, BSN, CCMTeam Manager/Managed Care Zurich Service Linda Hanf , RN, BSN, CCM, CRRN VP, Case Management Services, The Directions Group, Inc.

2. A Practical Approach to South Carolina’s New Rehab Regulations Does Brown v Bi-Lo still apply? New Reg made easy. The do’s and don’ts of communicating with physicians, attorneys, claimants and adjusters-Best Practices.

3. A LITTLE FUN-PEOPLE OF WALMART-I love Wal-Mart Let’s run through my rock star list…. Mullet? – check; big sunglasses? – check; heart shaped tattoo?  – u know I love my mom; Cut jean shorts? – are there any other type of shorts?; wife beater tied at the midriff – check;….. He is an official ROCK STAR!

4. One more Is that a gangster leotard?

5. A LITTLE HISTORY • PRE BROWN V BILO • PRE JUL 2007

6. PRE BROWN V BILO-SOME CALL WILD WILD WEST-borrowed from Ken Harrell’s presentation with permission • No effective limitations were in place on communications between an injured worker’s doctor and insurance carrier representatives. • Injured workers, already cynical about their treatment providers, were even more disillusioned due to unfettered access.

7. Why were injured workers so cynical about their treatment? • 42-15-60 – allows the employer/carrier to determine who treats the injured worker. • 2006 – tie vote in the S.C. House on a measure which would have provided employees with some ability to choose their treatment provider. • Many injured workers believe their doctors work for the insurance company, not for them (and they believe the same thing about their rehab nurses.)

8. Brown v. Bi-Lo – 2003 Decision • 42-15-95 requires doctors to provide employers and their representatives with written reports in a timely manner. (EXISTING) • Statute does not authorize “unauthorized” “ex parte” contact. Ex Parte defined as from or on one side or strongly biased point of view/on behalf of or involving on behalf of or involving only one party to a legal matter and in the absence of and usually without notice to the other party ex parte motion> ex parte> —used in citations to indicate the party seeking judicial relief • Employers may use approved discovery methods, and speak with the doctor with employee’s permission. • Applies to all injuries that occurred before July 1, 2007

9. SO DOES BROWN V BILO APPLY? • YES-TO INJURIES SUSTAINED BEFORE JULY 1, 2007

10. MANAGED HEALTH CARE PROVISIONS • NEW REGS APPROVED JAN 13 2010 AND EFFECTIVE FEB 26 2010 • R. 67-1307. Rehabilitation Professionals. • R. 67-1308. Communication Between Parties And Health Care Providers. • Available at South Carolina Worker’s Compensation Commission web page

11. R.67-1307. Rehabilitation Professionals • Rehabilitation professionals are coordinators of medical rehabilitation services, including but not limited to state, private, or carrier based, whether on site, telephonic, in or out of state. • The role of a rehabilitation professional is to ensure the primary concern and commitment in each workers’ compensation case is to advance the medical rehabilitation of the injured worker. • A rehabilitation professional must comply with S.C. Section 42-15-95 and R.67-1308 when communicating with a health care provider who provides examination or treatment for any injury, disease, or condition for which compensation is sought. A rehabilitation professional shall possess one of the following certifications:

12. CERTIFICATIONS (LICENSE-I ADDED) • Registered Nurse – RN-(LICENSE) • Certified Rehabilitation Counselor – CRC • Certified Registered Rehabilitation Nurse – CRRN • Certified Disability Management Specialist – CDMS • Certified Occupational Health Nurse – COHN • Certified Case Manager – CCM

13. Rehabilitation professionals shall be subject to the requirements, rules, regulations, and Code of Ethics specific to their license and certification.

14. R.67-1308. Communication Between Parties And Health Care Providers after July 2007

15. A health care provider who provides examination or treatment for any injury, disease or condition for which compensation is sought under the provisions of this title may discuss or communicate an employee’s medical history, diagnosis, causation course of treatment, prognosis, work restrictions, and impairments with the insurance carrier, employer, their respective attorneys or certified rehabilitation professionals or the Commission without the employee’s consent.

16. B. The claimant must be: 1. Notified by the employer, carrier or their representative requesting the discussion or communication with the health care provider in a timely fashion, but no less than ten (10) days notice unless the parties agree otherwise.Notification may be oral or in writing.

17. 2. Allowed to attend and participate with claimant’s attorney, if any.

18. 3. Advised by the employer, carrier or their representative requesting the discussion or communication prior to the discussion or communication.

19. 4. Provided a copy of the written questions at the same time the questions are submitted to the health care provider and provided a copy of the response by the health care provider.

20. QUESTIONS TO PONDER DO YOU HAVE TO BE LICENSED IN SC? DEFINE MEDICAL PROVIDER-PHYSICIAN, PT, OT, ETC. DO YOU HAVE TO NOTIFY INJURED WORKER/ATTORNEY YOU WILL ATTEND EVERY APPOINTMENT AND WILL ASK SAME QUESTIONS BEFORE EVERY APPOINTMENT? DOES 10 DAY RULE APPLY TO PT/OT APPOINTMENTS? HOW DO YOU COMMUNICATE REGULAR JOB DESCRIPTION TO MEDICAL PROVIDER? CAN YOU TELL THE PHYSICIAN RESTRICTED WORK IS AVAILABLE?

21. Best Practices for Case Managers/Rehabilitation Consultants MAINTAIN OPEN COMMUNICATION WITH INJURED WORKER AND/OR ATTORNEY FROM BEGINNING OF CASE. EXPLAIN ROLE TO INJURED WORKER/ATTORNEY AND AGREE TO WHAT WILL HAPPEN- FOR EXAMPLE-WILL ATTEND EACH APPOINTMENT, SEND LETTER WITH QUESTIONS EACH TIME?, WHAT ABOUT 10 DAYS RULE FOR MD APPT, FOR PT APPT? PROVIDE COPIES OF CASE MANAGEMENT REPORTS TO ALL PARTIES. OBTAIN SIGNED MEDICAL RELEASE IF POSSIBLE. KNOW THE SC GUIDELINES, CODE OF ETHICS FOR YOUR CERTIFICATION(S) AND STANDARDS OF PRACTICE FOR RN. ALWAYS ADVOCATE FOR THE INJURED WORKER. LET INJURED WORKER KNOW THEY HAVE RIGHT TO A PRIVATE EXAM. IF ASKED TO ATTEND EXAM, DOCUMENT IN REPORT.

22. QUESTIONS???

23. I can’t help myself at least he shaved his legsSweetheart ... those shoes with that skirt just make you look cheap!

24. raggedy Ann goes blue