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A Workers' Compensation Attorney's Guide to Medical Practice Questions

The format Questions and Answers were originally produced by the Oregon Workers’ Compensation Attorneys in 1996. The answers have all been substantially updated by Swanson, Thomas & Coon effective March 2000. Please note: This is intended as a guide for Medical Providers. It does not constitute legal advice. Because each individual situation is different, you should contact an attorney for legal advice on your specific situation. You can email us with specific questions at Swanson Thomas and Coon.

CONTENTS

1. Collection: rates, bills, settlements
   1. What forms are required for billing?
   2. Does the worker have to receive a copy of the bill?
   3. Is the workers’ compensation carrier required to pay the full billing?
   4. Can a doctor bill a patient for any amounts not paid by the workers’ compensation carrier?
   5. Can a doctor bill a patient for unpaid bills?
   6. When can medical providers protect themselves while claim acceptance is being decided?
   7. What happens if an injured worker settles a denied claim on a Disputed Claim Settlement (DCS) basis?
   8. What should a provider do if the insurance carrier is not paying medical bills on an accepted claim?
2. Aggravation
   9. Is an aggravation claim different from a new injury claim?
   10. How does a doctor assist the patient in the presentation of an aggravation claim?
   11. What is a Form 827?
   12. What is the significance of Form 827?
   13. How does a doctor obtain Form 827?
   14. What special information must be in the brief narrative report?
   15. What does "objective findings" mean in the workers’ compensation law?
   16. What is a "worsening" of the condition versus a "waxing and waning"?
3. Communication with attorneys, insurers and patients
   17. Is the medical provider required to make patient information available to workers’ compensation insurers?
   18. Is there any limit on what information must be released?
   19. What can a medical provider’s office do to protect patients’ rights to the privacy of their medical information and ensure the office does not release privileged information to persons not authorized to receive it?
   20. How can medical providers ensure payment of their bills?
4. Notices for return to regular or modified work
   21. Whom must the doctor notify when a worker is released to return to work?
   22. When a doctor releases an injured worker for "light" or modified duty, what information must be included in the release?
5. Report writing, magic words; standards for injury, aggravation and occupational disease
   23. What information should a physician expect to receive from a patient’s attorney when the attorney requests the doctor’s written opinion?
   24. What are some examples of "matters at issue"?
   25. What terminology is currently required for proving a new compensable injury when the worker has no preexisting condition?
   26. What is the definition of preexisting condition?
   27. What is the current terminology necessary to prove a compensable injury where the worker has a preexisting condition which combines with the accidental injury to cause a "combined" condition?
   28. How does a doctor show that an injury is the "major contributing cause"?
   29. How symptomatic must a preexisting condition be previously (if at all) to be considered a preexisting condition?
   30. What is a consequential condition?
   31. What is necessary for proving a consequential condition?
   32. What is the current terminology for proving aggravation of a compensable condition?
   33. What is the current definition of an occupational disease?
   34. What is the current terminology for proving an occupational disease?
   35. What does the "major contributing cause" mean in occupational disease cases?
   36. What non-job-related causes must be considered in occupational disease cases?
   37. What is the current terminology for proving a compensable occupational disease when a preexisting condition is involved?
6. Treatment after claim closure and in aggravation situations
   38. Are insurers obliged to pay for medical treatment for an injured worker after their claim is closed?
   39. Must a doctor obtain authorization for curative treatment for an injured worker whose claim has been closed?
   40. What is the legal meaning of the phrase "palliative care"?
   41. Are insurers obliged to pay for any palliative care after the patient is medically stationary?
7. Time loss authorization
   42. What is "time loss"?
   43. What does "authorized" mean?
   44. Who is an "attending physician"?
   45. Why does the doctor have to authorize time loss when the worker is treated for the first time immediately after a disabling injury?
   46. What happens if the insurer requests from the attending doctor verification of the worker’s inability to work and the doctor does not verify it?
   47. What is the limit for retroactive authorization of time loss?
   48. After a doctor authorizes time loss, how long must the insurer continue paying time loss to the worker?
   49. Can a doctor authorize time loss into the future?
   50. What happens if a doctor authorizes time loss for two weeks and does not see the worker until five weeks later?
8. Index

Last update: February 23, 2000