W. Va. Code R. § 85-20-6 - The Role of the Treating Physician

6.1. Each injured worker selects a treating physician of record who will treat the injured worker and be responsible for coordinating all subsequent health care. The treating physician of record may be a medical doctor, osteopath, podiatrist, or chiropractor. Any treating physician who is limited in number of treatments by another provision of this Rule shall, upon exhaustion of that limit, only seek reimbursement as a treating physician for services provided in intervals consistent with those of other treating physicians. The injured worker should not seek care from more than one provider without contacting the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, requesting the designation of a different attending physician, and having that request approved. Injured workers whose employer's or the employer's private carrier's managed care plans have been approved by the Commission or Insurance Commissioner, whichever is applicable, or who are covered by a managed care plan adopted by the Commission shall chose a treating physician offered under the applicable plan.

6.2. Whenever possible, the treating physician should use the least costly mode of treatment. This generally will require that outpatient services be used in lieu of inpatient care and the avoidance of referring injured workers to hospital emergency rooms for care that can be rendered in the office. The Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, will approve payment for initial use of emergency room facilities and services such as routine dressings, routine tests, routine medications and routine local anesthesia. Subsequent use of the emergency room for services will not be approved without a statement from the physician explaining the necessity for the services rendered. Routine visits to the emergency room shall not be approved or reimbursed by the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable.

6.3. Treating physicians should request referral of an injured workers who continues to report pain and dysfunction while showing no significant measurable or objective signs of improvement for a Permanent Partial Disability evaluation. Such injured workers may also be discharged or referred to a different, appropriate specialty for evaluation and possible modification of treatment.

6.4. When the treating physician finds the injured worker to be at maximum medical improvement, the treating physician may provide an impairment rating pursuant to applicable Guidelines for the injured worker. If the rating exceeds fifteen percent (15%), the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, may accept or reject the rating and may order an independent evaluation of the injured worker. The treating physician may also report a finding of Maximum Medical Improvement without making an impairment rating, reported on Form WC-219a, "Notice of Maximum Medical Improvement."

6.5. The treating physician of record shall provide a treatment plan for the medical care being considered in narrative form as set forth in section 3.11 of this Rule.

6.6. It is the responsibility of the treating physician to notify the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, of the injured worker's most accurate and current condition. The initial diagnosis reported when a claim is filed often requires updating based on diagnostic tests and clinical objective findings. Changes, additions and revisions of the injured worker's condition must be reported using the applicable Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, form. All changes related to a diagnosis code shall submitted to the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, and must be approved by the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable,, unless the new diagnosis is otherwise accepted by the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, as being causally related to the compensable injury. Bills submitted for treatment that is clearly unrelated to the compensable diagnosis shall be denied and may serve as evidence of abuse under W. Va. Code § 23-4-3c and/or fraud under W. Va. Code § 61-3-24g. The Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, may, in its sole discretion, recognize and identify the change, addition, or revision as a compensable condition.

6.7. Injured workers must request authorization from the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, to change the treating physician of record in their claim. This rule does not apply in the following cases:

a. Care transferred after initial emergency or first aid treatment if done so within 30 days of the date of injury;

b. Care transferred to a specialist by the original treating physician; or c. Care where an unforeseen emergency develops which requires special facilities and skills are not available to the treating physician or hospital.

6.8. Any change of treating physician that does not require authorization by the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, will require a detailed explanation to ensure that the change is documented on the claim file. Failure to do so may result in the delay of benefits and will result in the denial of payment for medical services.

6.9. When a change of physician is authorized, the previous treating physician must file a final report of the injured worker's physical status on the effective date of change. The new treating physician of record must file an initial narrative report of his/her findings. It is the responsibility of every provider to make reasonable effort to ascertain whether there was a prior treating physician.

6.10. Except in cases where a consultant, anesthetist or surgical assistant is required, or the necessity for treatment by a specialist is clearly shown, fees not pre-authorized by the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, will not be approved for treatment by more than one medical vendor for the same condition over the same period of time.

Notes

W. Va. Code R. § 85-20-6