A Practical Approach to South A Practical Approach to South Carolina’s New Rehab RegulationsCarolina’s New Rehab Regulations

BY BY Margaret McLarney, RN, BSN, CCMMargaret McLarney, RN, BSN, CCM

Team Manager/Managed Care Zurich ServiceTeam Manager/Managed Care Zurich Service

Linda Hanf , RN, BSN, CCM, CRRNLinda Hanf , RN, BSN, CCM, CRRNVP, Case Management Services, The Directions VP, Case Management Services, The Directions

Group, Inc.Group, Inc.

A Practical Approach to South A Practical Approach to South Carolina’s New Rehab RegulationsCarolina’s New Rehab Regulations

Does Brown v Bi-Lo still apply? Does Brown v Bi-Lo still apply?

New Reg made easy.New Reg made easy.

The do’s and don’ts of communicating with The do’s and don’ts of communicating with physicians, attorneys, claimants and adjusters-Best physicians, attorneys, claimants and adjusters-Best

Practices. Practices.

A LITTLE FUN-PEOPLE OF A LITTLE FUN-PEOPLE OF WALMART-WALMART-I love Wal-MartI 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!

One more One more

Is that a gangster leotard?

A LITTLE HISTORYA LITTLE HISTORY

• PRE BROWN V BILOPRE BROWN V BILO

• PRE JUL 2007PRE JUL 2007

PRE BROWN V BILO-SOME CALL WILD WILD PRE BROWN V BILO-SOME CALL WILD WILD WESTWEST-borrowed from Ken Harrell’s presentation with permission-borrowed from Ken Harrell’s presentation with permission

• No effective limitations were in place on No effective limitations were in place on communications between an injured communications between an injured worker’s doctor and insurance carrier worker’s doctor and insurance carrier representatives.representatives.

• Injured workers, already cynical about Injured workers, already cynical about their treatment providers, were even more their treatment providers, were even more disillusioned due to unfettered access.disillusioned due to unfettered access.

Why were injured workers so Why were injured workers so cynical about their treatment?cynical about their treatment?

• 42-15-60 – allows the employer/carrier to 42-15-60 – allows the employer/carrier to determine who treats the injured worker.determine who treats the injured worker.

• 2006 – tie vote in the S.C. House on a 2006 – tie vote in the S.C. House on a measure which would have provided measure which would have provided employees with some ability to choose their employees with some ability to choose their treatment provider. treatment provider.

• Many injured workers believe their doctors Many injured workers believe their doctors work for the insurance company, not for them work for the insurance company, not for them (and they believe the same thing about their (and they believe the same thing about their rehab nurses.)rehab nurses.)

Brown v. Bi-Lo – 2003 DecisionBrown v. Bi-Lo – 2003 Decision

• 42-15-95 requires doctors to provide employers and their 42-15-95 requires doctors to provide employers and their representatives with written reports in a timely manner. representatives with written reports in a timely manner. (EXISTING)(EXISTING)

• Statute does not authorize “unauthorized” “ex parte” contact. Statute does not authorize “unauthorized” “ex parte” contact. Ex Parte defined as from or on one side or strongly biased point 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 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 one party to a legal matter and in the absence of and usually without notice to the other party ex parte motion> ex parte> without notice to the other party ex parte motion> ex parte> —used in citations to indicate the party seeking judicial relief—used in citations to indicate the party seeking judicial relief

• Employers may use approved discovery methods, and speak Employers may use approved discovery methods, and speak with the doctor with employee’s permissionwith the doctor with employee’s permission. .

• Applies to all injuries that occurred before July 1, 2007Applies to all injuries that occurred before July 1, 2007

• SO DOES BROWN V BILO APPLY?SO DOES BROWN V BILO APPLY?

• YES-TO INJURIES SUSTAINED BEFORE YES-TO INJURIES SUSTAINED BEFORE JULY 1, 2007JULY 1, 2007

MANAGED HEALTH CARE MANAGED HEALTH CARE PROVISIONSPROVISIONS

• NEW REGS APPROVED JAN 13 2010 AND EFFECTIVE FEB 26 NEW REGS APPROVED JAN 13 2010 AND EFFECTIVE FEB 26 20102010

• R. 67-1307. Rehabilitation Professionals.R. 67-1307. Rehabilitation Professionals.

• R. 67-1308. Communication Between Parties And Health Care R. 67-1308. Communication Between Parties And Health Care Providers.Providers.

• Available at South Carolina Worker’s Compensation Available at South Carolina Worker’s Compensation Commission web pageCommission web page

R.67-1307. Rehabilitation R.67-1307. Rehabilitation ProfessionalsProfessionals

• Rehabilitation professionals are coordinators of medical Rehabilitation professionals are coordinators of medical rehabilitation services, including but not limited to state, rehabilitation services, including but not limited to state, private, or carrier based, whether on site, telephonic, in or out private, or carrier based, whether on site, telephonic, in or out of state.of state.

• The role of a rehabilitation professional is to ensure the primary The role of a rehabilitation professional is to ensure the primary concern and commitment in each workers’ compensation case concern and commitment in each workers’ compensation case is to advance the medical rehabilitation of the injured worker.is to advance the medical rehabilitation of the injured worker.

• A rehabilitation professional must comply with S.C. Section 42-A rehabilitation professional must comply with S.C. Section 42-15-95 and R.67-1308 when communicating with a 15-95 and R.67-1308 when communicating with a health care health care provider provider who provides examination or treatment for any injury, who provides examination or treatment for any injury, disease, or condition for which compensation is sought. A disease, or condition for which compensation is sought. A rehabilitation professional shall possess one of the following rehabilitation professional shall possess one of the following certifications:certifications:

CERTIFICATIONS CERTIFICATIONS (LICENSE-I ADDED)(LICENSE-I ADDED)

• Registered Nurse – RN-(LICENSE)Registered Nurse – RN-(LICENSE)• Certified Rehabilitation Counselor – CRCCertified Rehabilitation Counselor – CRC• Certified Registered Rehabilitation Nurse – CRRN Certified Registered Rehabilitation Nurse – CRRN • Certified Disability Management Specialist – Certified Disability Management Specialist –

CDMSCDMS• Certified Occupational Health Nurse – COHNCertified Occupational Health Nurse – COHN• Certified Case Manager – CCMCertified Case Manager – CCM

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

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

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

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

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

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

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

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?

1. MAINTAIN OPEN COMMUNICATION WITH INJURED WORKER AND/OR ATTORNEY FROM BEGINNING OF CASE.

2. 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?

3. PROVIDE COPIES OF CASE MANAGEMENT REPORTS TO ALL PARTIES.4. OBTAIN SIGNED MEDICAL RELEASE IF POSSIBLE.5. KNOW THE SC GUIDELINES, CODE OF ETHICS FOR YOUR

CERTIFICATION(S) AND STANDARDS OF PRACTICE FOR RN. 6. ALWAYS ADVOCATE FOR THE INJURED WORKER. 7. LET INJURED WORKER KNOW THEY HAVE RIGHT TO A PRIVATE

EXAM.8. IF ASKED TO ATTEND EXAM, DOCUMENT IN REPORT.

BEST PRACTICES FOR CASE MANAGERS/REHABILITATION CONSULTANTS

QUESTIONS???QUESTIONS???

I can’t help myselfI can’t help myself

at least he shaved his legsSweetheart ... those shoes with that skirt just make you

look cheap!

raggedy Ann goes raggedy Ann goes blueblue