News and Updates

The Original Notice and Petition for Independent Medical Examination Form 100A has been revised to reflect changes due to the decision in Dodd v. Fleetguard, Inc., No. 8-332/07-1342, filed August 13, 2008, and is a fillable form.

how your workers' compensation benefits can affect your social security benefits. (9-30-08)

For Answers to questions on how your social security benefits can be affected by workers' compensation benefits. (7-9-10)

RESOLUTION OF MEDICAL FEE DISPUTES

Over the past several months the Workers’ Compensation Commission has received numerous inquires regarding the resolution of medical fee disputes. As required by Iowa Code section 85.27(3), and rules 876 IAC 10.3 and 876 IAC 4.46, insurers and providers who have a medical fee dispute must take the following steps to resolve the dispute:

1.    An insurer who disputes a charge must give a provider written notice of the disputed charge within 60 days of receiving a bill. Charges not in dispute must be paid to the provider before using the procedures in rule 876 IAC 10.3.

2.    The notice should contain: names of employee and employer; date of injury; date of disputed treatment; the amount of the charge the insurer agrees to pay; the amount of the charge in dispute; the reason the charge is believed to be excessive or unnecessary, and the documentation relied on; the address for directing correspondence; and the procedures available through the Workers’ Compensation Commission to resolve the dispute.

3.    If the provider does not accept the amount the insurer agrees to pay, the provider must give written notice, and ask the disputed amount go to a reviewer for review.

4.    The person chosen as the reviewer cannot be the Workers’ Compensation Commission. If the parties cannot agree upon a reviewer, each shall submit a name to the commissioner, and the commissioner shall decide who is to act as a reviewer.

5.    The reviewer, as soon as practicable, is to determine in writing the amount of the charge that is reasonable and necessary. Costs of the review are to be paid as agreed to by the parties.

6.    A dispute over a charge can include the reasonableness of the charges. It may also include the necessity of the charge.

7.    A contested case proceeding may be commenced only after these steps for dispute resolution have been followed, and good faith efforts to resolve the dispute have failed. Such a proceeding must be commenced within 30 days after written determination is made by the reviewer.

8.    Rule 876 IAC 10.3 does not prevent providers and insurers from developing other procedures to informally resolve their disputes, if those procedures aid in the resolution of a medical fee dispute.

If the process, detailed in rule 876 IAC 10.3, does not resolve the dispute and the parties have attempted resolution in good faith, a contest case may be initiated, pursuant to rule 876 IAC 4.46. The following applies to contested cases regarding medical fee disputes:

1.   Evidence is filed at the time the contested case is initiated and is limited to that provided by the reviewer, and the determination made by the reviewer.

2.   The commissioner may request or allow additional evidence.

3.   If a brief is to be filed, it needs to be filed at the time the matter is commenced.

4.    The opposing party has 30 days from the date of service of the petition, to file a response and optionally a brief. (8-4-08)

876—2.4(85,86) Guides to evaluation of permanent impairment. The Guides to the Evaluation of Permanent Impairment, Fifth Edition, published by the American Medical Association are adopted as a guide for determining permanent partial disabilities under Iowa Code section 85.34(2)“a” to “s.” The extent of loss or percentage of permanent impairment may be determined by use of ~~this guide~~ the Fifth Edition of the guides and payment of weekly compensation for permanent partial scheduled injuries made accordingly. Payment so made shall be recognized by the workers’ compensation commissioner as a prima facie showing of compliance by the employer or insurance carrier with the foregoing sections of the Iowa workers’ compensation Act. Nothing in this rule shall be construed to prevent the presentations of other medical opinions ~~or guides~~ or other material evidence for the purpose of establishing that the degree of permanent disability to which the claimant would be entitled would be more or less than the entitlement indicated in the Fifth Edition of the AMA ~~guide~~ guides.

This rule is intended to implement Iowa Code ~~section~~ sections 85.34(2) and 86.8.

The amendment to Rule 2.4 is in response to the publication of the AMA Guides to the Evaluation of Permanent Impairment, Sixth Edition, and a call for clarity on the use of the new Guides by several constituencies. While the amendment has been filed on an emergency basis for immediate publication, the rule has also been filed for the allowance of public comment in the normal rule making process. Public comments are encouraged.

Benefit payments for permanent partial disabilities in Iowa for scheduled injuries are frequently based upon the use of the AMA guides. The new sixth edition touts a new paradigm to rating impairment, when compared to ratings under previous editions of the AMA guides and other medical impairment guidelines or treatises. The impact on the level of impairment ratings (and perhaps corresponding level of permanent disability) cannot yet be determined or appreciated as there are no comparative studies on where various injuries or impairment are rated under both the fifth and sixth edition.

Until such studies can be completed by medical and legal experts who commonly are involved in the Iowa Workers’ Compensation system, the use of sixth edition ratings are expressly discouraged. (4-08)