Gruhin & Gruhin Attorney's » BWC

Injured on the job in Ohio – get a Board Certified Ohio BWC Specialist Attorney

Mike Gruhin — Wed, 11 May 2011 00:26:27 +0000

Injured on the job in Ohio? You need a Board Certified Ohio Workers’ Compensations Specialist Attorney

Ohio Workers’ Compensation – Not User Friendly!

Mike Gruhin — Sat, 03 Jul 2010 13:16:23 +0000

Although the BWC system was created to allow injured workers to request coverage for work injuries without the need of legal services, the system has become a nightmare of red tape and denials.

Over 90% of the hearings we attend on behalf of our clients result from the BWC denying the injured worker’s doctor;s request for treatment authorization.

If you are injured on the job, you should obtain legal representation to protect your legal right to medical care and injury compensation.

Contact the governor of Ohio and tell him to fix the system that was created to protect Ohio’s injured workers. He needs to replace the current BWC Administrator with one who did not come from the insurance industry where the top goal is to save money and increase premiums.

Ohio Workers need to unite and tell the Governor that Ohio Wokrers’ Compensation needs to be fixed NOW to benefit Ohio’s Injured Work Force.

Contact the Governor NOW! Let him know you are not going to let him continue in office until he repairs the system he pledged to fix when he first ran for office.

Attending a Workers’ Compensation Claim Hearing Alone?

Mike Gruhin — Wed, 30 Dec 2009 23:56:49 +0000

If your claim is scheduled for a hearing before the Industrial Commission, you should hire a Board Certified Workers’ Compensation attorney to represent your interests.

Normally, the employer attends the Industrial Commission hearings with its attorney, arguing against the interests of the injured worker.

At times the BWC has an attorney from its Law Department appear at the hearing to represent the BWC’s interests.

FYI, we have never heard of any hearing or claim where the BWC Law Department lawyer appeared and argued in favor of the injured worker.

Only you can protect your legal interests and you can only do that when you have the legal representation backing your position. As an injured worker, you may have two (2) parties arguing against your legal interests at any Industrial Commission hearing.

Ohio BWC – Changing the Settlement Process

Mike Gruhin — Wed, 30 Dec 2009 19:27:40 +0000

Information received indicates that, effective 1-1-2010, the Ohio BWC will impose NEW rules regarding BWC settlement offers:

1) A response must be made within 7 days. Failure to respond will result in settlement application dismissal;

2) Once the settlement figure is agreed, the BWC will issue a C241 form to confirm the settlement amount. If the Injured Worker does not sign and return the C241 within 14 days of the BWC mailing, the settlement application will be dismissed.

Of course, there is no limit on how long it might take BWC to make an offer. .

At times, an Injured Worker can wait 3-6 or more months before the BWC will even make an offer. What is good for the Goose should be good for the Gander. But not in reality. Is this just another example of the Ohio BWC “concern” for Ohio’s Injured Workers?

Currently, we are seeing very low offers to settle claims. We believe it is due to the 2008 Internal Audit of the BWC, which stated their procedures needed modification. This audit resulted in no settlements being made for a very long period of time.

Furthermore, we believe that the BWC is “low-balling” settlements to take advantage of the economy and the Injured Workers’ need for funds due to layoff, etc. The settlement offers being made are in many cases egregiously low.

Citizens of Ohio must make their elected officials aware of the “anti-worker” sentiment that is now rampant in the Ohio BWC. This situation must be remedied.

I Have an Ohio BWC Claim, but I Moved and I Need to Find a Doctor – What do I do?

Mike Gruhin — Tue, 29 Dec 2009 23:22:46 +0000

If you have an Ohio BWC claim, you have to get your medical treatment from a Certified Ohio BWC medical Provider. If your provider is not BWC certified, the bills do not have to be paid by the BWC. So, what do you do?

You can go to the OhioBWC website and check out this link .

If you have an OhioBWC claim and you are looking for legal representation, give us a call. Board Certified OhioBWC Specialist Attorney. You need a lawyer? Call us.

Alternative Dispute Resolution Changes (When the MCO denies your Medical Treatment Request)

Mike Gruhin — Sat, 19 Dec 2009 18:49:17 +0000

Alternative Dispute Resolution Changes (When the MCO denies your Medical Treatment Request)

The Ohio Bureau of Workers’ Compensation is changing its ADR process

In March of 2008 an internal audit of the ADR Process was performed. The audit surmised that the timeframes for ADR’s are excessive; noting that appeal process could take between 73 and 261 days to reach a resolution. Internal Audit Recommendations included:

- Consider the feasibility of eliminating levels of appeal.
- Ensure management reporting of pertinent ADR processes to assist with developing strategies to reduce appeals.
- To Implement preventive controls to ensure services and treatment are addressed appropriately

In response to these recommendations, a workgroup was formed to review the entire ADR processes and identify opportunities for continued improvement. This workgroup consisted of MCO and BWC members. This group recommended:

- Rule change eliminating BWC level of review
- BWC to develop a robust program oversight and quality review program
- Maintain ADR Goals

(1)   Facilitate resolution of medical treatment disputes—timely, effectively, and efficiently
(2)   Maintain fairness and due process
(3)   Ensure Quality Control of treatment decisions
(4)   Improve parties’ satisfaction

The reform proposal was presented to all stakeholders, OAJ, BWC Legal, the BWC Administrator and Senior Leaders, the BWC Board of Directors (02/18 & 03/18) and the Joint Committee on Agency Review (the legislative oversight for rule changes).

ADR reform approved by BWC Board of Directors on 03/18/09 and the rule change went into affect 11/01/09;

What are the changes?

Copy of the updated ADR rule change (4123-6-16) is attached.

- MCO shall complete the ADR process and submit its recommended ADR decision to the bureau electronically (refer to paragraph (E) of the rule). BWC ADR Department will continue to serve as program oversight and quality assurance unit.
- (C)(2 allows MCOs to obtain a review from a more specialized area of medicine
- Previously reviews conducted by a physician having a like practice as the physician requesting the treatment
- (E) Allow the MCO time frame for completing the ADR process to be suspended during the time an independent medical examination is obtained
- When an IME is indicated, the dispute timeframe is tolled until the MCO obtains a completed report—once the report is received an order will be published within 7 days.
- In the case of a file review MCOs have 21 days to perform a file review and make a decision.

Negotiations with providers can take place at any level in an attempt to resolve issues and get treatment approved.

C-11 form updated:

Instruction to withdraw appeal added
Level 2 language removed
A new withdraw appeal section added

Question: Does the rule still apply that if the MOC does not respond to a C-9 within 10 days the service is approved?

Answer: The MCO Policy Reference Guide says:

A medical service request will be considered approved and the provider may initiate treatments when all of these criteria are met:

(1)   The MCO fails to communicate a decision to the physician within three business days of receipt of an original medical services request or five business days if the request was pended;
(2)   The physician has documented the medical services request completely and correctly on a C-9 or other acceptable document;
(3)   The physician has proof of submission to the appropriate MCO;
(4)   Medical services are for the allowed conditions;
(5)   The claim is in a payable status.

In instances when a C-9 is not responded to within three business days and the provider initiates treatment, the MCO will provide concurrent and retrospective review of that treatment. If it is found before, after or during delivery, that any treatment, approved or not approved within three business days, is not medically indicated or necessary, not producing the desired outcomes, or patient is not responding, the MCO will notify the parties of the decision to discontinue payment of said treatment. Only charges for treatments already rendered will be paid. If the provider, IW or employer wish to dispute the decision, they may do so via the ADR process. The MCO shall obtain beginning and estimated ending dates for inpatient services if not provided on the request for medical services.

HAVING TROUBLE WITH YOUR OHIO WORKERS’ COMPENSATION CLAIM ? CALL GRUHIN & GRUHIN

You Should Know – Even If Your Employer Does Not Have Ohio Workers’ Compensation Coverage You Can File a Claim! Don’t be Misled!

Mike Gruhin — Fri, 20 Nov 2009 14:09:01 +0000

Yesterday, I received a call from a prospective client regarding a workers’ compensation claim. This injured worker stated that the employer stated that it did not have any BWC coverage, so a claim should not be made.

The injured worker believed that if there is no coverage, there can be no claim. To make matters, the worker sent in a letter saying the injury did not take place during work to see if health insurance would cover all of the medical bills from the serious injury suffered on the job.

In Ohio, even if your employer has no BWC coverage, you can still make a claim. The employer would be considered a non-complying employer by the BWC. Once the injured worker is granted a valid BWC claim, the BWC pays all of the compensation (medical bills, prescriptions, lost wages, injury money, etc.). The injured worker is fully covered.

The BWC then goes after the non-complying employer and seeks reimbursement dollar for dollar. The bottom line – if you get hurt on the job, make an accident report, tell a co-worker, get medical attention if necessary, and call a workers’ compensation specialist.

You can’t go it alone. The climate in BWC is not employee friendly. You need protection in order to obtain all of the benefits to which you are entitled

Ohio Bureau of Workers’ Compensation – making a bad situation worse

Mike Gruhin — Sat, 07 Nov 2009 14:11:24 +0000

The current atmosphere at the OhioBWC is anti-injured worker. The MCO’s continue to deny requested medical treatment, the BWC is actively making settlements of claims more onerous.

It’s bad enough to get hurt on the job, but fighting the system that is supposed to protect injured workers is downright demoralizing.

The BWC is now forcing settlement allocations between compensation, future medical expense, and protection of Medicare interests. That would not be bad but when the BWC forces allocation in a settlement for an injured worker who will not be eligible for Medicare benefits until age 65 or 66, it becomes absurd.

As a result of an internal audit performed late in 2008, the BWC decided that, in order to clean house, it would reduce settlement offers to injured workers, utilize co-morbidity tables (taking a persons whole medical history into account in the settlement of a broken leg, for example), and use the current economic situation to ‘squeeze’ low settlement amounts for workers’ in economic distress (terminated due to economy, etc.)

So much for a system that makes a ‘Plegde’ of Service to injured workers.

Now, the Ohio Senate is considering bringing privatization to workers’ compensation in Ohio. Anyone who is injured in the service of a self-insured employer knows the extra nightmare of claim battles. Bringing privatization into the BWC arena will increase the battle between the injured worker and the benefits to which he/she is entitled.

Contact Governor Strickland and tell him that you want a change for the benefit of the injured worker.

Contact your state representative and tell him/her that you want a change for the benefit of the injured worker.

Ohio Workers’ Compensation Fraud – Don’t Do It !

Mike Gruhin — Sat, 31 Oct 2009 17:56:50 +0000

When an injured worker is receiving Temporary Total Disability (TTD) or Permanent Total Disability (PTD), work performed (remunerative employment for which payment is received) is prohibited by law.

If the BWC finds out that an injured worker, receiving TTD, is working, the Fraud Unit will investigate and pursue prosecution. Ohio BWC fraud is a felony.

Interestingly, based on the following article posted on the Ohio BWC website, it seems that an injured worker on PTD, who seeks a lump sum settlement may become the subject of a BWC Fraud Unit investigation.

FROM THE BWC WEBSITE:
Richland County Man Sentenced For Workers’ Compensation Fraud

Roger Roseberry found guilty of filing a false claim

COLUMBUS – A Mansfield man was sentenced yesterday in the Richland County Common Pleas Court after pleading guilty to fraud following an investigation by the Ohio Bureau of Workers’ Compensation (BWC) Special Investigations Department (SID). A judge ordered Roger Roseberry to pay at least $500 per month to BWC and will face incarceration for six years if he fails to pay. He was also sentenced to five years of community control. Roseberry was collecting Permanent Disability from the BWC for an injury that included total loss of use of his right arm and both legs due to Reflex Sympathetic Dystrophy, also known as RSD. A BWC Attorney referred the settlement to the SID for review after Roseberry submitted an application for a lump sum settlement in the amount of $617,000. The SID’s investigation revealed Roseberry did have use of both his legs as well as his right arm.

“Injured worker fraud draws resources from workers who have legitimately been injured on the job, and unfairly raises premiums for employers who are working to maintain safe workplaces,” said SID Director Tom Wersell. “Careful monitoring of claims helps us identify and prosecute those who abuse the system.”

Special Agents conducted several days of surveillance and observed Roseberry operating a motor vehicle, driving long distances, walking, opening and closing doors, holding items and writing. The videos were later shown to Roseberry’s treating physicians who indicated the video contradicted the conditions allowed in his workers’ compensation claim. Upon completion of the investigation, the settlement was rejected by the BWC and Roseberry was referred for prosecution. Roseberry admitted to fraud related to collecting Permanent Total Disability benefits and his request for the lump sum settlement.

On March 30, 2009, Roger Roseberry pleaded guilty in Richland County Common Pleas Court to one count of workers’ compensation fraud, a third degree felony and one count of theft, a fourth degree felony. As part of the plea agreement, Roseberry has agreed to repay $23,536.92 in restitution and $7,000 in investigative costs.

The Ohio Industrial Commission – What does it do?

Mike Gruhin — Thu, 29 Oct 2009 21:07:03 +0000

The Industrial Commission (IC) of Ohio conducts over 180,000 hearings annually and most of these hearings take place within 45 days of the original claim appeal. Since 1912, the IC has been resolving issues between parties who have a dispute in a workers’ compensation claim.

Hearings on disputed claims are conducted at three levels within the Commission: the district level, the staff level, and the Commission level. The Governor appoints the three-member Commission and the Ohio Senate confirms these appointments. By previous vocation, employment or affiliation, one member must represent employees, one must represent employers and one must represent the public. The executive director manages the agency’s day-to-day operations.

While BWC is responsible for collecting workers’ compensation insurance premiums, overseeing the insurance system, and paying out compensable claims, the IC is responsible for:

Providing a forum for fair and impartial claims resolution
Conducting hearings on disputed claims
Adjudicating claims involving an employer’s violation of specific safety requirements
Determining eligibility for permanent total disability benefits

The IC’s independence from BWC allows it to more fairly adjudicate disputes over those benefits.