by The Bainbridge Firm, LLC | Sep 07, 2018 | Workers' Compensation
For an injury or illness to be covered in a workers’ compensation claim, must be either a physical injury or occupational disease that is related to the injured workers’ employment. When the injured worker successfully proves a claim is work-related, his or her claim is “allowed,” meaning the Bureau of Workers’ Compensation (BWC) found that the claim was compensable, and the injured worker is eligible to receive benefits. Benefits are based on the medical conditions caused by the work injury or occupational disease and recognized as “allowed conditions” in the claim.
In most cases, medical benefits are limited only to treatment provided for the allowed conditions in the claim. However, in 2018, the BWC enacted a new rule that expanded medical benefits to include reimbursement for Health and Behavioral Assessment and Intervention Services (HBAI) in efforts to address the cognitive, emotional, social, and psychological issues in a claim that are not directly related to the allowed conditions. While the HBAI payment rule first went into effect on July 1, 2018, a modified version that further expanded eligibility for HBAI services to injured workers being evaluated for lumbar fusions became effective on June 1, 2019.
Having recognized that these types of issues often increase the risk of prolonged pain and disability, the idea behind this rule was to allow injured workers to get the guidance they need before health and behavioral factors hindered recovery, delayed a return to work, or developed into something more serious. Codified as Ohio Administrative Code 4123-6-33, the HBAI payment rule provides that an injured worker is eligible for consideration of HBAI services if he or she has the capacity to understand and respond meaningfully during the health and behavior assessment process and either:
(1) the physician of record determines that the injured worker is not progressing with their injury after the initial course of treatment and healing appears to be delayed due to behavioral barriers, or
(2) the injured worker is being evaluated for a lumbar fusion by the physician of record, treating physician, or operating surgeon.
If an injured worker is found eligible for HBAI services, the BWC will cover one health and behavioral assessment and up to six hours of intervention services per year. However, additional services may be approved during the year if the physician of record provides documentation that it is medically necessary.
It is important to understand that the focus of HBAI services is on the factors impacting prevention, treatment, and management of physical health problems and treatment, not mental health. As such, HBAI services are limited to coaching and counseling services addressing behavioral barriers identified or validated in the authorized assessment, and the BWC will deny payment for services aimed at diagnosing or treating psychological conditions.
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