By Joan M. Verchot and J. Andrew Recker, Dinsmore & Shohl LLP

Medical treatment in workers’ compensation claims has typically been limited to treatment of conditions that are “allowed” in the claim itself.  For example, if a claim is only allowed for conditions related to an injured worker’s right knee, he/she can only seek treatment for the right knee under the workers’ compensation claim.

Recently, however, the BWC has taken on a new initiative to address cognitive, emotional, behavioral, social and psychological issues in a claim that are not directly related to the allowed conditions.  It believes that these kinds of issues increase the risk of prolonged pain and disability.  To this end, new rules were enacted which will allow Health and Behavioral Assessment and Intervention Services (HBAI) for injured workers.  Codified as OAC 4123-6-33, the rules provide that when an injured workers’ physician of record (POR) determines recovery may be delayed due to either behavioral or health issues, the POR can request an assessment of the injured worker by an independent medical provider who will determine any potential behavior issues which may serve as a barrier to overall recovery.  This request may only be submitted, however, after the POR determines that (1) the injured worker is not progressing with their initial course of treatment, (2) the injured workers’ healing appears to be delayed due to behavioral barriers, and (3) the injured worker has the capacity to understand and respond meaningfully during the face-to-face encounter.

The face-to-face encounter (assessment) may be performed by any professional whose practice includes health and behavior assessment services.  After the assessment is conducted, the examiner then submits a report to the POR outlining the intervention services that should be performed, if any.  A C-9 form requesting these services must then be submitted by the POR.  The services may be performed by “any provider whose professional scope of practice as defined under state law includes health and behavior intervention services.”  However, these services are limited to “coaching and counseling” services that address the behavioral barriers identified in the assessment.

While HBAI services are limited to six hours per year, additional services may be approved within the year if the POR documents that the services are medically necessary.  Finally, HBAI services are not to be directed toward the diagnosis or treatment of psychological conditions.  The rationale behind this exclusion is that the focus of these services is not on mental health, but rather factors impacting the “prevention, treatment, or management of physical health problems and treatment.”

The purpose of HBAI services is to attempt to speed up the recovery of injured workers, thereby reducing claims’ costs and time off of work.  While these are worthy goals, it is unclear how frequently these requests will be seen in actual practice.  It is also unclear how emotional/behavioral barriers to recovery can and will be differentiated from the treatment of psychological conditions, which are not part of the underlying workers’ compensation claim and which is excluded under the rules.