North Carolina Industrial Commission Rules for Utilization of Rehabilitation Professionals in Workers’ Compensation Claims

Effective 1 June 2000

I. Application of the Rules.

1. These rules apply to:
    
1. All cases in which the employer is obligated to provide or is providing and the injured worker is obligated to accept medical compensation under the Act, or in which such compensation is provided by agreement, and during any period when the employer is paying temporary total disability benefits "without prejudice," and
    
2. Any Rehabilitation Professional (hereinafter RP) assigned under the Workers’ Compensation Act and approved by the Commission pursuant to Section VI. E.
2. Any RP who is not assigned under the Act and approved by the Commission must disclose his or her role to (1) the medical provider at the time of the initial contact and (2) any other person from whom the non-approved RP seeks information about the case.

II. Purpose of the Rules.

1. The purpose of these rules is to foster professionalism in the provision of rehabilitation services in Industrial Commission cases, such that in all cases the primary concern and commitment of the RP is to the medical and vocational rehabilitation of the injured worker rather than to the personal or pecuniary interests of the parties.
    
2. To this end, these rules are to be interpreted to promote frank and open cooperation among parties in the rehabilitation process, and to discourage the pursuit of plans or purposes which impede or conflict with the parties’ progress toward that goal.

III. Definitions; Description of Rehabilitation Services.

1. RPs are case managers and coordinators of medical rehabilitation services and/or vocational rehabilitation services, including but not limited to, state, private, or carrier based, whether on site, telephonic, or in or out of state. RPs do not include direct care providers, e.g., physical therapists, occupational therapists, or speech therapists.
    
2. The "parties" are the worker, the worker’s attorney, the employer, the workers’ compensation carrier (including claims administrator, third party administrator), and the employer or carrier’s attorney(s).
    
3. "Physician" means medical doctor, chiropractor, other physician, and, where the context requires, other health care providers.
    
4. "Medical rehabilitation" refers to the planning and coordination of health care services. The goal of medical rehabilitation is to assist in the restoration of injured workers as nearly as possible to the workers’ pre-injury level of physical function. Medical case management may include but is not limited to case assessment, including a personal interview with the injured worker; development, implementation and coordination of a care plan with health care providers and with the worker and family; evaluation of treatment results; planning for community re-entry; return to work with the employer of injury and/or referral for further vocational rehabilitation services.
    
5. "Vocational Rehabilitation" refers to the delivery and coordination of services under an individualized plan, with the goal of assisting injured workers to return to suitable employment.
    
1. Specific vocational rehabilitation services may include, but are not limited to: vocational assessment, vocational exploration, counseling, job analysis, job modification, job development and placement, labor market survey, vocational or psychometric testing, analysis of transferable skills, work adjustment counseling, job-seeking skills training, on-the-job training and retraining, and follow-up after re-employment.
    
2. The vocational assessment is based on the RP’s evaluation of the worker’s social, medical, and vocational standing, along with other information significant to employment potential and on a face-to-face interview between the worker and the RP, to determine whether the worker can benefit from vocational rehabilitation services, and, if so, to identify the specific type and sequence of appropriate services. It should include an evaluation of the worker’s expectations in the rehabilitation process, an evaluation of any specific requests by the worker for medical treatment or vocational training, and a statement of the RP’s conclusion regarding the worker’s need for rehabilitation services, benefits expected from services, and a description of the proposed rehabilitation plan.
    
3. Job placement activities may be commenced after completion of a vocational assessment and formulation of an individualized plan for vocational services which specifies its goals and the priority for return-to-work options in each case. Placement shall only be directed toward prospective employers offering the opportunity for suitable employment, as defined herein.
6. "Return to work" means placement of the injured worker into suitable employment, as defined herein. Return-to-work options generally should be considered in the following priority:
    
1. Current job, current employer
    
2. New job, current employer
    
3. On-the-job training, current employer
    
4. New job, new employer
    
5. On-the-job training, new employer
    
6. Formal vocational training to prepare worker for job with current or new employer.
    
7. Due to the high risk of small business failure, self-employment should be considered only when its feasibility is documented with reference to worker’s aptitudes and training, adequate capitalization, and market conditions.
7. "Suitable employment" means employment in the local labor market or self-employment which is reasonably attainable and which offers an opportunity to restore the worker as soon as possible and as nearly as practicable to pre-injury wage, while giving due consideration to the worker’s qualifications (age, education, work experience, physical and mental capacities), impairment, vocational interests, and aptitudes. No one factor shall be considered solely in determining suitable employment.

IV. Qualifications Required.

1. RPs in cases subject to these rules shall follow the Code of Ethics specific to their certification (i.e. CRC, CDMS, CVE, CRRN, COHN, ONC, and CCM) as well as any statutes specific to their occupation.
    
2. RPs who are Registered Nurses must have a North Carolina license to practice and are subject to the requirements of the North Carolina Nursing Practice Act.
    
3. RPs who are Licensed Professional Counselors are subject to the requirements of the North Carolina Licensed Professional Counselor’s Act.
    
4. RPs rendering services in cases subject to these rules shall meet the following criteria, and shall upon request provide a resume of their qualifications and credentials during initial meetings with parties and health care providers.

1. Requirements for Qualified Rehabilitation Professionals (QRPs):

1. Two years of full-time work experience, or its equivalent, in workers’ compensation case management, where a minimum of 30 percent of the time was spent in managing medical and/or vocational rehabilitation services to persons with disabling conditions or diseases. This experience should have been within the past 15 years; AND one of the following credentials, or a similar credential determined by the Industrial Commission as a substantial equivalent thereto:
    

Certified Rehabilitation Counselor (CRC)

Certified Registered Rehabilitation Nurse (CRRN)

Certified Disability Management Specialist (CDMS)

Certified Vocational Evaluator (CVE)

Certified Occupational Health Nurse (COHN)

Orthopaedic Nurse Certified (ONC)

Certified Case Manager (CCM)

or

2. Employed within the North Carolina Department of Human Resources as a Vocational Rehabilitation Provider;
    
3. The Commission may, through its Minutes, modify the list of credentials contained in subsection (a) above to add or delete appropriate credentials.

2. Requirements for Conditional Rehabilitation Professionals (CRPs):
    
1. A CRP is defined as a person who does not meet the requirements for QRP and who wishes to work as an RP in cases subject to this rule, including the following:
    
1. CRC, CRRN, CDMS, CVE, COHN, ONC or CCM without the workers’ compensation case management experience required;
    
2. A post-baccalaureate degree in a health-related field from an accredited institution, plus one year of experience in the provision of rehabilitation services to persons with disabling conditions or diseases;
    
3. A baccalaureate degree in a health-related field from an accredited institution, plus two years experience in the provision of rehabilitation services to individuals with disabling conditions or diseases; or
    
4. Current North Carolina licensure as a registered nurse and three years experience in clinical nursing providing care for adults with disabling conditions and diseases.
2. In order to work as an RP, a CRP will work under the direct supervision of a QRP until qualifications for a QRP are fulfilled. The supervisor must meet the requirements for providing workers’ compensation case management services in North Carolina. Supervision shall include regular case staffing between the CRP and the QRP supervisor, detailed review by the QRP supervisor of all reports, and periodic meetings no less frequently than quarterly. The name, address and telephone number of the supervisor shall be on all documents identifying the CRP. The QRP is responsible to assure that the work of the CRP shall meet all requirements including those of this rule.
    
3. Once an RP meets certification eligibility requirements, an RP may maintain CRP status for a period of two years only.

V. Professional Responsibility of the Rehabilitation Professional in Workers’ Compensation Claims.

1. The RP shall exercise independent professional judgment in making and documenting recommendations for medical and vocational rehabilitation for the injured worker, including any alternatives for medical treatment and cost-effective return-to-work options including retraining or retirement. The RP shall realize that the attending physician directs the medical care of an injured worker.
    
2. The RP shall inform the parties of his or her assignment and proposed role in the case. At the outset of the case, the RP shall disclose to health care providers and the parties any possible conflict of interest, including any compensation carrier’s or employer’s ownership of or affiliation with the RP.
    
3. Subject to the provisions for medical care and treatment set forth in the Workers’ Compensation Act, the medical RP may explain the medical information to the worker, and shall discuss with the worker all treatment options appropriate to the worker’s conditions, but shall not advocate any one specific source for treatment or change in treatment.
    
4. As case consultants or expert witnesses, RPs have an obligation to provide unbiased, objective opinions. The limits of their relationships shall be clearly defined through written or oral means in accordance with CRCC Code of Professional Ethics, Canon 2, Rule 2.4, or through similar provisions in the applicable code of ethics, if any.
    
5. There may be parts of the rehabilitation process for which an RP may not be qualified. The RP has the responsibility to refrain from those activities which do not fall within his or her qualifications. RPs shall practice only within the boundaries of their competence, based on their education, training, appropriate professional experience, and other professional credentials.
    
6. Prohibited Conduct:

1. RPs shall not conduct or assist any party in claims negotiation, investigative activities, or perform any other non-rehabilitation activity;
    
2. RPs shall not advise the worker as to any legal matter including claims settlement options or procedures, monetary evaluation of claims, or the applicability to the worker of benefits of any kind under the Workers’ Compensation Act. RPs shall advise the non-represented worker to direct such questions to the Industrial Commission, and the represented worker to direct questions to his or her attorney.
    
3. RPs shall not accept any compensation or reward from any source as a result of settlement.

VI. Communication.

1. At their first meeting, RPs shall provide the injured worker with a copy of these rules or a summary of the rules approved by the Commission.
    
2. RPs shall timely inform injured workers that the RP will share relevant and material information with the employer and insurance carrier and that the RP may be compelled to testify regarding any information obtained.
    
3. In cases where the employer is paying medical compensation to a provider rendering treatment under the Workers’ Compensation Act, the injured worker, if requested by an RP, shall sign a Form 25C Consent authorizing the RP to obtain records of such current treatment. Refusal to sign the consent may be deemed by the Commission to be noncompliance with rehabilitation and may result in the suspension of benefits.
    
4. In preparing written and oral reports, the RP shall present only information relevant and material to the worker’s medical and/or vocational rehabilitation and shall make every effort to avoid undue invasion of privacy.
    
5. The carrier shall promptly notify the Industrial Commission and all parties on a Form 25N when an RP is assigned to a case and identify the purpose of the rehabilitation involvement.
    
6. The RP shall provide copies of all correspondence simultaneously to all parties to the extent possible, making every effort to effect prompt service.
    
7. The RP shall make periodic written reports documenting accurately and completely the substance of all significant activity in the case, including the rehabilitation activity defined above, which reports shall be provided to all parties at the same time. A worker not represented by counsel shall be furnished with a copy of each periodic report, or, in the alternative, the RP shall advise orally or in writing (at least as often as reports are produced) as to the plan for and progress of the case, and shall advise the worker that he or she has the right to request a copy of the reports under Industrial Commission Rule 607.
    
8. Frequency and timing of periodic reports will be determined at the time of referral and will depend upon the type of service provided. However, prompt communication of significant activity to all parties by telephone, telecopier, electronic media, or letter should occur when information pertinent to the rehabilitation process is obtained, when changes or revisions are recommended or occur in medical or vocational treatment plans, or on any other occasion when the worker’s understanding and cooperation is important to the implementation of the rehabilitation plan.
    
9. Communication with worker’s attorney.

1. The first meeting of the worker and RP shall, if requested, take place at the office of the worker’s attorney. If this location is requested, it shall not delay the meeting more than 20 calendar days.
    
2. To promote cooperation among the parties, the RP shall coordinate activities with the injured worker’s attorney, and, at the employer or carrier’s discretion, with the defense attorney. If the RP believes that the worker is not cooperating with the provision of rehabilitation services, the RP shall advise all parties and shall describe what cooperative action on the part of the worker is sought.

VII. Interaction with Physicians.

1. At the initial visit with a physician the RP shall provide professional identification and shall explain the RP’s role in the case.
    
2. In all cases, the RP shall advise the worker that he or she has the right to a private examination by the medical provider outside of the presence of the RP. If the worker prefers, he or she may request that the RP accompany him or her during the examination. However, if the worker or the worker’s attorney notifies the RP in writing that the worker desires a private examination, no subsequent waiver of that right shall be effective unless the waiver is revoked in writing by the worker or, if represented, by the worker’s attorney.
    
3. If the RP wishes to have a personal conference with the physician following an examination, the RP should reserve with the physician sufficient appointment time for a conference. The worker must be offered the opportunity to attend this conference with the physician. If the worker or the physician does not consent to a joint conference, or if in the physician’s opinion it is medically contraindicated for the worker to participate in the conference, the RP will note this in his or her report and may in such case communicate directly with the physician and shall report the substance of the communication.
    
4. When the RP determines that it is necessary to communicate with a physician other than at a joint meeting, the RP shall first notify the injured worker, or his/her attorney if represented, of the RP’s intent to communicate and the reasons therefor. The RP need not obtain the injured worker’s or attorney’s prior consent for the following types of communication:
    
1. The communication is limited to scheduling issues or requests for time-sensitive medical records;
    
2. A medical emergency is involved;
    
3. The injured worker’s health or medical treatment would either be adversely affected by a delay or benefited by immediate action;
    
4. The communication is limited to advising the physician of the employer or carrier approval for recommended testing or treatment;
    
5. The injured worker or attorney has consented to such communications through a valid, current authorization;
    
6. The communication is initiated by the physician; or
    
7. The injured worker failed to show up for a scheduled appointment or arrived at a time other than the scheduled appointment time.

Whenever an RP communicates with a physician without the prior consent or presence of the injured worker, the RP must promptly document the reasons for and the substance of the communication and promptly report such to the injured worker or attorney, if represented, pursuant to Rule VI.
 

5. The RP may assist in scheduling second opinions requested by the treating physician, as well as supporting treatment. In such case, the worker shall receive at least 10 calendar days notice of an appointment for a second opinion unless otherwise agreed by the parties or required by statute.
    
6. The RP may assist in obtaining from the treating physician an opinion as to the degree of permanent partial impairment retained by the worker at maximum medical improvement. The decision to obtain a second physician’s opinion on the degree of impairment is not within the practice of rehabilitation. However, if requested by the party who desires a second opinion, the RP may assemble information, schedule, coordinate, and, with the worker’s consent, attend the appointment with that physician.
    
7. If a party requests a second opinion or an independent medical examination, the RP’s involvement is limited to assembling and forwarding medical records and information, and scheduling, coordinating, and, with the worker’s consent, attending the appointment with that physician.
    
8. The RP shall simultaneously send copies to the parties of all written communications to medical care providers, and shall accurately and completely record and report all oral communications.

VIII. Return to Work.

1. The RP shall obtain from the medical provider work restrictions which fairly address the demands of any proposed employment. If ordered by a physician, the RP should obtain a Functional Capacity Evaluation (FCE) or Physical Capacity Evaluation (PCE). Any FCE or PCE obtained should measure the worker’s capacities and impairments.
    
2. The RP shall refer the worker only to opportunities for suitable employment, as defined herein.
    
3. If the RP intends to utilize written or videotaped job descriptions in the return-to-work process, the RP shall provide a copy of the description to all parties for review before the job description is provided to the doctor. The worker or the worker’s attorney shall have seven business days from mailing of the description, to notify the RP, all parties, and the physician of any objections or amendments to the job description. The job description and the objections or amendments, if any, shall be submitted to the physician simultaneously. This process may be expedited on occasions when job availability is critical. This waiting period does not apply if the worker or the worker’s attorney has pre-approved the job description.
    
4. In preparing written job descriptions, the RP shall utilize recognized standards which may include but not be limited to the Dictionary of Occupational Titles and/or the Handbook for Analyzing Jobs published by the U.S. Department of Labor, which are recognized as national standard references for use in vocational rehabilitation.
    
5. In identifying proposed employment for the injured worker, the RP should consider the worker’s transportation requirements.
    
6. Follow-up after placement may be carried out to verify the appropriateness of the job placement.
    
7. The RP shall not initiate or continue placement activities which do not appear reasonably likely to result in placement of the injured worker in suitable employment. The RP shall report to the parties when efforts to place the worker in suitable employment do not appear reasonably likely to result in placement of the injured worker in suitable employment.

IX. Motion for Change of RP; Sanctions.

1. An RP may be removed from a case upon motion by either party for good cause shown or by the Industrial Commission in its own discretion. The motion shall be filed with the Executive Secretary’s Office and served upon all parties and the RP. Any party or the RP may file a response to the motion within 10 days. The Industrial Commission shall then determine whether to remove the RP from the case. The parties are referred to Industrial Commission Rule 609.
    
2. If the employer/carrier chooses to do so and the worker consents, the employer/carrier may replace the RP, in which case the moving party shall notify the Industrial Commission that the motion does not need to be decided.
    
3. For good cause, including ineffective delivery of rehabilitation services, failure to comply with applicable laws, rules or regulations, or failure to timely respond to lawful orders of the Commission or other regulatory authorities, the Commission may prohibit or restrict an RP, or group of RPs, further participation by particular workers, employers, or health care providers, groups or classes of them, or all of them. As provided in Industrial Commission Rule 802, the Commission may impose appropriate sanctions for violation of these Rules.
    
4. A party may request reconsideration of a ruling or appeal from an order as provided in Rule 703 or pursuant to N.C. Gen. Stat. §97-83; §97-84.

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