State Disability Evaluations - California Orthopaedic Association

EDDState Disability Evaluations:Role for OrthopaedicSurgeonsand SDI OnlineLaurel Waters, M.D.Medical Director18 April 2013

Overview∗ SDI Basics∗ Legal Basis∗ IME definition and logistics∗ IME Provider Applications and Agreements∗ SDI Online∗ Sign up∗ Use2

What is SDI?∗ Short-term disability insurance plan for approximately13 million California workers∗ Employee paid∗ Waiting period of only seven days∗ Partial wage replacement up to approximately 55% ofthe highest quarter in the base period3

Disability Insurance (DI) Compared toPaid Family Leave (PFL)Disability InsuranceUp to 52 weeks per claimEmployee’s personal illness, injury,or disabilityNot required to use vacationbenefitsVacation pay is not in conflict withDIBenefits are not reportable to IRS(unless in lieu of UI)Paid Family LeaveUp to six weeks per 12-monthsCaring for a seriously ill familymember or to bond with a new childEmployers may require employeesto use up to two weeks of vacationVacation pay conflicts with PFLwhen employer requires employeeto useBenefits are reportable to IRS4

IME Legal Basis∗ Title 22 section 2627(c) -1 must be reasonable asevidenced by one of the following circumstances:∗ Medical information from the physician does not justifylength of time excused in a first claim or extension∗ Conflicting medical evidence from different physicians∗ Claimant’s activities in conflict with reported disability∗ Additional information is necessary to confirm disability6

How is a Panelist Chosen?∗ By SDI staff from a database: IMELS∗ Clinical Specialty∗ Geographic proximity∗ Language needs∗ Subspecialty∗ Lack of complaints7

IME Timing∗ Claimant mailed IME Provider’s information∗ They must make appointment within seven days∗ Appointment must occur at earliest possible date∗ IME Panelist provided∗ Identifying information∗ ICD codes∗ Date disability began8

CA SDI IME Requirements∗ Not a consultation per Title 22∗ Differs from IME’s for other agencies∗ 1) Ability to perform regular or customary work(occupational history required)∗ 2) When return to work expected9

Ancillary Studies∗ Claimant asked to bring prior work which should beevaluated and noted in the record, but no separatecharge done∗ New studies can only be as extensive required todetermine ability to work∗ Bills for over $200 in tests requires preapproval∗ Prices are being re-evaluated10

Charges∗ Recent attempt to increase rejected at high level∗ Will try again in the future∗ Very limited IME∗ Non Board Certified $83.30∗ Board Certified $138.55∗ Payee Data Record (State form STD 204) required∗ Invoice form DE 2546INV11

Confidentiality∗ CUIC section 2714 requires confidentiality∗ Not required to maintain a copy∗ If you do save a copy it must be separate from otherrecords∗ Any requests for report copies should be referred tothe Field Office that requested the IME12

Clinical Issues Arising in IME∗ Previously undiagnosed significant medical condition∗ Inform claimant of suspicion∗ Ask them to seek attention from their medical provider∗ Do not treat or prescribe∗ Do not refer to another provider∗ Do not express opinions about care by others13

Application & Agreement Forms∗ Private practice setting∗ Application (DE 2546D)∗ Agreement (DE 2546SA)∗ Clinic setting∗ Clinic Application (DE 2546DC)∗ Clinic Agreement (DE 2546CSA)∗ Provider Application (DE 2546CS)14

Provider Documentation∗ Current license (photocopy)∗ Current curriculum vitae∗ Current professional liability insurance proof∗ Appropriate application∗ Private practice∗ Clinic setting15

Clinic or Private Practice Office∗ General liability insurance proof naming EDD asadditional insured (this is done for no charge)∗ Workers’ compensation insurance proof∗ Payee data record (State form STD 204)∗ Appropriate SDI agreement∗ Private practice∗ Clinic16

Acceptance to Panel∗ Application, agreement and documentationevaluated by the Medical Director∗ Upon acceptance∗ Notification sent out∗ Information added to IMELS database17

NEW! SDI OnlineNewly Introduced – SDI Online∗ State Disability Insurance (SDI) Online is anelectronic claim filing system, for claimants,employers, physician/practitioners, and voluntaryplans.∗ Option to create an online account and submitDisability Insurance and Paid Family Leave claimsinformation electronically.18

NEW! SDI OnlineSDI Online continued-∗ Physician/practitioners are able to electronicallycertify to their patients’ disability and submitpatient’s medical information through this secureonline site.∗ Note: paper forms will still be available in a newOptical Character Recognition (OCR) version whichcan be processed through SDI Online.19

Create an SDI Online Account20

Access SDI Online Accounts28

Add a Treatment Address33

123 Main St.Anytown, CA 95814000-000-000037

Assign a Medical Representative38

Jane Doe 1234 email@email.com 01-01-195042

Submit a DE 2501 Part B –Physician/Practitioner Certificate43

Jane DoeCA00000DoeJohn Doe01-01-195044

123 Main St.Anytown, CA 9581445

John DoeJane Doe123 Main St.Anytown, CA 95814CA0000046

Submit a DE 2525xx SupplementaryCertificate to Continue Benefits50

Jane DoeCA00000DoeJohn Doe 01-01-195051

John DoeJohn DoeJohn DoeJohn Doe52

Jane DoeJohn Doe1234CA0000001-01-195053

Jane Doe55

John DoeJohn DoeJohn DoeJohn Doe56

Summary∗ SDI Basics∗ Legal Basis∗ IME definition and logistics∗ IME Provider Applications and Agreements∗ SDI Online∗ Sign up∗ Use57

SDI Contact InformationDisability InsuranceEnglish800-480-3287Paid Family LeaveEnglish877-238-4373Disability InsuranceEspañol866-658-8846Paid Family LeaveEspañol877-379-381958

Questions?59