The Concussion Rule and its impact on treatment for head injuries 
By June McPherson, VP, clinical operations, Sedgwick MCO

The Ohio Bureau of Workers’ Compensation enacted a rule change in 2020 that impacts medical treatment for head injuries.  The rule (OAC 4123-6-22) is know as the “Concussion Rule”, and is designed to facilitate earlier identification and faster treatment for symptoms consistent with concussion. 

A common theme shared by many complicated and costly workers’ compensation claims include delays in medical treatment.  There are a number of factors that can cause delays in the treatment process, and one common situation is the additional allowance of conditions long after the injury and original adjudication (allowance) of the claim.  Until a condition is formally requested to be included in a claim by the physician of record and allowed by the BWC, treatment cannot be fully approved by the managed care organization (MCO).  For example, a knee injury may be treated with physical therapy because it is originally diagnosed as a sprain.  But after weeks with no improvement, diagnostics may find a ligament tear that requires surgery. Only when the additional condition of the tear is allowed can the surgery be requested, approved without a disclaimer, and scheduled so that a true recovery process can begin. 

This is a frequent pattern with head injuries.  We have all bumped our head, shaken off the cobwebs, and returned quickly to our business without a second thought. In the knee example, an injured employee may initially be evaluated for only the knee simply because the post-incident symptoms revolve around that primary source of pain.  If there was head impact involved in the injury, symptoms may not be evident at first, and the injured employee may not take that bump to the head nearly as serious as the knee issue. 

The Concussion Rule allows concussion-related treatment to be fast-tracked when symptoms emerge.  Treatment can be requested by the physician and approved by the MCO without the condition being formally added to the claim by the BWC, which accelerates the process by many days if not weeks.  Concussion-related symptoms like dizziness, nausea, sleeplessness, disorientation and confusion, and these symptoms can sometimes present days after the injury event and initial medical evaluation for other physical injuries.

The types of treatment that are most common to address concussion symptoms include a neurology consult, vestibular therapy, auditory/vision therapy, and sometimes a neuropsychological evaluation.  In order to qualify for the Concussion Rule the symptoms must be identified within six weeks of the injury date, and treatment can be approved under the Concussion rule for up to six months post-injury.  After six months, appropriate conditions must be formally added to the claim by the BWC in order for concussion-related treatment to be considered.

Although accelerated treatment is valuable to the recovery and return-to-work process, the approval of medical treatment for non-allowed conditions runs counter to the fundamentals of claims management and cost containment.  All parties to a claim maintain rights to appeal treatment decisions under the Concussion Rule.  Communication is a key element to this process.  The initial medical evaluation relies heavily on the injury description and the injured workers’ explanation the mechanism of injury and nature of symptoms, and the mention of a head injury at the start enhances confidence in this direction of treatment.  But even if the head injury is not mentioned or addressed at first, all involved should take note of developing symptoms indicative of concussion so that can be addressed medically.  Discussion of the symptoms and treatment options between the injured employee, employer, treating physician, and the MCO and TPA is important to ensure everyone understands and supports the process to resolve these complex issues.