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Influenza Claims Under the Industrial Insurance Act

Overview

More information is becoming available to the public on a daily basis regarding the prevention and treatment of influenza. Although symptoms are generally mild, influenza can sometimes cause severe illness and death in infected individuals.  The World Health Organization (WHO) has declared the rapid spread of the H1N1 virus (swine flu) a pandemic.

Although there was initial concern over the rapid spread of this virus, the Center for Disease Control (CDC) and WHO have stated that someone contracting the H1N1 virus usually will not experience flu symptoms any more severe than those seen with the seasonal flu virus.  However, there are certain conditions that make a person exposed to the influenza virus more likely to have more severe symptoms.  A general list of those who are at a higher risk for severe complications is included in the latest CDC “Updated Interim Recommendations for the Use of Antiviral Medications in the Treatment and Prevention of Influenza for the 2009-2010 Season”.

http://www.cdc.gov/h1n1flu/recommendations.htm

Most importantly, it is clear from recent data that pregnant women are disproportionately represented among those who are hospitalized with H1N1 infection, and those who die from such infections.

Can influenza ever be allowed as a work-related condition?

The increased focus on influenza has resulted in increased questions as to whether influenza can ever be allowed as a work-related condition.

Although in most cases, exposure and/or contraction of the flu is not considered to be an allowed, work-related condition, under certain circumstances claims for influenza may be allowed under the Washington State Industrial Insurance Act. In accordance with RCW 51.36.010 and WAC 296-20-03005, it is in the sole discretion of the insurer to authorize inoculation or other immunological treatment in cases in which a work-related activity has resulted in probable exposure of the worker to a potential infectious occupational disease.

Claims for influenza are adjudicated the same whether the flu is the H1N1 strain or the seasonal flu.

When to file a claim

The Industrial Insurance Act allows for post-exposure prophylaxis and treatment of influenza in cases in which work-related activity has resulted in probable exposure of the worker to the flu virus.  In these cases, the worker’s occupation must have a greater likelihood of contracting the disease on the job (e.g., first responder or health care worker), there must be a documented or probable work-related exposure, and there must be an employee/employer relationship. 

Before helping a worker file a workers’ compensation claim, the treating provider should consider if the following criteria are met:

  • Was there an increased risk or greater likelihood of contracting the condition due to the worker’s occupation? (e.g., first responder or health care worker)
  • If not for their job, would the worker have contracted the condition?
  • Can the worker identify a specific source or event during the performance of his or her employment that resulted in exposure to either seasonal or H1N1 influenza?(e.g., first responder or health care worker who has actually treated a patient with the virus)

If the criteria listed above are not met it is not necessary to file a workers’ compensation claim; however, a claim may still be filed if requested by the worker or if the provider is uncertain whether the criteria are met.

When will a claim likely be denied?

When the contraction of influenza is incidental to the workplace or common to all employment (e.g., an office worker who contracts the condition from a fellow employee) a claim for exposure to influenza and contraction of the disease will be denied.

To expedite adjudication of the influenza claim

For the medical provider aiding the worker in filing for compensation on a State Fund claim, please fax the Report of Accident (ROA) to one of the fax numbers listed below.  Please also fax a chart note which explicitly addresses the three criteria under “when to file a claim” to one of the dedicated fax numbers listed for chart notes.  That will help the department to process your patient’s claim as quickly as possible.

For State Fund claims, please fax the ROA to one of the following numbers:

(360) 902-6690 General Providers ROA
(800) 941-2976 General Providers ROA
(360) 902-5252 COHE Providers ROA
(877) 345-2189 COHE Providers ROA

Please also fax the initial chart note to one of the following dedicated lines:

(360) 902-4292 (360) 902-5230
(360) 902-4565 (360) 902-6100
(360) 902-4566 (360) 902-6252
(360) 902-4567 (360) 902-6460

For Self Insured claims, please send the Provider’s Initial Report (PIR) and related chart note to the self-insured employer (SIE) or their third party administrator (TPA). For a list of SIEs/TPAs, go to:

http://www.lni.wa.gov/ClaimsIns/Insurance/SelfInsure/EmpList/FindEmps/Default.asp

II. Filing a Worker's Compensation Claim - Exposure vs. Contraction of the Flu

The exposed worker must apply for benefits (e.g., submit the appropriate accident report form) before the insurer can pay for treatment. While in most cases, the department expects to receive claims for contraction of influenza, the Industrial Insurance Act also allows the insurer to provide post-exposure prophylaxis when a documented, work-related exposure has occurred as described above.

  • If a claim is filed for probable exposure or contraction of influenza and the three criteria listed above under “when to file a claim” are not adequately satisfied, the claim will be denied and payment for post-exposure prophylaxis and treatment/testing will not be authorized.
  • When a claim is filed for probable exposure and the three criteria are satisfied under “when to file a claim,” the claim will be denied if there is no evidence the worker actually contracted the flu. However, post-exposure prophylaxis may be authorized on the rejected claim if there is a greater likelihood of the worker contracting the disease as a result of their job duties.  If the worker subsequently contracts influenza from the occupational exposure, the worker should contact the insurer to determine if a new claim needs to be filed.
  • If the diagnosed condition on the original accident report form is contraction of influenza (seasonal flu or H1N1) and the three criteria are satisfied under “when to file a claim,” the claim will be allowed and treatment authorized.

III. Covered Treatment and Post-Exposure Care

If the exposure is work-related, and the three criteria are satisfied under “when to file a claim,” the insurer will pay for oseltamivir (Tamiflu®) or zanamivir (Relenza®) for post-exposure prophylaxis or treatment of influenza in accordance with CDC recommendations. 

The following information is included to inform medical providers of current CDC recommendations; however, coverage of treatment and post-exposure care will depend on work-relatedness of exposure (see section I: When to file a claim).
 
People who are not at higher risk for complications or do not have severe influenza requiring hospitalization generally do not require antivirals for treatment or prophylaxis.

The latest CDC recommendations on the use of antivirals for treatment of influenza, including H1N1 and seasonal influenza, are as follows: 

  • Any suspected influenza patient presenting with warning symptoms (e.g., dyspnea) or signs (e.g., tachypnea, unexplained oxygen desaturation) for lower respiratory tract illness should promptly receive empiric antiviral therapy.
  • Antiviral treatment is recommended for all persons with suspected or confirmed influenza requiring hospitalization.
  • In general, antiviral treatment is recommended for persons with suspected or confirmed  influenza who are at higher risk for complications (children younger than 5 years old, adults 65 years and older, pregnant women, persons with certain chronic medical or immunosuppressive conditions, and persons younger than 19 years of age who are receiving long-term aspirin therapy).

According to the CDC, H1N1 influenza will likely be the most common influenza virus among those circulating this coming season, particularly those causing influenza among younger age groups.  Therefore, when antiviral treatment is indicated, use of either oseltamivir or zanamivir is appropriate.  For guidance on empiric treatment when multiple influenza strains are circulating, please refer to the CDC for recommendations.

Table 1: Antiviral dosing recommendations for treatment of H1N1 influenza in adults
Antiviral
Oseltamivir (Tamiflu®) 1 capsule (75mg) twice per day x 5 days
Zanamivir (Relenza®) 2 inhalations (10mg total) twice per day x 5 days

For influenza chemoprophylaxis, the CDC recommends limiting use of antivirals to the following:

  • Persons who are at higher risk for complications and are a close contact of a person with confirmed, probable, or suspected influenza during that person’s infectious period.
  • Health care personnel, public health workers, or first responders who have had a recognized, unprotected close contact exposure to a person with confirmed, probable, or suspected influenza during that person’s infectious period.

Duration of post-exposure chemoprophylaxis is 10 days after the last known exposure to H1N1 influenza. Chemoprophylaxis is not recommended if more than 48 hours have elapsed since the last contact with an infectious person or when contact occurred before or after, but not during, the ill person’s infectious period as defined above.

Table 2: Antiviral dosing recommendations for post-exposure chemoprophylaxis of H1N1 influenza in adults
Antiviral
Oseltamivir (Tamiflu®) 1 capsule (75mg) daily x 10 days
Zanamivir (Relenza®) 2 inhalations (10mg total) daily x 10 days

The above CDC recommendations apply to the 2009-2010 flu season (http://www.cdc.gov/H1N1flu/recommendations.htm).  Please refer to the CDC website for the most current treatment recommendations.

IV. Pharmacies: How to Bill for Prescriptions of Anti-viral Medication Related to Influenza Claims

In general, payment for anti-viral medication requires prior authorization.  Anti-viral medication for exposure/contraction of influenza does not fall under first fill coverage.

For State Fund claims, if the claim is not yet allowed, the pharmacy may ask the worker to pay for the prescription of the anti-viral medication, but submit the bill through the point-of-service (POS) system with the amount paid in the patient paid amount or co-pay field.  The department will capture the bill and reimburse the worker if and when the claim is allowed and/or treatment authorized.  

For Self Insured claims, if the claim is not yet allowed, the pharmacy may ask the worker to pay for the prescription of the anti-viral medication. If there are questions, the pharmacy should call the self-insured employer (SIE) or their third party administrator (TPA). For a list of SIEs/TPAs, go to:

http://www.lni.wa.gov/ClaimsIns/Insurance/SelfInsure/EmpList/FindEmps/Default.asp

V. Testing for H1N1 Flu

There are a number of laboratory tests that can be used to detect influenza.  These tests differ based on sensitivity, specificity and the amount of time required for results.  Rapid influenza diagnostic tests (RIDTs) detect influenza A and/or B but cannot specifically identify the H1N1 virus.  However, false negatives can frequently occur, so if there is a high clinical suspicion of influenza, empiric antiviral treatment should be administered for high risk patients.
 
Confirmatory testing for H1N1 by real-time reverse transcriptase-polymerase chain reaction (rRT-PCR) is not routinely recommended but may be necessary for surveillance purposes and for special situations.  The insurer’s coverage of laboratory testing of influenza is restricted to those limited circumstances when it is medically necessary and then only with prior authorization. 

VI. Flu Vaccinations

Under the Industrial Insurance Act, the insurer cannot pay for flu vaccinations, either for the H1N1 strain or the seasonal strain, as part of a worker’s compensation claim. 

VII. Further Information on Influenza

For up-to-date information on H1N1 and seasonal influenza, go to the following websites:


For more information on claim status and prior authorization of influenza treatment and testing:
State Fund claim status or name and number of the claims manager:
Automated Claim Information Line
800-831-5227

Self-Insured claim status:
Contact the self-insurer or third party administrator. http://www.lni.wa.gov/ClaimsIns/Insurance/SelfInsure/EmpList/FindEmps/Default.asp

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