Shoulder Program of Care - Q and A

Program Overview

1. What is the Shoulder Program of Care (Shoulder POC)?

The Shoulder POC is an evidence-based health care delivery plan for workers with a shoulder injury. The Shoulder POC aims to achieve the best outcomes for recovery and return to work through the delivery of evidence-based care.

The Shoulder POC was developed for workers with a diagnosis of: bursitis, bruises/contusions, impingement syndrome, rotator cuff tendinitis, sprains/strains and/or partial tear(s) of the rotator cuff or other structures.

2. Is the Shoulder POC the first line of care, similar to the Low Back and Musculoskeletal POCs?

Yes. If a worker has one of the injuries listed above, the Shoulder POC must be used as the first line of care. The Shoulder Program of Care is specific to shoulders, focuses on function and enables early/quick identification of cases that need specialized services. Reports for the Shoulder POC provide detailed information to the Service Delivery Team, which help support case management activities.

3. Who should health care professionals call for general questions about the Shoulder POC?

Health care professionals should call the WSIB Health Care Practitioner Access Line at 416-344-4526 or 1-800-569-7919 to discuss any general questions about the Shoulder POC or any other Programs of Care.

Program Eligibility & Admission Requirements

1. What are the admission criteria for the Shoulder POC?

The Shoulder POC is for workers with:

  • An allowed shoulder claim by the WSIB and,
  • A diagnosis of bursitis, bruises/contusions, impingement syndrome, rotator cuff tendinitis, sprains/strains or partial tear(s) of the rotator cuff or other shoulder structures
  • Within 16 weeks of injury or recurrence.

2. How should a health care professional proceed if they assess a worker and determine them to be ineligible for the Shoulder POC?

The health care professional should contact the WSIB Clinical Expert Line to discuss the case to determine the appropriate way to proceed. The WSIB Clinical Expert will discuss the presence of clinical red flags or other reasons why, despite a diagnosis of a musculoskeletal injury, the worker may not benefit from the Shoulder POC. The WSIB Clinical Expert may suggest a referral for further assessment to determine whether care is required.  The WSIB Clinical Expert line can be reached by calling 416-344-5739 or 1-866-716-1299.

3. What is an allowed claim? How would a health care professional or worker know if a claim has been allowed?

An allowed claim means that the work related injury has been registered, reviewed and accepted by the WSIB. An allowed claim may have entitlement to health care benefits, such as treatment in a POC.

To determine whether a worker has an allowed claim, a health care professional should ask the worker at the time of assessment whether the injury is work related. If the injury is work related, the health care professional should confirm whether they have registered their claim with the WSIB and if they have received a claim number and whether their claim has been allowed.

The assignment of a claim number does not equate to the claim being allowed.

If the worker’s claim status is uncertain, the worker or the health care professional can call the WSIB at 1-800-387-0750 or 416-344-1000 to verify the status of the claim.  The WSIB will not pay for services delivered to patients whose claim is not allowed.

WSIB Clinical Expert Role

1. What is a Clinical Expert and what is their role?

A Clinical Expert is a regulated health care professional who has clinical experience with the use of Programs of Care. The Clinical Expert’s role is to discuss clinical aspects of the claim including worker diagnosis, appropriate treatment as well as barriers to recovery. Clinical Experts will help treating health care professionals to determine the suitability of a worker for a POC. They can discuss appropriate treatment for a worker and provide a recommendation on next steps where a worker is not progressing as expected.

2. How do I reach a Clinical Expert?

The Clinical Experts are available by telephone to Health care professionals from Monday to Friday by calling 416-344-5739 or 1-866-716-1299.

Program Delivery and Structure

1. Who can deliver the Shoulder POC? When is a referral required for the Shoulder POC?

Most often, chiropractors and physiotherapists will deliver the program of care. Other regulated health care professionals may deliver the program of care if it is within their scope of practice and individual competencies and they have received a referral from the worker’s primary health care professional (in the context of WSIB, this includes physicians, chiropractors, physiotherapists and/or nurse practitioners).

2. What is required in order to register to deliver the Shoulder POC?

The health care professional is required to review the relevant documents and materials available here. These documents include the Shoulder POC reference guide, the outcome measure, the Initial Assessment and Care and Outcomes Summary Reports, the fee schedule and other materials.

Following review of the documents, the health care professional must complete and submit the Application to Deliver Program(s) of Care (POC) form, available here.

3. What process should be followed if a worker is referred to a health care professional who does not want to deliver the Shoulder POC?

When a health care professional chooses not to treat an eligible worker through the Shoulder POC, the worker must be referred to another regulated health care professional who will deliver the POC. Alternately, the health care professional may call the WSIB for assistance. The POC Directory on the WSIB website lists health care professionals who deliver the Shoulder POC by geographic area.

4. What is the length of the Shoulder POC, and how many visits must be completed?

The Shoulder POC is up to eight weeks in length. A minimum of seven visits must be delivered in order to bill the full program fee; however, it is the expectation that health care professional will treat the worker as often as is necessary to achieve the RTW and recovery goals.

5. What if the worker needs fewer than the minimum number of visits or is discharged before 7 visits are delivered?

In cases where the worker has completed the program early or in cases of self-discharge, it may be possible that fewer than the minimum required number of visit were delivered. In these cases, indicate the actual number of units (visit) delivered on both the Care and Outcome Summary form and electronic invoice using the appropriate billing service codes. Payment for the individual visit(s) will be made.

6. How is the first date of service/treatment determined?

The date of the initial assessment is considered the first date of service. The date of initial assessment should be indicated on the Shoulder POC Initial Assessment Report and should correspond to the date entered on the electronic billing system.

7. Should a health care professional complete a Form 8 and the Shoulder POC Initial Assessment Report?

When a health care professional is the first health care professional to assess the worker following the injury, both the Form 8 and the Shoulder POC Initial Assessment Report should be completed.

When a health care professional is not first to assess the patient following the work-related injury or if the worker was referred by another health care professional, then only the Shoulder POC Initial Assessment Report should be completed.

8. As a regulated health care professional, will I be able to continue determining the most appropriate treatment for a worker with a shoulder injury?

Yes. The Shoulder POC allows the flexibility to select the appropriate treatment intervention(s) for your patient. Treatment interventions not listed in the Shoulder POC Reference Guide may be used if, in your clinical judgment, they are in the best interest of your patient; however, the WSIB will not pay for these interventions in addition to the program of care fee. If you have any questions related to the recommended treatment interventions, please call the WSIB Clinical Expert Line at 1-866-716-1299 or 416-344-5739.

9. Can a worker receive treatment from multiple providers, for example, a chiropractor and a physiotherapist, under two separate Shoulder POCs?

Treatment interventions may be delivered by multiple health care professionals; however, billing must be submitted by only one health care professional/clinic.  

10. Can a worker change to another health care professional after beginning treatment in the Shoulder POC?

When the worker has received partial treatment in the Shoulder POC and wishes to continue treatment with another health care professional at a different facility, the worker must obtain approval from the WSIB Service Delivery Team.  The WSIB Service Delivery Team can be reached by calling the WSIB at 1-800-387-0750 or 416-344-1000.

11. If a worker has multiple areas of injury will regular fee-for-service treatment be allowed for areas other than the shoulder injury?

A maximum of two different POCs may be delivered at the same time, providing the worker meets the admission criteria for each POC and the claim is allowed.

For example: a worker may have moderate injuries to their shoulder and low back, and a less severe injury to their knee. In this case, the health care practitioner may choose to deliver treatment via the Shoulder POC and the Low Back POC, as the shoulder and low back injuries are most severe. As the less severe injury, neck treatment should be encompassed in the overall treatment provided to the worker.

If the health practitioner feels that the nature of the multiple injuries precludes the worker from receiving treatment in two POCs, they should contact the WSIB Clinical Expert Line at 416-344-5739 or 1-866-716-1299 to discuss the case.

Recovery, Return to Work, and Communication with the WSIB

1. Should I submit a Treatment Extension Request Form if I am requesting further treatment after the Shoulder POC?

No. If further treatment is requested beyond the POC, the treating provider should contact the WSIB Clinical Expert Line at 1-866-716-1299 or 416-344-5739 to discuss the case. The WSIB Clinical Expert may request further information regarding: the type and frequency of treatment provided during the POC; the workers response to treatment; description of any persistent barriers; updated clinical and RTW information. The Clinical Expert will also request rationale for further treatment, including type, frequency and duration. Once the Clinical Expert has reviewed the details of the claim, they will make a recommendation regarding the request for further treatment.

The Treatment Extension Request Form should only be completed if requested by the Case Manager or Nurse Consultant, or if further treatment is being requested for a claim that is not receiving care through a Shoulder POC, Low Back POC, or Musculoskeletal POC.

2. What is the Health care professional’s role when contacting the employer/workplace?

Health care professionals are required to contact the employer to discuss the worker’s functional abilities to help facilitate work activities. The frequency and method of communication should be appropriate to facilitate return to work activities throughout the program of care. The health care professional is asked to document the method of communication on the Care and Outcomes Summary, which is submitted at completion of the Shoulder POC.

Case Managers (CM) support and facilitate return to work (RTW) activities by reviewing the functional abilities of the worker outlined on the Initial Assessment Report and Care and Outcomes Summary, as well as the Functional Abilities Form (FAF), if requested. The CM may refer the case to a WSIB Return to Work Specialist for further facilitation of RTW activities.

3. How is return to work defined in the Shoulder POC? What are the expectations of the Health care professional to support return to work during the Shoulder POC?

Return to work means being able to return to all regular duties and regular hours. It is expected that the health professional’s opinion about the worker’s ability to return to work at the conclusion of the Shoulder POC has been discussed with the worker.

4. How should the Initial Assessment and Care and Outcomes Summary reports be submitted to the WSIB? When should they be submitted?

The reports should be faxed to 1-888-313-7373  or 416-344-4684. Alternatively, the reports can be mailed to WSIB’s head office:

Workplace Safety & Insurance Board
200 Front Street West
Toronto, Ontario
M5V 3J1

The Shoulder POC Initial Assessment Report should be submitted within two working days from the date of assessment. The Care and Outcomes Summary should be submitted within two working days of discharge or the last visit within the 8 week program.

Billing

1. Can a health care professional bill a worker directly for treatment provided for a shoulder injury?

The health care professional may not bill the worker. Section 33(5) of the Workplace Safety and Insurance Act (WSIA) states: “No health care practitioner shall request a worker to pay for health care or any related service provided under the insurance plan.”

2. If a worker does not yet have an allowed claim but they want to start treatment, should I bill them directly?

The WSIB strives to make timely decisions on the status of claims. If a worker presents with for an assessment with an undetermined claim status and wants to commence treatment, we recommend the health care professional and/or worker contact the WSIB at 1-800-387-0750 or 416-344-100 to verify the status of the claim.

If the claim status is still unknown or pending after speaking with the WSIB and the worker still wants to proceed with treatment, the health care professional should discuss payment responsibility with the worker.  The health care professional should explain that payment would be the responsibility of the worker if the claim is not allowed. If the claim is allowed, the WSIB will pay for approved health care benefits according to the WSIB Fees, and any prior payments made by the worker should be reimbursed by the provider.

It is recommended that the health care professional and/or worker check back regularly with the WSIB until a decision has been made on the status of the claim.

3. What will happen if the health care professional does not submit the Care and Outcomes Summary Form when the worker is discharged?

Failure to submit the Care and Outcomes Summary Report may impact payment of services. Health care professionals who deliver the Shoulder POC must submit the Care and Outcomes Summary Form within two working days of the worker’s discharge or end of the 8 week Shoulder POC, whichever happens first.

If the Care and Outcomes Summary Form is not received within 14 days of the worker’s discharge or last visit in the 8 week Shoulder POC, the form fee will not be paid. In addition, the POC block service payment will be held until receipt of the form.

4. What are the fees for the Shoulder POC?

Please refer to the WSIB Shoulder Program of Care Fee Schedule available on the WSIB website.

5. Is there a requirement for health care professionals to bill electronically?

Yes, all bills must be submitted electronically for efficient payment. Please bill electronically through the WSIB’s payment processor, TELUS Health Solutions.
For further information on electronic billing, please contact the TELUS Health Solutions Support Centre at 1-866-240-7492 or visit www.telushealth.com/wsib.

6. How do I bill for services if I assess a worker but then determine that they are not appropriate for the Shoulder POC?

If you assess a worker but then determine that they are not appropriate for the Shoulder POC, please contact the WSIB Clinical Expert Line at 1-866-716-1299 or 416-344-5739 to discuss the best way to proceed.

7. Who can the health care professional contact if they have questions regarding payment?

The health care professional can contact the WSIB at 1-800-387-0750 or 416-344-1000 and ask for the Health Care Payment Inquiry Line.

8. Where can I find more information about the Shoulder POC?

Read our reference manuals, fee schedules, and other supporting documents for the Shoulder POC and other Programs of Care.