CALIFORNIA  

The California Division of Workers' Compensation, in response to SB 863, adopted emergency regulations related to bill review and Independent Bill Review (IBR) on 12/31/12.  The regulations are effective for medical treatment services rendered on or after 1/1/13 and for medical-legal expenses incurred on or after 1/1/13.  The new regulations:

• Create a second review process for providers to dispute payment of medical treatment services and medical-legal expenses
• Establish an IBR process where an Independent Bill Review Organization will resolve disputes not resolved by the second review process.   

Additionally, the California Division of Workers' Compensation adopted emergency regulations concerning Utilization Review and Independent Medical Review (IMR) on 1/1/13.  Effective 1/1/13, the new regulations: 

• Change notification requirements for the UR entity when approving, delaying, modifying or denying treatment authorization
•  Adopt an IMR process where an Independent Review Organization will resolve medical treatment disputes
• Establish a Request for Authorization form (Form RFA) that must be used by a treating physician to request treatment authorization
• Creates an Independent Medical Review request form (Form IMR) to be used by the employee to dispute UR decisions. This form must be prepared and sent by the UR entity along with the decision to modify, delay or deny treatment authorization
• Establish a schedule of penalties for UR and IMR violations.  

Note: Prior to 7/1/13, requirements established by the changes in regulations are dependent on whether the date of injury is before or after 1/1/13.  After 7/1/13, requirements will be the same for all dates of injury. 

COLORADO

The CO Department of Labor and Employment/Division of Workers' Compensation has adopted revisions to Rule 17, Exhibit 10, Traumatic Brain Injury Medical Treatment Guidelines. This rule was adopted on 11/26/12 and became effective on 1/1/13.  Exhibit 10 is specific to Traumatic Brain Injury, however there are pertinent sections of the law that affect case management and vocational rehabilitation which are listed below, including but not limited to: 

• Introduction to Traumatic Brain Injury: Return to Work provisions- page 7;         
•  Non-operative therapeutic procedures: Return to work and Vocational Rehabilitation provisions-pages 104-107;      
• Adoption of the International Classification of Functioning, Disability and Health (ICF) of disablement model (Previous law adopted the Nagi scheme of disablement)-pages 7-8;
• Addition of requirement that case managers should be certified through the Commission for Case Management certification and the primary functions of TBI case management (specific to Traumatic Brain Injury only)- pages 12-13;
• Changes to special tests for return to work assessments including job site evaluation and alterations and Functional Capacity Evaluation (FCE)-pages 42-44;     
• Long-term maintenance programs should be managed by an experienced certified case manager who may intervene quickly when necessary (specific to Traumatic Brain Injury only)-page 117; and
• Changes to the Medication/Pharmacological Rehabilitation treatment section-pages 57-67

For the complete CO Medical Treatment Guidelines, Rule 17, Exhibit 10 may be accessed at the following link: http://www.colorado.gov/cs/Satellite?blobcol=urldata&blobheader=application%2Fpdf&blobkey=id&blobtable=MungoBlobs&blobwhere=1251837293309&ssbinary=true 

Louisiana

Michigan

Michigan has recently adopted changes to the Workers' Compensation Health Care Services section of the Michigan Administrative Code (R 418.10101, et. seq.)  Coventry was notified of the adoption on 12/31/12 and the changes became effective 12/24/2012. The new rules establish:

• New reimbursement requirements for certain vision and hearing services
• New conversion factor for medicine, radiology and surgical procedures
• Reimbursement requirements for dispensed and repackaged medications
• Penalties for failure to file annual reports or Professional Certification for Health Care Review Programs

New Mexico

The New Mexico Workers' Compensation Administration (WCA) has adopted revisions to workers' comp rules (11.4.3, .4 & .7 NMAC).  These rules became effective December 31, 2012 (unless otherwise specified).  Coventry was notified of the adoption on January 4, 2013.  These revisions include, but are not limited to, the following: 

• Reimbursement to the injured worker for mileage, meals, and commercial lodging expenses
• Discovery in administrative hearing procedures
• Initial selection of health care provider
• Treatment guidelines
• Authorization for treatment and inpatient/outpatient services
• Billing provisions and procedures (i.e., e-billing).  

Effective November 28, 2012, New York Pharmacy and DME Fee Schedule and Pharmacy Network Rules, 12 NYCRR Part 440 and 442 replaced a series of emergency regulations enacted following the 2007 reforms that authorized employers to require injured workers to use pharmacy networks and the Chair to set pharmacy and DME fee schedules. There are several significant changes to the law, including but not limited to the following: 

• New definitions (Insurance Carrier, Pharmacy Benefit Manager,etc)
• Compound medication reimbursement
• DME direction of care outside of the certified PPO is prohibited
• Updated pharmacies lists must be issued quarterly to the Chair 
• New section for payment of bills and reimbursement requests for DME 

North Carolina 

The North Carolina Industrial Commission has adopted revisions to several workers' compensation rules.  These rules will become effective 1/1/2013 and include, but are not limited to, the following:

• Communication for medical information  
• Preauthorization for surgery and inpatient treatment
• Rehabilitation Professional's communication, mandatory training
• Medical provider fee dispute procedure; and,
• Electronic medical billing and payment    

Texas

Texas Workers' Compensation Division has adopted a new rule relating to exams by a treating doctor or referral doctor after a designated doctor exam.  The rule includes the following: 

• Allows for an exam by the injured worker's treating doctor after a Designated Doctor Exam for certain reasons
• Requires the treating doctor to complete a narrative report on such exams
• Requires the insurance carrier to reimburse the injured worker for miscellaneous expenses related to such exams.   

Official notice of adoption was received by Coventry on December 27, 2012, and the rule became effective January 6, 2013.