California

The California Division of Workers' Compensation has adopted numerous rules in response to SB863.  Rules designated below as, "Emergency Regulation" are temporary in nature, and are only in effect for 180 days while the state moves forward with finalized regulations.  To view the most updated changes in the regulations, visit the DIR website at http://www.dir.ca.gov/dwc/SB863/RegulationTimeline.htm

•  Inpatient Fee Schedule Changes: Adopted 12/31/12; Effective for patient discharges occurring on or after 1-1-2013 unless otherwise noted.  The amended Inpatient Fee Schedule has the following updates or changes:
  • Updates references, definitions, adjustment factors, indexes and formulas for calculating reimbursement
  • Creates flat fees for devices used during complex spinal surgery based on specified MS-DRGs
  • Completely removes additional reimbursement for implants/devices used during complex spinal surgeries, for discharges on or after 1/1/14
  • Revises bill submission guidelines for both electronic and paper billing
• Outpatient and ASC Fee Schedule Changes: Adopted 12/27/12; Effective 1/1/13.  The amended Outpatient/ASC Fee schedule has the following updates or changes:
• Updates references, definitions, conversion factors, multipliers, indexes and formulas for calculating reimbursement
• Adds provision that for any date of service, the most current  CPT /HCPCS version should be used
• Revises bill submission guidelines for both electronic and paper billing
• Revises high cost outlier reimbursement
• Caps ASC reimbursement at 80% of what Medicare OPPS pays for the same service
• New Lien and Electronic Filing Regulations: Adopted via Emergency Regulation on 12/31/12; effective 1/1/13 - 6/30/2013
• Excludes medical treatment disputes that are subject to IMR and IBR from the lien process.
• Establishes requirements and forms for the electronic filing of liens
• Allows filing of liens for transportation expenses for medical treatment, and for interpreter fees
• Creates an initial lien filing fee of $150 for liens filed on or after January 1, 2013 which is payable  prior to, or at the time of, initial filing
• Creates a lien activation fee of $100 for liens filed prior to January 1, 2013, payable prior to the earliest of the following events: (1) the filing a Declaration of Readiness to Proceed for a lien conference (2) an appearance at a previously-scheduled lien conference,  or (3)  January 1, 2014
• Dismisses all liens with prejudice effective 1-1-2014, for all those existing liens for which the activation fee has not been paid, by operation of law
• Final Proposed Regulations scheduled for public hearing March 26, 2013
• Independent Bill Review (IBR)  (Adopted via Emergency Regulation on 12/31/2012; effective 1/1/13 - 6/30/2013)
• Applies to medical treatment and medical-legal expenses incurred on/or after 1/1/13, for dates of service beginning 1/1/2013
• Creates a formalized  Second Bill Review process for providers to request a re-review of an initial reimbursement determination, no later than 90 days from receipt of an EOR from a payor
• Allows a provider to then have the dispute forwarded to an Independent Bill Review Organization, upon the filing of a $335 filing fee, if requested no later than 30 days from receipt of the Final EOR from a payer, in the event that a provider is still unsatisfied following the Second Bill Review determination
• Updates complexity factors that are used when considering reimbursement for complex comprehensive medical-legal evaluations
• Interpreter Certification Rules: Adopted via Emergency Regulation on 12/31/2012; effective 1/1/13 - 6/30/2013
• Defines "Qualified Interpreter for purposes of medical treatment"
• Requires "qualified" interpreters be used during medical treatment appointments
• Adopt a fee schedule for interpreter services
• Final proposed rules scheduled for public Hearing on March 19. 2003
• Independent Medical Review (IMR) (Adopted via Emergency Regulation on 12/31/2012; effective 1/1/13 - 6/30/2013)
• Applies to injuries on or after Jan. 1, 2013, and starting July 1, 2013, applies to ALL dates of injury
• Medical treatment disputes will be resolved by physicians through a process known as independent medical review(IMR), rather than through the often cumbersome and costly adjudication system (at the WCAB)
• If utilization review denies, delays or modifies a treating physician's request for a specific course of medical treatment for the reason that the treatment is not medically necessary, the injured employee will have the right to request a review of that decision by IMR conducted by a physician
• The physician review will be expeditious and based upon evidence-based standards to ensure that injured employees receive timely and appropriate medical treatment
• The costs of IMR are based upon the nature of the medical treatment dispute and the number of medical professionals needed to resolve the dispute
• The 2013 costs for IMR were based upon the DWC data regarding the estimated number of medical necessity disputes and the expertise of the IMRO
• Only the injured worker or his designee may invoke IMR
• IMR must be invoked with 30 days of receipt of UR denial notice
• During the 180-day emergency regulation effective period, the state will undertake formal final rule-making via a series of stakeholder meetings, comment periods, etc.
• The state is scheduled to commence the stakeholder meeting process in March 2013
•  Supplemental Job Displacement Benefit: Effective for injuries occurring on or after 1/1/13, for 180 days. The new regulations:
  • Revise the process that the employer/claims administrator must use to either make an offer of work or provide a supplemental job displacement voucher to the injured worker
  • Create new forms:
  • For the employer/claims administrator to provide to the physician a description of job duties
  • For the physician to provide the employer/claims administrator with work capacities of the injured worker
  • For the employer/claims administrator to make an offer of work
  • Revise the timeframe the Supplemental Job Displacement Benefit must be offered to the employee for injuries occurring on or after 1/1/13
  • Revise the dollar amounts for supplemental job displacement vouchers for injuries occurring on or after 1/1/13 and how the injured worker can use them 
• Qualified Medical Evaluators (QMEs) and Agreed Medical Evaluators (AMEs): Effective 1/1/13, for 180 days.  The new regulations specify what communications are allowed with the AME. Prior to 7/1/13, for dates of injury prior to 1/1/13, medical treatment disputes will continue to utilize the AME/QME process. After 7/1/13, all medical treatment disputes must go through the IMR process regardless of the date of injury. However, AMEs and QMEs will continue to provide opinions over disputes regarding the need for future medical care.

Florida

On January 17, 2013, Florida adopted amended rules 69L-29.001- 011, which revises the process by which health care providers are certified. This rule includes, but is not limited to, the following:

• Establishes the FL Workers' Comp Health Care Provider Certification Tutorial
• Deems certified a provider under contract with a licensed managed care organization
• Revises certification time frames
• Repeals the Occasional Health Care Provider, Decertification Process, and Recertification Process sections of the rules

Hawaii

The Hawaii Department of Commerce and Consumer Affairs adopted regulations impacting auto only effective 11/11/12. The adopted regulations became available on 1/7/13.  Significant changes include, but are not limited to:

• The revision of rules and procedures for IME as required by the insurer for injuries covered by PIP
• The addition of naturopathic treatments to the list of services that require authorization
•  Revision of fee schedule rules related to surgery    

Kansas 

Kansas has amended rule KAR 51-9-17 which mandates the use of the IAIABC Claims Release 3 EDI Standard for regulatory reporting of Worker's Compensation Claims.  This rule was adopted on January 24, 2013 and has an effective date of February 8, 2013.  The significant  impact of this rule includes, but is not limited to, the following:

• Instruction on submission of EDI trading partner profile to the director
• Compliance schedule for test-to-production  
• Compliance schedule for implementation    

New York 

The New York Workers' Comp Board adopted the amendments to Medical Treatment Guidelines and related rules. These rules will become effective 3/1/2013 and  include but are not limited to the following:

• Adding a definition for denial
• Amending the definition of MMI
• Adding Carpal Tunnel Syndrome guidelines
• Removing procedures from the pre-authorized list
• Amending the variance process (i.e. requests can be partially granted, resubmission of variance requests, etc.)
•  Amending the informal resolution process/timeframe   

North Carolina Office of Administrative Hearings/Rules Review Commission (RRC) received objections to a portion of the Industrial Commission's recently approved rules; therefore, per the North Carolina rules process, those rules are subject to legislative review and will not be effective January 1, 2013, as previously published.   

In addition, the Industrial Commission rules that were approved by the RRC and were not subject to review by the legislature will also be delayed so that all of the rules become effective at the same time with one exception, the Fees for Medical Compensation/Medical Fee Schedule.  

Texas 

Notice of adoption of Texas Administrative Rules 28 TAC 134.803 and 134.807 was received on February 4, 2013.  These rules become effective February 17, 2013 and include the following:

• Adopt the updated Texas EDI Medical Difference Table
• Update the website for obtaining copies of the IAIABC EDI Implementation Guide and division tables to http://www.tdi.texas.gov/wc/indexwc.html
• Require insurance carriers to report ICD-10-CM and ICD-10-PCS codes contained on bills in the associated ICD-9-CM elements with the ICD-9-CM code qualifiers

Washington

The Washington Department of Labor and Industries adopted rules for Independent Medical Examinations (IMEs) effective 2/25/13. The new rules: 

• Require a licensed provider to submit an IME provider application to the Department to become an approved IME provider
• Require an IME firm to have a medical director who has a Washington state medical license
• Update IME examiner qualifications
• Establish new educational requirements for IME examiners in the state that examiners must comply with by 3/1/14 

California

• MPN Regulations
• The State is undertaking administrative rule-making in anticipation of the Jan 1, 2014 effective date for most MPN regulations
• Initial public stakeholder meeting held Jan 31, 2013 was attended by Coventry
• Coventry will continue to provide feedback and work closely with the State
• SB 146: Pharmacy Documentation Elimination; Removal of Pharmacies as "Service Providers." This bill would REMOVE the requirements that a pharmacy submit with its request for payment:
• An itemization of services provided and the charge for each service
• A copy of all reports showing the services performed
• The prescription or referral from the primary treating physician if the services were performed by a person other than the primary treating physician
• Any evidence of authorization for the services that may have been received
• Prohibit a payor from requiring a pharmacy provide a copy of the prescription with a request for payment and would give any entity 90 days after Jan. 1, 2014, to resubmit pharmacy bills for payment originally submitted in 2013 and for which payment was denied because the bill did not include a copy of the prescription
• Reference Official Bill Text
  http://www.leginfo.ca.gov/pub/13-14/bill/sen/sb_0101-0150/sb_146_bill_20130131_introduced.html
  

SB 238: Changed reimbursement schemas for hospitals and ASCs

Amends §2322B(8) and (9), Chapter 23, Title 19 of the Delaware Code.

Florida

3-Member Panel Meeting/Report

Annual 3-member panel meeting held Jan 9, 2012 in Tallahassee, FL to introduce recommendations from the Dept. of Insurance for the 2013 legislative session.  Highlights of recommendations include:

• Introducing caps on the prices of repackaged medications
• Caps on hospital fees at 120-140% of Medicare
• The panel introduced the Medicare-based hospital fee schedule proposal in response to the continuing 6-year dispute with the FL Hospital Association over fees
• Coventry was in attendance at the meeting and will continue to actively participate as legislative hearings, meetings or comments are scheduled or requested

Reference  FL 3-Member Panel and Report
http://www.myfloridacfo.com/wc/pdf/Three-Member-Panel-Materials-(January-9-2013).pdf

• HB 1176:  Dispute Resolution
• Authorizes the employer and provider of services to notify the director of labor and industrial relations in the event of a reasonable disagreement relating to a specific medical service charge
• Requires that the notice of dispute is done in writing and that the parties negotiate during the thirty-one calendar days following the date of the notice to the director
• Allows parties to request the director to render an administrative decision without a hearing in the event the parties fail to reach an agreement within the thirty-one day negotiation period.  Establishes that the administrative decision rendered by the director is final and non-appealable
• Passed Second Reading 2/12/2013 as amended in HD 1, and referred to the committee on Finance
• Reference :  Official State Bill Status:
  http://www.capitol.hawaii.gov/measure_indiv.aspx?billtype=HB&billnumber=1176
• SB 876: New Dispute Resolution Process
• New bill introduced to allow the director of the Department of Labor and Industrial Relations to resolve billing disputes
• Would authorize an employer and a medical provider to ask the director to render an administrative decision in a dispute over "a reasonable disagreement relating to specific medical service charges" 
• After petitioning the director for review, the parties would have to continue negotiations for 31 calendar days
• If they cannot resolve their differences, the director could render a decision without holding a hearing. The decision would be final and non-appealable
• Status:  Passed with amendments on 2/11/2013 and 2/12/2013 in the Senate Committee on Health, and the Senate Committee on Judiciary and Labor, respectively
• Reference Link to Official State Web Site:
  http://capitol.hawaii.gov/measure_indiv.aspx?billtype=SB&billnumber=876
• HB 152:  Proposal to Increase from 110 to 130% of Medicare
• Re-introduction of proposal to increase reimbursements from 110% to 130% of Medicare's Resource-Based Relative Value Scale (bill died last year with discussion  over whether an additional study was necessary to examine whether there is an access issue in HI)
• Status:  Heard by Committee on Labor and Public Employment on 1-29-2013; Passed 8 Ayes; 1 No on 1-29-2013 - recommended to pass with amendments
• Reference:  Official State Link to Bill:
  http://capitol.hawaii.gov/measure_indiv.aspx?billtype=HB&billnumber=152
• Link to Testimony of 1-29-2013 Hearing Testimony
  http://www.capitol.hawaii.gov/session2013/Testimony/HB152_TESTIMONY_LAB_01-29-13_.PDF
• SB1122: Drug Reimbursement; Dispensing Fees
• Official bill digest:  Establishes price caps for the Hawaii workers' compensation insurance system for drugs.  Authorizes reimbursement of a dispensing fee to physicians who dispense prescription medications directly to patients.  Effective July 1, 2013
• Closes a loophole in Hawaii's workers' compensation insurance law to restrict markups of repackaged prescription drugs and compound medications to an amount that will help deter inflation of health care costs by preventing prescription medications from becoming an unreasonable cost driver
• Promotes the practice of physician dispensing of prescription medication in an ethical and transparent manner by authorizing reimbursement of a dispensing fee for each prescription dispensed by a physician
• Sets the reimbursement amounts for drugs in accordance with the medical fee schedules adopted by the director pursuant to subsection (c) or a lower amount for which the carrier contracts
• Provides for payment for prescription drugs at the average wholesale price as listed in the Red Book, plus no more than 40% of the AWP for drugs sold by a physician, hospital, pharmacy, or provider of service other than a physician, with certain exceptions
• Sets the price for repackaged drugs at the standard prescription drug price + a pre-defined "repackaging premium"
• For compound medications, reimbursement is based on the sum of the fee due for each medication ingredient having an assigned NDC that is used in the compounded medication
• Provides that if information pertaining to the original labeler or manufacturer of the underlying drug product used in repackaged or compounded medications is not provided or is unknown, then reimbursement shall be based on the most reasonable and closely related AWP for the underlying drug product
• Status:  Introduced and referred to committee on Jan 24, 2013
• Reference:  State Link to Official Bill http://capitol.hawaii.gov/measure_indiv.aspx?billtype=SB&billnumber=1122&year=2013
• SB1302: Pharmacy
• Repackaged/Compounded Drug Pricing Same as Retail Pharmacies
  Proposal to restrict reimbursement of repackaged prescription drugs and compound medications to amounts comparable to that of retail pharmacies under state law
•  Effective July 1, 2013
• Reimbursement for brand name prescription medication shall be the AWP as listed in Red Book plus 40% of AWP, except where the carrier and the specific provider seeking reimbursement have directly contracted between one another for a lower reimbursement amount
• If the brand name medication has been repackaged or relabeled, reimbursement shall be calculated by multiplying the number of units dispensed by the AWP set by the original manufacturer of the underlying medication, plus 40%
• Reimbursement for generic prescription medication shall be the AWP as listed in Red Book plus 60% of AWP, except where the carrier and the specific provider seeking reimbursement have directly contracted between one another for a lower reimbursement amount
• If the generic medication has been repackaged or relabeled, reimbursement shall be calculated by multiplying the number of units dispensed by the AWP set by the original manufacturer of the underlying medication, plus 60%
• Compounded medications shall be reimbursed based on the sum of the average wholesale prices due for each medication ingredient having an assigned national drug code that is used in the compounded medication, plus 40%
• If information pertaining to the original labeler or manufacturer of the underlying medication product used in repackaged or compounded medications is not provided or is unknown, then reimbursement shall be based on the most reasonable and closely related AWP for the underlying medication product
• Status:  Introduced 1/24 - referred to multiple committees 1/28/2013
• Reference - State Official Link to Bill:
  http://capitol.hawaii.gov/measure_indiv.aspx?billtype=SB&billnumber=1302&year=2013 

Indiana

• HB 1320
• Bill introduced to cap inpatient hospital fees and remove "savings" model of compensation for bill review companies
• Proposal to introduce Medicare-based hospital fee schedule for treating injured workers, with a cap of 175% of Medicare charges for workers' compensation services
• Would increase the maximum weekly benefit for injured workers from $650 to $750
• Would remove ability for a bill review service to be paid based on the amount by which claims are reduced
• Status: In committee - first House
• Reference  official IN legislative information http://www.in.gov/apps/lsa/session/billwatch/billinfo?year=2013&session=1&request=getBill&docno=1320#latest_info
• SB 470:  Act to Require Facility Services Fee Schedule by 1-1-2014
• Requires the worker's compensation board, not later than January 1, 2014, to adopt rules to establish the reimbursement rates for charges for medical services, treatment, and supplies provided by a medical services facility to an employee for purposes of determining the pecuniary liability of an employer or an employer's insurance carrier for a specific service, treatment, or supply covered under workers' compensation or occupational diseases  compensation.
• Increases benefit amounts for injuries and disablements occurring on and after July 1, 2013
• Status:  In committee - first House
• Reference :  Sen. Tallian's Web Site - highlights the bill
  http://www.in.gov/portal/news_events/74917.htm

• Pricing update to Title 40, LABOR AND EMPLOYMENT, Part I. Workers' Compensation Administration, Subpart 2. Medical Guidelines, Chapter 31.
• Vision Care Services, Reimbursement Schedule
• Billing Instruction and Maintenance
• Highlighted was a presentation on upcoming fee schedule changes.  Louisiana will be proposing use of APR-DRG for inpatient reimbursement, which is currently used for New York's pricing (from 3M)
• A new item introduced is Enhanced Ambulatory Patient Groups (EAPGs) for outpatient services
• EAPGs also come from 3M
• Currently, no other workers' comp jurisdictions use this methodology
• Reference:  http://www.laworks.net/Downloads/OWC/CPTCodes.pdf

Maryland

• SB 139: Health Care Practitioners - Prescription Drug or Device Dispensing - Medical Facilities or Clinics that Specialize in Treatment Reimbursable
• Repeals an exception to the requirement that an individual be licensed by the Board of Pharmacy before the individual may practice pharmacy in the State
• Points requires a dentist, physician, or podiatrist who dispenses a prescription drug or device in the course of treating a patient at a medical facility or clinic that specializes in the treatment of medical cases reimbursable through workers' compensation insurance to obtain a dispensing permit and meet other  requirements.
• Reference Maryland General Assembly link
  http://mgaleg.maryland.gov/webmga/frmMain.aspx?pid=billpage&stab=01&id=SB0139&tab=subject3&ys=2013RS
• SB 247: Workers' Compensation Payment for Physician Dispensed Prescriptions Cross Filed with HB 174
• An employer or its insurer may not be required to pay for a prescription that is dispensed by a physician to a covered employee who has suffered an accidental personal injury, compensable hernia, or occupational disease unless the prescription was: 
• Dispensed within 72 hours after the accidental personal injury or compensable hernia occurred or the occupational disease was discovered
• Limited to no more than a 30-day supply of the medication
• Status: Talking  In committee
• Reference:  Link to MD General Assembly web site
  http://mgaleg.maryland.gov/webmga/frmMain.aspx?id=sb0247&stab=01&pid=billpage&tab=subject3&ys=2013RS
• Bill text:  http://mgaleg.maryland.gov/2013RS/bills/sb/sb0247f.pdf

• Allowing an employer or the employer's insurance carrier or self-insurer to select a health care provider during the first 10 days of an employee's injury
• Requiring pharmacies to substitute generic drugs unless the prescribing physician indicates that the brand name drug is medically necessary
•  Establishing a 3-year pilot program in certain counties for a 90-day preferred provider network
• Allowing an employer or employer's insurance carrier or self-insurer to provide a pharmacy benefits management program
• Note:  Not included in the analysis is a provision to allow payment of medical services at a reasonable fee
• Status:  Due out of Labor, Industrial and Rehabilitative Services committee on 3/7/2013. 
  http://www.gencourt.state.nh.us/bill_status/Results.aspx?q=1&txtsessionyear=2013
• Text of bill as of 1/22/2013
  http://www.gencourt.state.nh.us/legislation/2013/HB0255.pdf

Ohio