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State of California
Gavin Newsom
Governor
George ParisottoAdministrative Director
Overview
Legislative Update
Anti-Fraud Measures
Medical Treatment Utilization Schedule
• MTUS Formulary and Drug List
• Qualified Medical Evaluators (QME)
• Electronic Reporting (DFR)
• Utilization Review
• Independent Medical Review
• Independent Bill Review
• Fee Schedules – EAMS
2019 Legislation
AB 5
Addresses problem of misclassification of workers
Extends basic rights, benefits and protections to California workers
Codifies the “ABC test” for determining whether a worker is an employee or
an independent contractor (Dynamex)
Expands the application of the ABC test
Outlines exemptions from application of ABC test
Dynamex– ABC Test: The burden is on the hiring entity to establish that the worker is
an independent contractor. In order to meet the burden, the hiring entity must establish:
(A) that the worker is free from the control and direction of the hiring entity in
connection with the performance of the work, both under the contract for the
performance of the work and in fact;
(B) that the worker performs work that is outside the usual course of the hiring entity’s
business; and
(C) that the worker is customarily engaged in an independently established trade,
occupation, or business of the same nature as the work performed.
SB 537:
• Requires AD to publish utilization data for physicians treating 10 or more
workers’ compensation patients
• Defines “normal business day” for UR
• Updates provider listing requirements for MPNs
• Codifies current requirements to provide NPI number on billings
• Expressly prohibits anyone other than the requesting provider from altering
treatment requests prior to submission to the claims administrator
• Prohibits MPNs and related entities from adjusting billing codes without review of
provider’s documentation and giving explanation
• Requires that written disclosure of pricing be given to payor if the contracted
reimbursement rate is more than 20% less than the applicable OMFS rate
Anti-Fraud Measures
Lien Stays
• Labor Code section 4615
• Liens filed by physicians or providers who are criminally charged with
workers’ compensation fraud, medical billing fraud, insurance fraud, and
Medicare or MediCal fraud automatically stayed pending the disposition of
criminal case.
• Over 180 criminally charged individuals (and their entities) currently have
their liens stayed by operation of law under Labor Code 4615.
• Over 650,000 liens are designated as “4615” in EAMS (May 1).
Provider Suspension
Labor Code section 139.21
California Code of Regulations, title 8, sections 9788.1 – 9788.4
Convicted of any felony or misdemeanor that involves fraud or abuse of
Medi-Cal, Medicare, or workers’ compensation system, or fraud or abuse
of any patient; license revoked or suspended; suspended, due to fraud or
abuse, from Medicare or Medicaid programs.
Over 400 physicians, practitioners, or providers have been suspended
under Labor Code § 139.21(a).
Lien Consolidation Proceedings
• If the disposition of the criminal proceedings provides for dismissal of liens,
the liens will be dismissed with prejudice by operation of law.
Liens of 11 convicted suspended providers dismissed.
• If the disposition of the criminal proceedings doesn’t address the
disposition to be made of the liens pending in the workers’ compensation
system, the liens will be identified, consolidated and subjected to special
lien adjudication proceedings.
• Presumption that liens connected with criminal activity
19 consolidated special lien proceedings, pursuant to section 139.21 (f),
have been initiated since the effective date of the statute.
Lien Declaration Labor Code section 4903.05
All liens for medical treatment subject to the filing fee, must be accompanied by a declaration signed under penalty of perjury affirming that the dispute is not subject to independent bill review and verifying that the lien claimant is eligible to file that lien.
The declaration requires that the entity filing the lien indicate on what basis they are eligible to file the lien.
The failure to file the declaration will result in the dismissal of the lien with prejudice. The filing of a false declaration will serve as grounds for dismissal of the lien with prejudice.
Approximately 300,000 liens have been dismissed for failure to file a Labor Code Section 4903.05 Declaration.
Liens reduced from 30,000 per month to 5,000.
MTUS Update
• Labor Code section 4600(b): Medical treatment that is reasonable and necessary to cure or relieve an injured worker from the effects of injury means treatment based on the MTUS guidelines.
• The MTUS is a set of regulations found within the California Code of Regulations.
• Contains definitions, establishes the primary role of the treatment guidelines in the MTUS, provides a Medical Evidence Search Sequence and a Methodology for Evaluating Medical Evidence when there are conflicting recommendations.
• Is based on the principles of evidence-based medicine (EBM).
• Adopts and incorporates by reference the treatment guidelines of the American College of Occupational and Environmental Medicine
ACOEM Treatment Guidelines (December 2017)
Cervical and Thoracic Spine Disorders Guideline
Shoulder Disorders Guideline
Elbow Disorders Chapter
Hand, Wrist, and Forearm Disorders Guideline
Low Back Disorders Guideline
Knee Disorders Guideline
Ankle and Foot Disorders Guideline
Eye Disorders Chapter
Chronic Pain Medical Treatment Guideline
Opioids Treatment Guideline
Initial Approaches to Treatment
Hip and Groin Guideline
Occupational/Work Related Asthma Guideline
Occupational Interstitial Lung Disease Guideline
Evidence-Based Updates to the MTUS
Effective October 30, 2018
Traumatic Brain Injury
Prevention
General Approach to Initial Assessment and Documentation
Cornerstones of Disability Prevention and Management
Effective April 18, 2019
Ankle and Foot Disorders
Cervical and Thoracic Spine Disorders
Elbow Disorders Guideline
Hand, Wrist, and Forearm Disorders
Workplace Mental Health: Posttraumatic Stress Disorder and Acute Stress
Disorder
Effective August 11, 2019
Low Back Disorders Guideline
Introduction to the Workplace Mental Health Guideline
Pending Approval
Hip and Groin Disorders Guideline (Public hearing August 26)
Upcoming
Workplace Mental Health Guideline – Depression
Online Training on use of MTUS
Free Access to MTUS-ACOEM Guidelines
MTUS Drug Formulary
MTUS Drug Formulary applies to drugs dispensed on or after January 1, 2018
Applies to all Dates of Injury (except as specified for ongoing course of treatment)
MTUS Drug Formulary applies only to drugs dispensed for outpatient use at home or
outside a clinical setting
Not applicable to physician-administered drugs
Not applicable to drugs self-administered within a facility, e.g. hospital
MTUS rules other than formulary rules apply to physician-administered drugs
ACOEM Treatment Guidelines – The Backbone; presumed correct on scope of medically
necessary treatment.
MTUS Drug List – guides the prospective review requirements.
Exempt drugs – No Prospective Review if in accord with MTUS.
Non-Exempt & Unlisted Drugs – Prospective Review require.
Special Fill & Perioperative Fill of specified Non-Preferred drugs.
Ancillary Formulary Rules
Special Fill policy.
Perioperative Fill policy.
Physician dispensed drugs.
Generic/Brand selection.
Compounded drugs.
Off-label use of drugs.
Pharmacy and Therapeutics Committee (Last meeting July 24)
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MTUS Formulary
Adopted the MTUS Drug List v. 5 effective August 1, 2019
This is the 5th update since the formulary became effective January 1, 2018.
Addition of drugs addressed in the Post-Traumatic Stress Disorder Guideline.
Designation of additional drugs as “special fill” eligible, due to treatment recommendation in the Post-Traumatic Stress Disorder Guideline.
Deletion of codeine phosphate from the MTUS Drug List. New drug recommendations pertaining to diclofenac sodium and
divalproex sodium.
WCIRB Study (August 2019)
Share of prescriptions for exempt drugs – not subject to prospective
utilization review - increased by 41 percent compared to the pre-2018
level, while that of non-exempt drugs declined by 18 percent.
The use of opioids, compounded drugs, physician-dispensed drugs, and
brand name drugs with generic alternatives dropped significantly in 2018.
Pharmaceutical costs continue to decline.
Med-Legal Fee Schedule
May 18, 2018 DWC posts proposed changes to the Medical-Legal fee schedule to clarify interpretation. Over 500 negative responses received from QME community
October 17, 2018 Public forum held for all QME stakeholders to ascertain what the entire community wanted to see in a new Medical-Legal Fee Schedule.
December 12, 2018 DWC posts invitation for written proposals from QME stakeholder community with models for a new Medical-Legal Fee Schedule. Over 30 proposals received from stakeholders.
May 21, 2019 Small stakeholder meetings held with QME advocates and employers/carriers separately to June 11, 2019 review proposals.
August 6, 2019 Draft for new Medical-Legal Fee Schedule consisting of a synthesis of the proposals received by the DWC is posted to the forum. (Forum closed August 23.)
• A single, flat fee for comprehensive ($1,650), follow-up ($1,100), and
supplemental ($275) medical-legal evaluations.
• Additional payment for review of medical records based upon the amount
of pages reviewed.
• Elimination of complexity factors.
• An increase in the hourly fee for medical-legal testimony.
• An increased modifier for evaluations performed by a psychiatrist or
psychologist.
• An increased modifier for evaluations performed in an underserved area.
• Cap on the fee that can be charged for a missed appointment.
ML101 - Comprehensive Medical-Legal Evaluation.
$1650 Flat fee; $2.00 per page for record review over 400 pages
Typical case: 1054 pages of records
Typical fee: $1650 + $1308 (654 pgs x $2 excess record fee) = $2,958.00
Psychiatric Exam
$2475 flat fee; $2.00 per page for record review of new records over 400
pages
Typical case: 3000 pages (est.) of records
Typical fee: $2475 + $5200 (2600 pgs x $2 excess record fee) = $7675.00
ML 102 - Follow-up Medical-Legal Evaluation (any face-to-face evaluation after initial
evaluation)
• $1100 flat fee; $2.00 per page for record review of new records over 400 pages
Typical case: 1054 pages of records
Typical fee: $1100 + $1308 (654 pgs x $2 excess record fee) = $2,308.00
Psychiatric Exam
• $1650 flat fee; $2.00 per page for record review of new records over 400 pages
Typical case: 1500* pages (est) of records
Typical fee: $1650 + $2200 (1100 pgs x $2 excess record fee) = $3,850.00
*Assumes half the amount of records originally received in the typical case.
ML 103 - Supplemental Medical-Legal Evaluations (no face-to-face
time)
• $275 flat fee; $2.00 per page for record review of all new records
Typical case: 500* pages of records
Typical fee: $275 + $1000.00 (500 pgs x $2 new record review) =
$1,275.00
*Assumes half the amount of records originally received in the typical case.
Modifier for Underserved Geographical Areas
• Underserved area is defined as an area with fewer than three
physicians in a given specialty with certified office locations.
• Underserved area receives a 25% increase in the base fee for ML
101 or ML 102 evaluations
Additional Regulations?
•Update discipline procedures
•Update qualifications and training requirements
•Review of reports for quality and bias
Electronic Reporting
Doctor’s First Report
• Labor Code section 6409.1
• The current Doctor’s First Report to be submitted electronically to both
the DWC and the employer’s claim administrator
Reporting UR Data to DWC
• Mandatory electronic reporting of UR data by claims administrators to
DWC.
Physician Reporting – Request for Authorization
Document Repository
Utilization Review
New DWC Form PR-1 combines prior RFA & other “PR” forms.
• Definition of RFA (in 9792.6.1) will change to accompany the change in
format of an RFA. Narrative format still allowed but must follow the format of
the PR-1 as required in regulations.
• When an incomplete RFA is submitted, CA will either accept and comply
with timeframes (and be held liable therefore) or reject and send written
notice. (This is getting rid of minimum standards of completion.)
• Can still agree to any format
UR Plan Approval
• URAC accreditation is required for UR Plans that modify or deny
requests for authorization. (July 1, 2018)
Financial Interest Prohibition
• Claims administrators cannot refer matters to a UR entity in which the
claims administrator has a financial interest unless there is a prior
written disclosure to the employer and AD of the name of the UR entity
and the financial interest in the UR entity.
• Employers and Utilization Review Organizations (UROs) are prohibited
from offering financial incentives to physicians based on the number of
UR denial or modification decisions they issue.
SB 1160: Prospective UR is not required for treatment provided within 30
days of the initial date of injury. Labor Code section 4610(b).
Conditions:
-Accepted body part or condition;
-Addressed by and consistent with the MTUS;
-Rendered by MPN or HCO physician; by predesignated physician; or by
employer-selected physician;
-Reporting requirement (DFR and complete RFA, timely);
-Specific services excluded; and
-Timely submission of bills (30 days of the treatment)
30-day Exemption can be lost if…
• Failure to timely submit RFA may result in loss of ability to provide UR-
exempt treatment to that injured employee for the remainder of the 30-day
period.
• Non compliance w/ MTUS
• An employer may conduct retrospective UR but only for the purpose of
determining if treatment rendered was consistent with the MTUS.
• Provider who has pattern and practice of rending treatment inconsistent
w/ the MTUS could (1) lose exemption for any employee; (2) be removed
from MPN/HCO; or (3) Employer may petition for change of physician.
IMR Application Filings 2014-2018200,000 “unique” applications (less duplicates) filed in 2018
0
50,000
100,000
150,000
200,000
250,000
300,000
CY 2014 CY 2015 CY 2016 CY 2017 CY2018
Total Apps
Unique
Eligible
IMR Application Filings Jan.-Jul. 2019
0
3,000
6,000
9,000
12,000
15,000
18,000
21,000
January February March April May June July August September October November December
Total IMR Apps Unique Apps Eligible Apps
Ineligible IMR Applications 2014-2018
The number of applications deemed ineligible decreased in half in three years.
The ratio of ineligible applications to all
“unique” applications (less duplicates)
filed has decreased steadily for the past
several years.
29,04630,258
23,605
17,420
14,173
CY 2014 CY 2015 CY 2016 CY 2017 CY2018
Ineligible IMR Applications Jan.-Jul. 20196,500 ineligible out of 106,400 “unique” applications (6.1%)
Reasons for Ineligibility
• Untimely submission of application
• UR report not attached to application
• Application lacks Injured Worker’s signature
• Conditional Non-Certification*
* Denied because the treating physician has not provided the medical information requested by the claims
administrator that is required to make a medical necessity determination on the treatment recommendation.
No Signature,
415
No UR, 1,664
Other, 771
No Sig and No UR, 80
Untimely, 1,666
CNC, 1,696
IMR Decisions Issued 2014-2018
143,840
165,496175,960 172,145
184,733
CY 2014 CY 2015 CY 2016 CY 2017 CY2018
IMR Mailed and Processing Times98% of all case decisions issued within statutory time requirements.
IMR Case Decisions Jan.-Jul. 2019
At the case level…
• Uphold – None of the disputed items/services are medically necessary and appropriate.
• Partial Overturn – Some (but not all) of the disputes items/services are medically necessary and appropriate.
• Overturn – All of the disputes items/services are medically necessary and appropriate.
84%
6% 10%
Upholds (83,391) Partial Overturns (5,571) Overturns (9,836)
IMR Case Outcomes by Geographic Region Jan.-Jul. 2019
Case decision outcomes continue to be consistent across all geographic regions.
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Others/Out-of-State (2,154)
San Diego (5,884)
Sacramento Valley (N.) (1,520)
Sacramento Valley (5,028)
North State-Shasta (1,346)
Los Angeles (22,831)
Inland Empire (17,713)
Eastern Sierra Foothills (2,192)
Central Valley (12,682)
Central Coast (7,644)
Bay Area (19,804)
Upholds Partial Overturns Overturns
IMR Treatment Requests Outcomes Jan.-Jul. 2019
At the treatment level…
• Uphold – The IMRO decided that
the disputed
service was not medically
necessary and appropriate.
• Overturn – The IMRO decided
that the disputed
service is medically necessary
and appropriate.
10.3%
89.7%
Overturned (19,924) Upheld (173,515)
IMR Service Categories/Treatment Requests
Pharmaceuticals = 37% of all UR denials that are sent to IMR
16,435
29,439
9,487
65,447
28,847
12,761
1,548
6,689
1,642
1,527
2,860
988
7,451
3,290
1,508
300
1,404
489
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
DMEPOS
Rehabilitation
Surgery
Pharmaceuticals
Diagnostic Testing
Injection
Programs
Evaluation & Management
Behavioral & Mental Health Svc.
Upheld Overturned
IMR Service Category Outcomes Jan.-Jul. 2019
IMR Physician Reviewers Jan.-Jul. 2019The majority of IMR cases are reviewed by
physicians licensed in the state of California.
The IMRO medical reviewer does not necessarily have the same Board Certification as the requesting physician, but is
knowledgeable and qualified to review the requested treatment.
Board Certification / Specialty of
IMR Reviewer assigned to Cases
Percent of IMR
Reviews
Completed
Occupational Medicine 24%
Physical Med. & Rehab. 15%
Family Practice 15%
Emergency Management 9%
Orthopedic Surgery 9%
Pain Management 8%
Internal Medicine 8%
Other Specialty 11%
California, 62.6%
Other State, 37.4%
Independent Bill Review (IBR) 2014-2018Application filings decreased for the second consecutive
year.
Applications Filed Case Decisions Issued
CY 2014 CY 2015 CY 2016 CY 2017 CY 2018
2,009
2,345 2,3852,151
1,692
CY 2014 CY 2015 CY 2016 CY 2017 CY 2018
1,489
2,1891,945
1,570
1,129
IBR Application Filings Jan.-Jul. 2019
0
20
40
60
80
100
120
140
160
180
January February March April May June July August September October November December
IBR Applicable Fee Schedule 2018Physician services at least half of all evaluated services
0 100 200 300 400 500 600
Interpreter
Pharmaceutical
Durable Medical Equipment, Prosthetics, Orthotics, Supplies
Inpatient Hospital Services
Pathology and Laboratory Services
Medical-Legal Fee Schedule
Hospital Outpatient Departments and Ambulatory Surgical Centers
Contract for Reimbursement Rates
Physician Services
IBR Decisions Issued Jan.-Jul. 2019
The 507 overturned cases, where
the IBRO has determined that
additional reimbursement is
warranted, have resulted in
providers being awarded a total of
$923,681 in the first seven months
of Calendar Year 2019. Overturned,
507
Upheld,
208
Ineligible,
242
Withdrawn,
38
IMR and IBR Search Tools on DWC Web Site
https://www.dir.ca.gov/dwc/imr
/IMRDecisionSearch.asp
• Updated monthly
• Access to all decisions issued from
February 2013 to July 2019
(approximately 945,000 FDLs)
• Search by treatment request
categories, expert reviewer’s specialty,
date of injury, etc.
https://www.dir.ca.gov/dwc/ibr/
IBRDecisionSearch.asp
• Updated monthly
• Access to all decisions issued from
June 2013 to July 2019 (approximately
9,250 FDLs)
• Search by Applicable Fee Schedule,
date of filing, etc.
EAMSDWC working with DIR IT Unit and Cal. Department. of Technology to update EAMS
Goals:
• Streamline staff work and filing system.
• Improve use of online forms.
• Improve the community experience with EAMS (more easily file documents and access information on our on line system).
• Reduce costs and allow for easier upgrades.
• Allow for better processing of payments to DWC.
• Allow for easy access for judges and staff for trial and reconsideration purposes. (Currently judges must sift through multiple documents to determine which documents are trial exhibits.)
Fee Schedules
Copy Service Fee Schedule
Revisions on DWC Website Forum (closed August 16)
A one-time increase of the flat fee rate for copy services from $180 to $210
Annual cost-of-living adjustments to the flat fee for copy services
Mandatory billing codes, including proposed new codes for sales tax, contracted fees and additional sets
OMFS Fee Schedules Annual Updates
Pharmacy Fee Schedule (Change in Medi-Cal Dispensing Fee)
Interpreters Fee Schedule
Home Health Fee Schedule
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