workers compensation division rulemaking advisory committee … · 2019. 11. 18. · 05:40: stan...
TRANSCRIPT
Workers’ Compensation Division
Rulemaking advisory committee meeting
OAR 436-009, 010, and 015
Room 260, Labor & Industries Building, Salem
Date: Monday, Nov. 18, 2019
Members attending:
Travis Brooke, Cascade Health
Joy Chand, Takacs Clinic
Tavis Cowan, Corvallis Clinic
Timothy Craven MD, Providence MCO | MAC
Jeanette Decker, Providence MCO
Jessica Dover, Oregon Society of Translators and Interpreters
Leslie Fenstermacher, TRISTAR Managed Care
Adam Fowler, Optum
Jaye Fraser, SAIF Corporation
Greg Gilbert, Concentra
Diana Godwin, Attorney at Law
Michael Gray, Corvallis Clinic
Laura Grossenbacher, Broadspire
Elizabeth Gutzwiler, Mitchell
Dee Heinz, SAIF Corporation
Isabel Hernandez, Healthesystems
Lisa Johnson, Majoris Health Systems Oregon, Inc.
Richard Katz, Therapeutic Associates
Mary Ann Lubeskie, Tristar Group
Joe Martinez, Concentra
Melissa McGarry, Aetna
Dan Miller DC, Oregon Chiropractic Association
Sheri North, Mitchell
Jovanna Patrick, Hollander Lebenbaum et al
John Powell, John Powell and Associates
Sue Quinones, City of Portland
Dan Schmelling, SAIF Corporation
Ann Schnure, Concentra
Schooler Elaine, SAIF Corporation
Patti Snow, Clackamas Risk and Benefits
Ramona St. George, Majoris Health Systems Oregon, Inc.
Sheri Sundstrom, Hoffman Construction
Tammie Sweet, Integrity Medical
Julie Tucker PT, Salem Health
Tom Williams PT, Capital Physical & Hand Therapy | MAC
Kimberly Wood, Perlo Construction | MLAC
Agency staff attending:
Stan Fields
Cara Filsinger
Tasha Fisher
Jessica Lowman
Juerg Kunz
Fred Bruyns
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BEFORE THE WORKERS' COMPENSATION DIVISION OF
THE STATE OF OREGON
RULEMAKING ADVISORY COMMITTEE
WORKERS’ COMPENSATION DIVISION RULES
The proceedings in the above-entitled matter were held in Salem,
Oregon, on the 18th day of November 2019, before Fred Bruyns, Administrative
Rules Coordinator for the Workers' Compensation Division.
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TRANSCRIPT OF PROCEEDINGS
00:00: Okay. We're on. So thank you, all, very much for coming, my
name is Fred Bruyns, I coordinate rulemaking for the Workers' Compensation
Division. And this is a rulemaking advisory committee, it's not a formal process like
a public hearing; it's a conversation really and our chance to get your best advice on
the issues that we have on our agenda, and if time allows, and it probably will allow,
at the end of the agenda we'll, you know, take new issues that you may have and be
delighted to discuss those with you.
There are handouts over on the table by the door and I would
encourage you to pick up an agenda. I will actually read from the agenda, however,
so if you're on the telephone with us and you don't have access to an agenda and
you'll still be able to have a good understanding of the issues, I think, but feel free to
ask questions at anytime if you don't have enough information. We also have the
agenda posted to our website, so you're welcome to go to WCD.org and .gov and go
to Laws and Rules and you'll see a link then to meetings and hearings and you'll find
today's meeting listed there along with the agenda and some advice documents and
which we also have on the--on the table by the entrance, several people submitted
written advice that were pertinent to the issues today, so I would encourage you to
pick one of those up as well.
As we go along, if you have any advice for us on the costs of making
any of the changes that we discuss, please give your best advice about what those
costs may be or savings, as the case may be, to you or the people that you
represent because we estimate those costs when we file rules with the Secretary of
State and we rely on information from folks like you.
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If you're on the telephone with us today, please do not put us on hold if
you have another incoming call or a visitor because we may get your background
music or any background messages your phone system has and there's really no
way for us to turn those off without muting everyone, so we don't want to have to do
that, so you're welcome to, you know, leave and rejoin the meeting as many times
as you need to.
With that, I've introduced myself, I'd like to begin with the folks on the
telephone with us and have you introduce yourselves to the committee, so go ahead
and let us know you're there.
02:32: I'm Sue Quinone, City of Portland.
02:35: Welcome, Sue.
02:39: This is Jovanna Patrick, claimants attorney in Portland.
02:42: Thanks for joining us, Jovanna. Anyone else?
02:47: (unintelligible) Broadspire.
02:49: Okay, the person at Broadspire, I apologize, we didn't get your
name.
02:54: Laura Grossenbacher.
02:56: Oh, welcome, Laura.
03:01: (unintelligible)
03:05: Okay. Let's see. Go ahead.
03:16: Ann Schnure from Concentra.
03:18: Okay. Welcome.
03:22: Joy Chand from Takacs Clinic.
03:25: Okay. Welcome, Joy.
03:27: Thank you.
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03:30: Anyone else.
03:31: This is Mary Ann Lubeskie, Tristar.
03:33: Oh, thanks for joining us, Mary Ann.
03:38: Patti Snow from Clackamas County.
03:40: Welcome.
03:43: Greg Gilbert, Concentra.
03:46: Thanks for joining us, Greg. Anyone else.
03:49: (unintelligible)
03:52: Okay, Joe, I think you were coming in, we'll let you go first
because I got that your part of your name, is it--is that Joe Martinez?
03:59: It is, Fred, how are you, sir--
04:00: Okay, welcome, Joe. And someone else was trying to come in
at the same time, who is that?
04:05: Sheri North from Mitchell.
04:07: Oh, welcome, Sheri. Anyone else.
04:15: (unintelligible) Systems.
04:19: Okay, I heard Adam; Adam, would you go ahead?
04:23: Yeah, I'm Adam Fowler with Optum.
04:26: Okay, welcome, Adam. And someone else is trying to talk, tell
us, let us know they're there as well.
04:34: Okay. It's Isabel Hernandez from Healthesystems.
04:37: Okay. Welcome. Anyone else? Okay. With that, we'll go
around the table, I'll begin (unintelligible) with Diana.
04:52: Diana Godwin, representing private practice physical therapy
clinics.
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04:56: Rich Katz with Therapeutic Associates of Northwest Rehab
Alliance.
05:00: Lisa Ann Bigford (phonetic) government (unintelligible) part of
Aetna (unintelligible)
05:05: Jessica Dover, Oregon Society of Translators and Interpreters.
05:08: Jaye Fraser, SAIF Corporation.
05:10: (unintelligible) physical therapy work injury management
(unintelligible) Workers' Compensation Division.
05:16: Dan Schmelling, SAIF Corporation.
05:18: Dee Heinz, SAIF Corporation.
05:19: Lisa Johnson, Majoris Health Systems.
05:22: Kimberly Wood, Perlo Construction.
05:24: Ramona St. George, Majoris Health Systems.
05:27: Sheri Sundstrom with Hoffman Construction.
05:29: Jennifer Flood, ombudsman for injured workers, DCBS.
05:33: Michael Gray from Corvallis Clinic.
05:35: Tavis Cowan, also Corvallis Clinic.
05:37: Dan Miller, Oregon Chiropractic.
05:40: Stan Fields, Workers' Comp Division.
05:42: Jessica Lowman, Workers' Comp Division.
05:44: Tasha Fisher, Workers' Comp Division.
05:46: Juerg Kunz, Work Comp Division.
05:49: Thanks again to all of you for taking your afternoon and coming
to join us. It says that our agenda is going to take from 1:30 to 4:30, but I have no
idea if that's true, it seems to me that our agenda is not terribly long, but we'll take as
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long on the issues as, you know, as they require or they deserve to get the advice
from you, and with that, is there anyone who is unable to stay the entire time and
would like us to address any particular issue in a different order? We'd be glad to
rearrange things for you if that would help.
06:25: (unintelligible) be in Portland around 5:15, so 4:30 might be a
little--
06:29: Okay.
06:30: --tight--
06:31: Okay.
06:31: --doesn't have to be first (unintelligible)
06:32: Okay. Well, we'll definitely keep that in mind, if we're--if we get
like about an hour in and it looks like we're going to run a little long, well, I guess it
wouldn't really do any harm to address your issue first if that's okay if you're ready to
go, that would be--
06:49: Sure.
06:49: --the issue on it affects Rule 110, I think it's the second to the
last issue on the--on the document--
06:55: Page 11.
06:56: Yeah, and Jessica submitted some advice this morning that I
sent, I sent a fairly recent, very recent email to you all, letting you know that the
advice is posted to our website, so if you're on the telephone with us, I would
encourage you to go there and have a look, there's also copies over on the table by
the door. So this is the issue that's on page 11, it is in the Division 9 rules, it affects
Rule 110, Section (3), and here's a description of the issue. Interpreters may not bill
any amount for interpreter services or mileage if the worker fails to attend a medical
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appointment. Some background. Since April 1, 2019, medical providers may bill
workers for missed appointments under certain circumstances. The Division 9 rules,
Rule 110(13), Section (13), Subsection (b) provides in relevant part that a provider
may bill a patient for a missed appointment if the provider has a written missed
appointment policy that applies not only to Workers' Compensation patients but to all
patients, the provider routinely notifies all patients of the missed appointment policy,
the provider's written missed appointment policy shows the cost to the patient, and
the patient has signed a missed appointment policy.
The missed appointment rule states that the implementation and
enforcement of the rule is a matter between the provider and the patient. The
Division is not responsible for the implementation or enforcement of the provider's
policy. And interpreters also may not bill any amount for interpreter services or
mileage if the provider cancels or reschedules the appointment.
So options would be to modify this rule, Rule 110, to mirror the
changes to the rule that affects medical providers, so interpreters would have the
same provisions, which would then allow an interpreter to bill a patient under specific
circumstances, and then you can see there's draft rule language there, I won't read
all of that, because it does mirror the other rule for the most part, and with that, we
all--we put various options on our document, it's not meant to be exhaustive, so if
you--you know, if you have alternatives to recommend, then we're certainly open to
talk about those. One option on there is to make no change, it often is, just in case
the status quo ends up being the preferable course, but with that, I guess I'll kind of
look to Jessica and then to all of you to provide advice on this particular potential
change to the rules.
09:42: My apologies for sending this in so late to the game, my notes
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as we probably know, we have to go through a few people and get the Board to
approve it and everything, so that's why it was (unintelligible) for awhile, but we
definitely support paying interpreters for cancellations, most of the notes that I had
on here had to do with some of the options that were brought up as far as providers
have been getting cancellations in (unintelligible) it makes sense to have something
in there that if they themselves cancel it, they don't get paid for it, but I feel like for
interpreters that maybe (unintelligible) or through already (unintelligible) contracted,
if the provider cancels or reschedules within that cancellation period, I--our position
is that the interpreter should be paid for that cancellation as opposed to excluding it
like it sounds like it's written at the moment, so that was our point of first things, I
cannot (unintelligible) reading that incorrectly.
10:41: No, you're correct, it's the way it's written is really when the
patient doesn't show up--
10:50: No-shows--
10:50: --it's not when the provider cancels. Now, if the provider
cancels, you know, then one question would be, well, who is going to pay--
11:04: Right.
11:04: --for the interpreter--
11:06: Right.
11:06: --so do you have any thoughts on that?
11:10: I do know that, I mean, as an independent interpreter myself, if
I show up I put aside that time for my day and it's not an opt--you know, it's not
optional anymore if it's outside the cancellation time, so I'm not entirely sure who
pays, I know sometimes I know if it would be up to the clinic or if it'd be up to the
insurance that would be covering that person to include that, I know of some third-
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party agencies that subcontract interpreters who end up floating the cost because
they can't get an interpreter to go without the cancellation policy, which is not
necessarily great for them either, so I'm not entirely sure, but it would seem like it
would be something that could be covered under the insurance for--but again it's not,
it shouldn't seem to fall on the interpreter's pocketbook (unintelligible) make an effort
to show up on time only to have a provider decide that they double-booked
themselves, for example.
12:09: Does that happen with some frequency, Jessica?
12:11: I've heard, I don't do a whole lot myself, I will say, from where
I'm the vice president the (unintelligible) have talked with interpreters who do a lot
more of this work and that does sometimes happen and I've talked with interpreters
who have their own agencies but contract that out and they've said that that
happens, so enough that people were (unintelligible)
12:33: I guess maybe we can kind of discuss these one--the overall
concept of kind of including under the umbrella of this particular change interpreters
as well as we have for healthcare providers, maybe we could talk about that or you
could provide feedback on that concept. Any concerns, I guess.
13:00: All right. So that--like I said, that's our position. Other things in
there would be like that mileage also be included if he didn't actually show up, this is
especially important when you do have subcontracted interpreters, they don't always
know that they're showing up to a Workers' Comp appointment, and so they're not
necessarily going to know like, oh, I can't bill for mileage for this, I can't, but it's just
their policy is to pay mileage, so again someone's floating that, but I don't feel like it
should fall on the interpreter who did come on time and was canceled at no fault of
their own (unintelligible) pay.
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13:36: Juerg, do you know if the way the rule was drafted that mileage
might be, if it was part of the written policy, would mileage be covered?
13:44: I think it's really depends on what the policy, the interpreter's
policy says that the patient signs, so I think if that includes the mileage--
13:58: Okay.
13:58: --then I would say the rules would allow that--
14:03: Okay.
14:03: --the way it's--well, it's kind of pre-proposed rate--
14:08: Right, and that was something that I kind, I was reading that
the policy but it was something that I think some agencies, third-party agencies
aren't paying interpreter miles, interpreters mileage, so this is something they might
have to go back to the interpreters to bring up to the agencies if the agencies are
getting mileage and not (unintelligible) to them, so one thing that's in--that was a
common theme and it goes with like what comes on the second point of the second
page where it talks about quality, quality assurance or some type of system for I
totally understand like making a contract, that's something that we'd have to do with
all of our clients to make a contract and try to get them, but I'm wondering, because
many interpreters do this and we're not big agencies that have lots of money to
litigate things, if there is a clinic or some type of client that's not honoring the system,
I'm wondering if there's some type of free or non-legislatives or pre-judicial option
available to talk to Workers' Comp Division or call out that this is not getting, a
grievance procedure of some time--type to not--I realize you don't want to mediate
every single thing that comes up, but before we start filing paperwork for
nonpayment, I wonder if there's a way for the Workers' Comp Division to get
involved.
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15:42: (unintelligible) the case. (unintelligible) I do (unintelligible)
15:48: I think (unintelligible)
15:50: Small claims court--
15:52: Just go straight to comp--small claims--
15:53: Yeah.
15:53: --and there's no--
15:55: And they might have some mediation services there.
15:57: Okay, but workers, Workers' Comp Division doesn't have any--
16:01: I mean--
16:01: --research--
16:02: --(unintelligible) the rule for the physicians is structured, it's not
a matter that the Division would get involved in--
16:13: Okay.
16:13: --as I understand that, so--
16:16: So it's the same policy for physicians that if they're not paying,
they have to go straight to small claims, there's no...
16:21: They, yeah (unintelligible) turn it in for collection (unintelligible)
decide to (unintelligible)
16:34: Okay. So that was--so that kind of tied into the second one.
The last point was more to reiterate that the definition of a medical interpreter did not
include family and friends and then we talked about this at length two years ago
when we went--we were here, and the definition includes that, but with the rule as it
is written or it seems like in the draft, it still brings up family and friends and ad hoc
and clinic and not qualified clinic staff, which isn't even considered under the
definition of an interpreter to be interpreter, and I suppose just wanted to re--I
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wanted to reiterate that it is very, very important for quality control that qualified,
depending on the language, certified or qualified interpreters are used at every step
of this situation and that it's greatly discouraged using non-qualified clinic staff and
family members both from the liability standpoint and from the (unintelligible) policy
and that that needed to be clarified in every section that for that family members are
brought up that they are not actually considered interpreters. Yeah.
17:59: There was a rule change made, I don't know if it was last time,
last year maybe, in the last couple of years, anyway, that requires that if an
insurance company chooses an interpreter, selects one, it has to be from one of the
lists of qualified or certified interpreters, as I understand it. So that was one change,
but, yes indeed, the rules still allow the patient to maybe bring in a brother or a
parent or something like that to do the interpreting for them.
18:27: Right.
18:28: And we understand that is a concern that has been expressed.
18:31: I suppose the main thing is that when point two on the back
part talking about (unintelligible) quality control--quality control system, some
(unintelligible) referred in, I mean, myself when I've gone to independent medical
exams have seen some things that are clearly mistranslations that happened at the
very beginning of a whole series of appointments where, you know, something was
misinterpreted from the very beginning, it makes its way into that paperwork, it goes
into the next paperwork, and eventually you're talking about like a big settlement
perhaps for the person when in the very beginning of the process they used a family
or a friend or somebody who they didn't know interpreting policies, guidelines, or
ethics and maybe didn't know the difference, but introduced this error and now
they're having to unravel it throughout the whole process, so I just--I understand that
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they can bring someone that they feel comfortable with, but sometimes people don't
know that they don't have to pay for that, that they don't know that the person is
(unintelligible) going to treat them confidentially, and so they think that bringing a
family member's better, so I just really want to stress that that's a bad idea from the
long--the long (unintelligible) concern of it. And it was asked that maybe in future
rule or rulemaking sessions that that the Workers' Comp Division think about
implementing a quality control system or some type of survey to patients about how
their interpreting experiences have been going, anecdotally some of our interpreters
have come into clinics with interpreters just waiting in the clinics and they're not
necessarily certified or qualified, they're just waiting to fill whomever comes in and
get the claim number and see if they can do it that way, which seems shaky
ethically, and also, you know, people giving them their, you know, calling them at
home or giving them rides or things that is--that when they're not insured to do that
and things like that, so I feel like there's some bad practices going on and it would be
good to find a--have a quality control system work that out.
20:44: Okay. Thank you for that advice.
20:47: I think it's good for us to be aware, too, I'm glad you're saying
that because I've seen that in Washington (unintelligible) I had not seen it in Oregon,
so that's good to know.
20:55: That (unintelligible)--
20:57: Yeah, because that can be really problematic--
21:00: Yeah.
21:00: --create a lot of issues.
21:03: A lot of--
21:04: Dee--
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21:04: --a lot of the major health systems have a language help line
which and they just subscribe to the service and so they're not billed per call and so
if they have that and we know that they have that, oftentimes we won't request one,
so if--and the language help lines have gone through all kind of certifications and
they're insured for liability and all that kind of stuff, but I know that every major health
system I've ever worked for used the language help lines and it's just a simple
number they file and they have the paperwork (unintelligible) call in.
21:36: For sure. That's definitely preferable (unintelligible) the
(unintelligible)
21:50: The last point that was on here, I'm not entirely sure this falls
under Workers' Comp Division or Workers' Comp Board, but one interpreter that I
talked to said that she's noticed that interpreter fees have been coming out of
settlements for cases, which seems like it's on legally shaky ground from Title VI
saying that patients have access to language services at no cost to themselves.
There was more something to put out there that I'd heard from our interpreters that
this was happening and I don't know what else to do with it other than (unintelligible)
22:26: It's a Board issue.
22:27: Board issue?
22:41: Would now be a good time then to just open all this up for
general discussion any--
22:45: Absolutely.
22:45: --any and all of Jessica's points and the broader concept of
including interpreters in the right to bill if someone is a no-show.
23:00: Well, I think the only comment or question I had is on the issue
with if the doctor cancels the or the medical provider cancels the appointment--
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23:09: Right.
23:09: --who pays? I'm not--I'm not that super comfortable with the
self-insured employer or the Workers' Comp carrier paying for that, if it's the doctor
that's making the change, not the injured worker not showing up or I don't know
about--I don't know how I feel about that.
23:29: Yeah, I don't think we would let (unintelligible)--
23:32: Jaye Fraser, SAIF Corporation--
23:34: I know (unintelligible)
23:36: And Juerg, maybe you can clarify, I think that I thought that the
point of the rule was when the provider has a--and the interpreter has a policy that
the worker signs--
23:51: Right.
23:51: --that then we would allow a direct billing to the worker and they
would be responsible for that fee. Is that right?
24:00: Correct.
24:00: Correct.
24:01: Correct, but that's, for--
24:02: Just for the--for the record, SAIF doesn't have any objection to
that--
24:04: Yeah. And that's, again that's for when the worker--
24:10: Right.
24:10: --misses the appointment, it does not address when the doctor
cancels--
24:17: Yeah, that's--
24:17: --you know, considering that the practice of medicine, it almost
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is occupational hazard that there may be an emergency that the doctor has to go to
and has to cancel appointments, you know, at the very last minute, and so I'm not
sure, you know, what a good solution is, I certainly can understand insurers
employers not wanting to pay for that, I certainly can understand providers not
wanting to pay for that because all they do is basically try to help another patient, but
I also understand your frustration--
25:07: Yeah.
25:07: --so I'm not sure--
25:09: And I can understand why a worker would not pay for that, too--
25:12: Correct--
25:12: Yeah--
25:13: Yeah--
25:14: Like I said, Title VI would make it so a worker shouldn't pay for
it, but I feel like I might--if it's part of doing business as a clinic or as a provider, it
might be rolled into your cost of doing business as a clinic or provider that
sometimes you're going to have to pay a cancellation for your normal course of
business of rescheduling.
25:30? So I guess I have a question and that is are there fees that
are--that are approved by the Department for translation, is there a limit to the fees,
or do they get to set their own fees?
25:44: No, we have for--
25:45: So, I mean, suppose maybe one of the things I--to me it's a
cost of business for you that you should build in, but if there's a fee that's scheduled
there, I guess that you kind of have to address that, but it seems like to me if I knew I
had five cancellations in a year, I'd build that into my costs so I've got my costs
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covered and it's--it comes out kind of out of everybody or whoever it is that you're
billing, but it kind of gets covered that way, so I don't know if that's, you know, is
there a range on that fees that they can charge or is it just set fees?
26:20: We have a maximum fee--
26:22: There's a max--
26:23: --and so--
26:23: So--
26:23: --so it depends on if the interpreter bills less than the maximum
fee, then the interpreter would only get paid what they bill, but if it's more, they only
get billed the fee schedule amount.
26:38: So somebody's under that, they could certainly build in the
costs in that way, I think it's going to be really difficult, the provider's not going to do
it, they're not going to want to do it, we need to encourage providers in every way
that we can and not discourage them, the employee's not going to want to take it
because they certainly had no control over the provider's cancellation and the
employer's going to feel the same way that they didn't have any control over the
provider having something come up, so I get you guys are kind of on the short of it,
seems like the way to address it perhaps would be in your fees to go in some
overhead costs that are going to account for that.
27:15: I mean, yeah, I mean, I see it on the other side only from we're
contractors, so the fee that's in there is a contracted fee, so knock out 30 percent
per, knock out their mileage, knock out of all of that, we have probably, you know,
there's, I don't know if there's a minimum, but we take maybe several, maybe two to
three appointments a day, but if the provider cancels something, they have another
file that they can pick up and bill, right, like they have another patient they can see
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and bill for that time. If I get canceled, I don't get to bill for that time, I've turned
down jobs to take that time, so I don't get to recoup that cost other than just lose it, I
feel like a provider can pick up another file and make up that cost again and I don't
necessarily get to do that, so that's why I'm more likely to say that a provider should
build it in because it's not my fault that they had an emergency or whatever and you
know that that's going to happen, it's highly unlikely that--I mean, for sure definitely
there are patients that no-show, but at least I have the comfort of going like, okay,
well, if they don't show, at least I've been paid for my time because I was here. I
don't get to, though, go out and put a sign out on the street and say interpreter for
hire, you know, so if that is--that's my feeling about it.
28:3: Well, what percentage of the services are contracted through
agencies?
28:38: I think a high percentage, I don't have the number to, you guys
know by chance, I would have to look (unintelligible)--
28:45: (unintelligible) the agency needs to build it into their cost and let
the contract between the interpreter and the agency requires the payment for a
provider canceled appointment.
28:59: That's true and some do that, I think my goal or at least the
(unintelligible) goal is to have more independent interpreters be able to take on
these jobs themselves and to be able to navigate the system, not have to go through
third-party agencies because of course their agency takes a cut, a lot of times it's a
very large cut, so it--to me it feels like it should be uniform, but I don't I--my goal is
not to have so many agencies doing it.
29:38: Additional thoughts?
29:46: Just for clarification, isn't there a--there's a difference between
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a patient no-showing and a provider canceling the patient, and it sounds to me like
you're talking about the provider willfully canceling a patient and it affects your
income, and I represent providers and if our providers did that to you, I actually think
that we should bear some liability for it, but from the other side of things, if I'm a
provider, we've got one population in the state that has a 19-percent no-show
cancellation rate--
30:24: Sure, and I think this--
30:25: --so what--
30:26: --is talking like if the patient no-shows--
30:29: Yeah, but it seems like the law has to take into account the
cause, whether it's the provider choosing to cancel the patient or the patient being a
no-show or a cancellation of their own volition, to me there's almost has to be a
distinguishing factor there; otherwise, you're not getting the equity that you're looking
for out of the relationship.
30:53: The provider cancellations, is that a big problem, I mean?
30:59: Is--I'm not sure what the--
31:00: Okay, okay.
31:00: --percentage would be, I just know that that was called out in
the--in the rule as an exception for getting paid, so I would hope that it doesn't
happen all that often, but it sounds like it does.
31:11: Well, and I think, Jessica, it would be helpful for the Division if
it's thinking about this if, and I think that (unintelligible) has kind of a good point, I'm
kind of thinking about day-to-day to data, if we knew how often, the Division knew
how often this does happen, I mean, is it 50 percent of the time that you are headed
off to a provider, the provider, or is it like once a month? I mean, it's, you know,
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knowing that the gravity I think would be helpful in crafting a solution.
31:48: Sure. I might look to the Workers' Comp Division. Do you guys
keep track of things like that?
31:55: No, no--
31:55: --because that would seem like, I mean, like how do we figure,
how would I even go about figuring that out other than polling interpreters but at the
same time (unintelligible) I don't know (unintelligible) hard numbers.
32:06: (unintelligible) have now.
32:07: Yeah, other than, like I said, I wouldn't have even brought it up
if it wasn't mentioned in the rule--
32:13: Right.
32:13: --so that's a...
32:17: We keep track of that.
32:18: Yeah?
32:18: I didn't know that we'd be talking about this so I didn't bring any
numbers, but we might be able to pull up some numbers about how often a provider
cancels--
32:26: Okay.
32:26: --in the clinics that we are--that we're in.
32:31: We've done the same, again for a different population, and we
worked with payers to account for that in the rates that they population might have
as much as almost 20-percent no-show cancellation rate.
32:48: Yeah, I'm not really hearing any disagreement about the worker
no-show--
32:53: Right.
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32:53: --it's just the provider cancellation piece.
32:55: Oh, we would track the provider cancel, too, in physical therapy
I suspect it's pretty low, wouldn't you agree, Rich, very low.
33:04: We sell our time and we don't get to make it up either, so we're
going to do everything we can do accommodate a patient even if there were a
double-booking or something like that, my experience as Tom's probably is is that
we'll figure it out, we'll--we don't want you to have to be inconvenienced and lose the
continuity of the care being provided or something like that. I just think that you have
to distinguish between the two types of missed appointment, that's all.
33:34: Right.
33:35: So do you want some at least physical therapy numbers, I can
get some for you.
33:39: Yeah (unintelligible)
33:40: Okay.
33:40: Thank you.
33:41: But I think your best bet for providers canceling is going to be
going back to your interpreters and asking them how many times in the last six
months have you had a provider cancel appointment with 24 or 48 hours--
33:54: Okay.
33:55: --or whatever your cancellation window is.
33:59: And then anything you can share with us, we would appreciate,
it will certainly help.
34:05: And it's also important to recognize if you're going to do that,
though, that the provider might be telling the interpreter that we're canceling because
the patient already canceled--
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34:14: That's true--
34:15: Yeah, that's principally why (unintelligible)--
34:15 --then you're getting--then you're getting, you know, something
that's just third-party assessment on that, so the interpreter is going to say, well, the
provider canceled but there's (unintelligible) have a patient.
34:29: (unintelligible) pertinent--
34:29: That's the--that's the other thing, that's always the risk of data,
what is it really telling you?
34:35: Yep.
34:36: So I agree, I didn't hear much disagreement with the concept of
the--on changing the policy for no-shows, for worker no-shows, unless there is
some, I mean, speak now. And also if you're here on the telephone with us, I would
encourage you to fully participate, speak up at anytime, you don't have the
advantage of seeing who might have a hand up here or that kind of thing, and while I
think of it, if you're on the telephone with us and I don't have your contact
information, if you wouldn't mind, you know, getting in touch with me after the
meeting so that I can get you on our contact list, you'll get the proposed rules when
we have those, for instance, and I'm Fred dot--it'll be Fred.H, as in Harry, dot
Bruyns, B-R-U-Y-N-S, at oregon.gov, and that would really help keep you in the
loop. With that, that was good discussion. Is there--is there any other thoughts on
payment to interpreters related to no-shows?
35:48: Thank you for having this--
35:48: Okay. Thank you very much, Jessica. I guess with that,
anybody else have an issue that we need to look at out of order? And with that, we'll
begin at the beginning at issue number one, which is a standing issue we've had for
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several years now, it affects Rule 4 and the appendices, which are fee Schedules B
through E. And it has to do with a temporary rule that we would issue effective
January 1 of 2020. The AMA and CMS publish new CPT and HCPCS codes
effective January 1, 2020. However, the Workers' Compensation Division does not
publish its permanent fee schedule updates until April 1. This prohibits providers
from using the latest set of codes for Workers' Compensation billings and forces
insurers to return bills as unpayable if providers use new codes between January 1
and April 1.
Some background. In order to allow time for public input, WCD
publishes a new fee--physician fee schedule and ASC fee schedules and also the
DMEPOS, demeepose (phonetic), fee schedule effective April 1 of each year,
adopting new CPT and HCPCS codes, which simplify billing for providers and
wouldn't force insurers to return bills as unpayable due to invalid new codes. For
those new codes that CMS publishes relative value units or payment amounts, WCD
would update Appendices B through E effective January 1 and assign maximum
payment amounts using the 2019 conversion factors, which are multipliers. One
should bear in mind that due to time and staffing restraints, it may not be possible to
update all the appendices. It will also depend upon when CMS publishes all the
informations.
WCD being initially--began issuing temporary rules in January of 2016
to allow providers to bill insurers using new codes from January 1 through March 31
of each year. As in years past, the temporary rules would not delete any codes from
any appendix and providers may continue to use valid codes in 2019.
So options would be to adopt new CPT codes for a temporary rule
effective January 1, 2020, update Appendices B through E with payment amounts
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for new codes using the 2019 conversion factors, multipliers where possible. Those
are really kind of one and the same, it'd be two components of the same concept.
And then not issue a temporary rule would be an option, which would be what we did
before January 1 of 2016, kind of going back to that. So I appreciate your thoughts
on both the wisdom of doing that and maybe any repercussions of the fact that it has
been done for several years now and feedback on how well that has worked, if it has
worked well.
38:44: This is Jaye Fraser again from SAIF Corporation. We
absolutely appreciate the Department, the Divisions doing this, adopting the
temporary rules, it makes it much simpler in processing bills and it's a good thing.
39:01: Lisa Ann?
39:03: Lisa Ann Bitberg (phonetic) of Coventry, I concur with my
colleague, it's much easier on the bill review side if it's current, it's just creates a little
bit of a headache and (unintelligible) so it just makes it easier (unintelligible)
39:16: Any downside to doing it all that? Okay. With that, we will
move right along to issue number two. This is also a standing issue that we have
each year. And again it affects Rule 4 and Appendices B through E. So
ORS 656.248(7) requires that WCD update the fee schedules annually. The
references listed in Rule 4, Sections (1) through (9) in the fee schedules published in
Appendices B through E will be outdated when the permanent rules become
effective on April 1. The above listed appendices are based on conversion factors
and multipliers developed by DCBS and on values and fee schedule amounts listed
in separate spreadsheets published by the Centers for Medicare and Medicaid
Services, or CMS. And then it goes on to actually specifically describe where each
of those fee schedules comes from, CMS publishes them, and basically we do rely
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on those for updating the fee schedules annually. And then I'm going to skip down
to the last two bullets.
Every year there are some CPT and HCPCS codes that are deleted
and some new codes are introduced. Adopting new billing codes and updating
Appendices B through E allows us to stay current with valid CPT and HCPCS codes,
and then every year DCBS develops updated conversion factors and multipliers,
taking into account stakeholder input, utilization of medical services, and the new
values and fee schedule amounts developed by CMS.
So an option would be to adopt update references listed in Rule 4 and
update Appendices B through E using more current CMS spreadsheets and updated
WCD conversion factors, and again I say this is a standing issue, we have always
updated those resources based upon changes that CMS makes, although
occasionally CMS will do something that we're not anticipating, it's something that's
unexpected, we've been warned about it on occasion or told about it by a committee
much like this one, so this would be an opportunity to let us know if there's anything
strange and different coming our way or if there are just anything that, you know, any
maybe unforeseen consequences in adopting those updates, so appreciate your
feedback on adopting the updates. Any concerns?
With that, I have a note here to refer to an issue submitted by Dr. Miller
and Dr. Miller sent us a letter, there are copies over on the side table, also posted to
our website, where it just refers to there are several pieces of advice that are posted
there, and with that I'll kind of turn it over to Dr. Miller to kind of go through your
recommendation and we're here to listen.
42:25: Thank you, Fred. So the first thing that I'd like to do is
apologize, on my letter I listened to our lobbyist advice on (unintelligible) throw him
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under the bus, but this is not a violation of that particular OAR that's or ORS that's
relating to the discrimination, that's typically a private insurer issue that our
association was also (unintelligible) other entities on, but the important aspect that I
want to bring up is the fact that even though, you know, Workers' Comp has
(unintelligible) built-in anti-discrimination pattern by having a fee schedule set
amongst provider types that this code is reimbursed at this rate regardless of who
you are, it's important to note my first section there that there is an osteopathic
manipulation code and there's a chiropractic manipulation code, and if you look at
the CPT code definitions there, they are identical verbatim, so the fact that there's
two separate codes for the exact same service but one of them's being reimbursed
at a 10 percent higher than the other is another major reason (unintelligible)
chiropractic fees deserve another increase, we haven't really had one, other than the
cost-of-living increase four years ago, we haven't really had one prior to that other
than what got us back to where we were from 2000 (unintelligible) I addressed fiscal
impact Workers' Compensation (unintelligible) chiropractic cases (unintelligible), so
(unintelligible) interest (unintelligible) so (unintelligible) case, cost per case is going
to be relatively minimal.
44:11: Thank you, Dr. Miller.
44:15: As far as the fiscal impact, I also looked into for the whole
system what that--what a 10-percent increase would create for the Work Comp
system as a whole, and we estimate that increase would create an increase in
payments of $350,000 and--
44:45: Is that based upon chiropractic payments in general?
44:48: Yeah, in Work Comp--
44:50: Right, so--
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44:50: --all the payments and--
44:51: One of the things you have to consider--
44:51: --and the thing that we need to consider is the total Work Comp
medical payments are 300 million, so--
44:03: Right.
44:04: --so that kind of shows that it's not--it wouldn't be a huge--
44:10: Correct, but--
44:10: --impact to--
44:10: --the other thing to recognize is that in the overall
reimbursement to chiropractic, chiropractic has their own physical therapy unit
usually, so this wouldn't fall into any expense additional on that because it's not part
of the physical therapy codes, we typically will (unintelligible) radiology, we definitely
do our own E&M's, and so, you know, physiotherapies, all of those things would not
fall in this increase that is being reflected as an overall (unintelligible)--
45:42: No, this is just to chiro codes--
45:44: Oh, specifically (unintelligible) oh--
45:45: --(unintelligible) yes, just to chiro codes.
45:48: I'm sorry I dragged in that last thing.
45:53: Discussion?
45:58: I'm just confused. Are we on number two?
46:04: We're actually in between number two and number three, it
was--
46:06: Okay, that's what I'm saying--
46:07: Okay.
46:07: --I'm confused as--
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46:08: Okay.
46:08: --as to where we're at in here--
46:10: Because it had to do with updating the fee schedule, so it's a
good--it's a good place for it.
46:14: Okay, so this is just it's a separate issue that--
46:15: It is, it is--
46:15: --we're talking about is, okay, thank you, I just was trying to
mention up that--
46:19: I apologize for that, I should have--
46:20: No, it's okay, yeah--
46:21: --I should have said we're not really on number three yet, so...
46:23: Okay.
46:27: What would you propose to in the RBRBS formula, would you
say that chiropractors would have to have a different conversion factor if the whole, if
the whole fee schedule is based on CMS RBU's--
46:40: Right.
46:40: --there has to be--
46:42: So--
46:42: --you can't have a common conversion factor, you'd have to
either change it or just supplant it with hard codes.
46:48: So years ago we supplanted it with hard codes because what
was happening with CMS is is they were taking physical medicine as a group from
the CPT book and they were trying to make sure that the end result was a net zero,
but they had increased some and decreased others, and at one point they
decreased chiropractic codes by 12 percent on one year to the point where, you
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know, not recognizing that those three codes really affected an entire profession,
thinking that, well, physical medicine didn't really have much negative impact and so
they thought that, you know, it would be a wash, but it really obviously affected an
entire profession because they rely upon those three codes.
47:31: I understand, but what are you suggesting that we do with the
formula, would you hard code those fees in or would you give chiropractic a different
conversion factor?
47:41: We're already--
47:41: They're currently do--
47:43: They have?
47:43: --hard-coded, so--
47:44: They're hard coded, okay--
47:45: Yeah, which is--
47:46: So they've already done that part just to try to prevent--
47:48: Gotcha.
47:48: --the negative effect of, you know, just a few codes being
washed underneath.
47:54: Yeah, they were carved out, I gotcha.
48:02: So are--is the request then not to use the CPT codes set forth
by CMS?
48:09: No, the request is just to increase our--
48:11: Fee schedule.
48:11: --fee schedule to be more compliant with what the osteopathic
manipulation codes are.
48:22: And is it just these three codes or the E&M codes as well--
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48:25: No, our E&M codes are the same as--
48:26: Oh, okay--
48:26: --everybody's E&M codes, so it's just... But we don't get to
have E&M codes because you're not familiar with this, chiropractor can only use an
E&M code on an initial visit or reevaluation visit, it's vetted in these codes so we
can't, we can't, you know, say what a five-percent increase in our E&M codes and I
get to use that on a daily basis, you know--
48:53: Okay.
48:55: You know, this issue wasn't something I thought we would,
knew that we were talking about, so it makes it we can't go back and look at our data
to sort of see (unintelligible) and I will confess and kind of hard care to coded--I'm
hard coded to say no increases, but I recognize that that's not always the right
answer, so, you know, without looking to see what our payment data looks like, it's
kind of hard to provide any (unintelligible) testimony the Department at this point.
49:32: One thing we do have to keep in mind when we make a direct
comparison to the osteopathic codes, so, for example, if the chiro and the osteopath
they both adjust the cervical and thoracic spine and the shoulder, the osteopath is
going to use their 98926 code, which is for three to four body regions involved, and
the chiro is going to use the 98940, which is one to two spinal regions, but then also
the 98943, which is the extraspinal region, so in that case the chiro actually would
get paid more than the osteopath, so--
50:32: So the 98926 on the osteopath includes?
50:37: Three to four body regions, and so the osteopathic codes don't
make a--don't differentiate between spinal areas or--
50:46: Gotcha, gotcha.
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50:46: --vertebrae or nonspinal areas, so we just have to be careful
we--I don't think we can directly--
50:56: Yeah, if I can--
50:56: --pay bills to--
51:01: Yeah, yeah, and so that's another error on this, the 98943 there
marked down there should be a 98942, so the 943, which is the extremity codes, I
didn't mark (unintelligible) I don't know any chiropractors that use though, I'm sure
they do.
51:26: Additional input? And I realize you haven't had a long time to
see the information, I sent--I sent word out, I guess, a--I don't know it was early in
the month, but it was--it was relatively recently letting you know that Dr. Miller's
advice was there, we also had advice from Dolores Russell (phonetic) that was
posted on our website regarding one of the issues, but, you know, that--you know,
you had a, I don't know, maybe week and a half hardly, so I know that's not a long
time to--
51:58: Another thing to consider is last year we did increase the fee
schedule for the E&M visits, which is for a lot of MD's and MDO's the bread and
butter, it's really that's when the patient comes in, they charge an office visit, and we
gave increased that last year by five percent. The manipulation code are the bread
and butter of the chiropractic physician and the chiropractic physician really did not
benefit much at all from the E&M increase that we did last year, and so that's
another thing to potentially consider is that (unintelligible) gave the MD's a raise,
MD's and DO's a raise of five percent last year for the routine visit, but we didn't do
that for the chiros, so that's just something to consider also.
53:01: And we almost always, unless we're under really tight
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timeframe requirements, which we're not for these--this rulemaking, we almost
always allow some time for additional written advice or phone calls, you know, within
a week or two after meetings like this, and so if there's more information you'd like to
provide, input you'd like to, you know, data or advice, we certainly are open to it.
The fee schedule is really is like it's a standing issue and the amount that providers
are paid in a general sense is always open for discussion every year, and it--and it
should be, so we appreciate Dr. Miller's input and we appreciate hearing from you,
but here you're welcome to provide feedback, additional feedback now, or you're
also welcome to provide written or telephone advice.
54:02: Fred.
54:03: Yes--
54:03: Is it pah--it sounds like that there's apples and oranges to some
degree, the codes are, so is there some way for the Department to do the--a little bit
of research to figure out are they--so if one got an increase and one has not, but if
they're able to use multiple codes to get to the same thing and it's a higher amount,
what's is--are we at a wash, are we not at a wash? I guess to me I'd be interested to
see what the--if they have multiple opportunities to different codes that equal the
osteopathic codes, then we should be looking at those as opposed to like straight-
line comparisons, so why would--before I think we could give feedback, you'd want
to know, it seems to me, what those are and how does that really work? Because I
don't--at this point if we said, "Yeah, we support an increase," we're really kind of
doing that in the dark, I don't unders--
55:04: So as far as the direct comparison, we can't really look at the
bills. While we can look at the bills from a chiropractor and know pretty much
exactly what the chiropractor did, with the osteopaths we don't, we don't know if they
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did just the spine or if they did extremity adjustments, and if it's just a spine that the
osteopath adjusted, manipulated, then Dr. Miller's comparison is absolutely correct
that the osteopath is going to get paid more than the chiropractor is, but there's no
way for us to know when we look at the--at the billing and payment data that's
reported to us whether the osteopath manipulated just the spine or not the spine and
how that invoice compared to the chiro. But what we do know again is that the E&M
visit is it's increased five percent in the last year and the chiropractor manipulation
codes did not. And another interesting thing is that the statute specifically allows an
osteopathic physician to charge an E&M visit in addition to the manipulation codes,
whereas the chiropractor is basically not allowed to charge an E&M code with the
regular manipulation code unless, like Dr. Miller said, it's the initial exam or a
reevaluation visit.
56:49: I can also say that most of the time under Workers' Comp we
would have a tough time getting paid for us for both codes, if we did a spinal and an
extremity, because they'll say, well, that was part of the accepted diagnosis even if
we look, you know, five or six diagnosis, they'll, you know, really like to address the
initial one, so I do have one question, though. It used to be and it may still be that if
you had multiple, you know, therapy codes, the second one or the third one would
get reimbursed at a different rate under Workers' Comp, like it'd be if you did an
ultrasound and a massage, that'd be different, you know, listed medicine code, is
that? So that was maybe back in the '90s, I'm dating myself a few years.
57:40: Well, that (unintelligible) should get paid the full amount.
57:46: I remember that was a long time ago.
57:49: Yeah.
57:50: I mean, I just don't deal with that.
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57:53: Isn't there something about multiple imaging studies--
57:54: No--
57:54: --that that's a different matter, though, right--
57:58: Yeah, it was a therapy code--
57:59: Yeah, that the therapy should pay (unintelligible)
58:04: Keep in mind about the limit for how many therapy codes you
could do in a visit.
58:08: Yeah, it's--
58:08: Yeah.
58:09: --three.
58:09: Yeah.
58:10: Three, right, three, three (unintelligible) codes. And not units,
but--
58:18: Correct.
58:18: --actually three codes.
58:22: Okay. Last thoughts about this one and keeping in mind we're
open to additional information that you could provide. Okay, thank you very much,
Dr. Miller. And we're on to issue number three.
Telemedicine services are not prohibited under the Oregon Workers'
Compensation rules. However, the rules do not include a definition of telemedicine
or specific standards for billing and payment of telemedicine services. Some
background. Telemedicine services include two sites, the originating site where the
patient is located and the distant site where the practitioner providing the service is
located. There are two broad types of telehealth. One is telemedicine service
rendered by a realtime interactive audio and video telecommunication system; that is
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synchronous. The other is store and forward, where the distant site practitioner
reviews the transmission at a later date, and that is asynchronous. The Workers'
Compensation Division had multiple discussions with stakeholders regarding
telemedicine. Although many stakeholders opined that regulations around
telemedicine should be kept to a medicine--a minimum, the majority agreed that it
would be beneficial to adopt billing and payment standards by rule. WCD has
adopted the AMA's CPT code book; hence, under the current WCD rules, providers
may bill for telemedicine with CPT codes that are listed in Appendix P of the CPT.
When the distant site provider bills for synchronous telemedicine services, the place
of service should be coded 02. Generally, distant site providers should add modifier
95 to the CPT codes used to bill for telemedicine services.
WCD's billing and payment data show that most distant site
telemedicine services are paid at the non-facility rate. The same holds true for most
healthcare--excuse me, most healthcare insurers and other state's Workers'
Compensation systems. However, our current rules do not specify whether the
services of the distant site provider should be paid at the facility or the non-facility
rate. Generally an originated site, such as the doctor's office or hospital, may bill a
facility charge using HCPCS Code Q3--3014. Under the current fee schedule, this
code does not have a maximum payment amount, so payment is 80 percent of the
billed amount. Although there is a code for telehealth transmission, which is HCPCS
Code T1014, it appears that the vast majority of health plans, including Medicare, do
not allow payment for HCPCS Code T1014. Under current rules, since it is a valid
code, insurers could be required to pay any charges billed with Code T1014 at
80 percent of bill.
So some options would be to define telemedicine services as
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synchronous, telemedicine service rendered by a realtime interactive audio and
video telecommunications system. So at this point I'm going to actually stop and ask
for a discussion on each of the bullet points rather than just read them to you and
having to go back, so define ,in terms of a proposed definition, define telemedicine
services as synchronous telemedicine service rendered by a realtime interactive
audio and video telecommunications system, and I believe this comes right out of
the CPT book, doesn't it? Isn't that the definition?
1:01:55: I think so.
1:01:55: Okay. Lisa Ann?
1:01:56: Just a quick question, so are--so what's--I guess I'm--what I'm
wondering is what about like store and forward and all those kind of things, which
would not be synchronous, it's asynchronous, so what are we saying that right now
for today we're just going to focus on this type only and not address the other or
what are we saying?
1:02:19: Well--
1:02:20: I'm just thrown off because there are other--I mean, it's widely
used in other contexts as well, that's what I'm confused--
1:02:26: Well, that's what we're here to discuss--
1:02:28: That's what, yeah--
1:02:29: Yeah.
1:02:29: Maybe there's a part B with this, too, I don't know. I'm not
saying this is bad, but I'm only saying this is half the picture, so--
1:02:36: Okay.
1:02:40: So like if you had imaging studies that--
1:02:44: Right, that's what I'm going to use (unintelligible)--
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1:02:46: Okay, that are on a disk and--
1:02:47: Yep.
1:02:47: --and then the provider reads it--
1:02:52: Yep.
1:02:52: --reads the report, I don't think providers, you know, use the
place of service code 02 on that and I doubt that--
1:03:06: Probably--
1:03:06: --they use modify and 91, they just use the regular HCPCS
code and insurers pay the regular fee schedule and it's just being done--
1:03:19: So Dee Heinz, SAIF Corporation, I used to (unintelligible) for
a health system here in the valley and I had never heard of enter--in the context of
telemedicine, I've never heard of a prerecorded visit that you look at later, but we've
had--I know that it's we've done telephonic and it's not video, but especially in the
context of mental health, it's not uncommon to have a telephonic telehealth visit and
then the live, I've never heard of it prerecorded, so if you do, for example, an
ultrasound and you transmit that ultrasound realtime to a radiologist, the radiologist
is charged a radiology fee, you don't charge a telemedicine fee, and in terms of the
of it pre-recorded, so if you do, for example, an ultrasound and you transmit that
ultrasound realtime to a radiologist, the radiologist is charged a radiology fee, you
don't charge a telemedicine fee, and in terms of the HCPCS code, you cannot
following (unintelligible) stop me because I (unintelligible) kind of talk fast assume
everybody knows these things, in terms of a HCPCS code, that's a code that a key
code facility charges when there's no provider present, so if you go to Salem
Hospital and you go have an outpatient X-ray done, they charge HCPCS code, right,
and then the radiologist charges their radiology fee, so this would be charging an
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office visit, which is a CPT code, and a HCPCS code when there's a provider
involved, so you can't stack HCPCS and CPT codes that I'm aware of. Does that
make sense?
1:04:42: Okay, I'm not sure what we're talking about. So if you're
referring to the--to the facility fee HCPCS code--
1:04:50: HCPCS, uh-huh.
1:04:51: Okay, that's the originating place--
1:04:54: Right, right.
1:04:55: --so that would be Salem Hospital.
1:04:57: Right.
1:04:57: The distant provider is a different provider, which one of the
doctors sitting on the table here--
1:05:05: Right.
1:05:05: --and they charge the office visit, so that's a different provider,
so sort of two different bill--
1:05:12: Did I read it incorrectly that it sounds like it wants they want to
bill both for one visit?
1:05:18: Correct, if the--if the patient is at Salem Hospital and Salem
Hospital wants to charge a facility fee, they would use this code, and that seems to
be quite common in telemedicine practice in general health. Medicare allows for--it's
$35, something like that, they do allow the facility to charge, they define exactly what
facilities can charge that and it's very limited, and then the doctor is--so the hospital
is the originating site and the doctor is the distant site provider and the doctor is the
entity that actually charges the CPT code that represents the service actually
provided.
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1:06:22: I can see an example, it's been awhile (unintelligible) in the
federal system that someone used these codes, but for example, tele-dermatology,
like if I was in an isolated place, they would come in and set up a very specific
procedure for lighting issue or all these kind of things, so (unintelligible) the same
way, then sent to the dermatologist to review that somewhere else, so I guess this is
saying did your billing for having that setup and staffing there and then
(unintelligible) something like that.
1:06:55: So I'm just thinking in terms of telemedicine and we used it so
I came from like city hospital and we used tele strobe and they had a telemedicine
for mental health because of the facilities were so small that we didn't have those
services set up and so we charged for the visit and we typically in the emergency
room, we didn't charge a facility fee for the telemedicine piece of it because they
were charging a provider piece, so I don't know why you would charge both--
1:07:26: So if you charge for the visit, then you are providing the
service, so what--
1:07:40: But you never really consulted someone else--
1:07:43: Right.
1:07:45: So that's a different story, yeah, if you charge a service, like if
you provide a 99 whatever 283 or whatever code, then, yeah, you wouldn't be
allowed to charge that, but if the patient just, you just provide the room where the
patient can be and then a--and the telemedicine equipment and then the doctor is,
you know, in Portland and interacts with the patient, so you as the facility, you don't
provide any service other than just providing the room and the equipment, but you
don't have to--you don't even need to have a doctor in there or a nurse or anything;
they can just be the patient. Oftentimes you also--
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1:08:53: Hey, this is Greg--this is Greg Gilbert with Concentra, so
maybe a good way to approach this just so everybody understands, but Colorado
did a really good job of basically defining what an originating site means and how
you would bill that fee and when you would bill that fee because a lot of telemedicine
being done today there's not even an originating site because it's a patient sitting on
the other side with their--with their iPhone and their iPad, potentially in Work Comp
sitting in a room at the employer and so the originating site fee would not be, would
not be billed, so in some cases it is and the traditional telemedicine model,
especially the Medicare-based model, though I think there's some language, Fred,
that Colorado put together in their regulations that are really clear in outlining what
that really means and when you use it.
1:09:42: Okay. Thanks, Greg, we have a copy of Colorado's
regulations, so we'll look at those.
1:09:48: And I guess I'm finding myself confused a little bit on the
conversation a little concerned because you indicated that you had feedback from
participants that you spoke with about this and the general consensus was not to do
a live rulemaking in this area yet and yet I think what my concern is and what I'm
hearing is that if we start talking about how to build, then we're defining what tel--
what services can be done and how they can be done through telemedicine and,
you know, before we get too far on this, on along on this bunny trail, you know, I
think first of all we talked about defining the definition and we want to have it state
versus asynchron--ah, asynchronous, you know, where do we want to fit there, good
conversation, but the other thing I guess I'm--I think SAIF would like you to consider
would be to kind of go slowly, we were amongst those that said, wait a minute, we
think telemedicine has a place, but we don't want to just jump in there with both feet
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yet because I think our folks are telling us is that we don't see a lot of telemedicine
yet, and so what we are wondering is whether or not there are providers who don't
know what they can bill and so the first step would be to say, yes, you telemedicine
is something we can do, have a code, use the 9--I think it's 95, to say this is a
telemedicine code, then we can keep track of it and we can see what are--where--
what are we seeing, what's working, what's not working, instead of creating this
ginormous, what's the originating patient, is there, can you have a--and I just, maybe
I've just been in insurance for a long time, I just think that we need to go a little, be
cautious a little bit, that would be our advice.
1:11:55: Well, I think that--
1:11:56: Well, this is Greg--go ahead.
1:11:58: No, you go ahead, Greg.
1:12:00: Well, I would say this actually is pared down, frankly, and
(unintelligible) Lisa Ann Bigford is sitting there as well been along this in several
state, some states have gone you--way overboard on this, so basically you're doing
just what you said and that is you use an 02, you use a 95, and you're saying if
you're using an originating site, here it is, and so I'm actually--I think this was well
done and it is very similar to Colorado, which was pared down, but it gave you the
information you needed, it also avoided situations where people were billing for
something they didn't have that information that they should not have been billing
for, and I would say that, you know, may not see a lot of telemedicine yet and maybe
that's a plain fact they're not sure how to do it or, number two, because they haven't
outlined the codes, we don't know that, and so unless you specify this is what you
should use, you're just getting a regular bill, a telemedicine bill and you don't know--
1:13:04: Well, that's why I think you (unintelligible)--
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1:13:05: (unintelligible) the approach here is methodical, it's well
thought out, and it's not too complex, that's my two cents.
1:13:13: J.R., some of your concerns around trying to identify
circumstances where telemount that--telemount--telehealth is appropriate and has
good outcomes versus places where it's just adding, yeah, it's causing more chaos,
so it's not around the coding, necessarily, but opening that all up might encourage a
mass entrance--
1:13:40: Yeah, I think from what I think that's exactly the our concern
is to start telling people how to, how to build and they'll go, woo, here we go and, you
know, I--great Colorado's had a great experience, I actually have a colleague over
there that I will be contacting to, you know, to give us, you know, to give me some
personal advice, I don't think we don't object to it, we think it's could be a really
wonderful opportunity for injured workers, but we just, we're conservative--
1:14:12: Well, and Oregon has some unique things in the law
regarding compensability and objective medical findings--
1:14:17: Yes.
1:14:17: --and those are the kind of things I think that sort of bring
some concern about the ability to accurately capture that via telehealth in some
circumstances where you can't, you know, touch the patient and, you know, look for
muscle spasms and some of those very specific things that really are required in the
realm of compensability in Oregon, and so--
1:14:43: Well, the way we've addressed that in other states that have
compensability, similar compensability rights area is you leave that to the physician
that's doing that service to make that decision critically just like they do elsewhere,
and so, Ann, you can jump in here, but I think, you know, you--there are things that
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need to be done clinically by telemedicine, things that can't be done, and I
mentioned other states, Tennessee's a great example who's going through minutia
all the way down to what services can and can't be done, which frankly we don't
recommend because I think you have to leave it up to the clinician to decide what's
appropriate because it is ultimately the clinician's decision to decide this is an
appropriate venue for this particular service or not, and if the rule says you can't do
these things based on compensability, then you don't do telemedicine visit for that,
Ann, did I say that right?
1:15:39: You did and, you know, the--for a first visit that telemedicine
is appropriate for (unintelligible) claims and, you know, if you're determining, first of
all (unintelligible) doctor doesn't (unintelligible) and their decision or their opinion is
that they don't believe the injury is industrial nature or not based on mechanism of
injury and causation and causation is, is an interview with the injured worker and
then the mechanism of injury, if they can't determine that mechanism of injury from a
telemedicine (unintelligible) encounter, it's time for some more, again that's a
stopping point right there, if there is they can't tell from that that they shouldn't go
any further, so we're talking about mild (unintelligible) claims for the first visit and
then there's also (unintelligible) that can happen where the person was seen a
second or third visit was seen in bricks and mortar then the rest of the care can be
done telemedicine so I--in telemedicine it's just a tool for a clinician the way to
deliver care (unintelligible) a quality physician clinician is going to determine what's
the best care delivery model for this--for this patient, I have telemedicine, I have
bricks and mortar, but what's the right care for this patient, can they do telemedicine,
yes or no, and they all have a standard of care to follow, any clinician needs to be
following a medical standard of care of what's appropriate and well behaved.
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1:17:16: Thank you very much, Ann. Yes, everyone, and, Jaye, the
goal here was not really to get into when it is or it isn't appropriate, because that
would be a very difficult conversation where--
1:17:28: We're already there.
1:17:29: Right.
1:17:29: We're talking about it right now.
1:17:31: Well, we really want to talk about, you know, how to--
1:17:35: I think that's a key, key word is appropriateness. That's what
we have and what (unintelligible) that's what we have the MCO's for is to determine
whether or not treatment is appropriate and I think the delivery of treatment should
falls into exact that same thing, it's just something new, we're just used to we look at
the service and see is that appropriate, but now all of a sudden we're also looking at
is it appropriate to deliver that service in this way or that way, but I think it is an
appropriateness thing that has nothing to do with the fee schedule, with billing and
payment rules; it's really a medical appropriateness issue and I totally agree that I
would want to stay away from that, I really would--
1:18:35: I think there's something in the write-up that we do believe is
this appropriate piece, please point that out, because that was not the rule, I think it
is our concern and then (unintelligible) to listen to the conversation and I appreciate
the folks from Concentra and their, you know, their advice, but I hear us talking
about appropriateness and I think that, you know, it's--obviously you all are going to
do what you think is best, but I think that we are concerned that there will be times
where as the carrier looking at, you know, is this a Comp claim, is the treatment
appropriate, et cetera, because we can't direct care and we don't get to weigh in on
that conversation of whether telemedicine is appropriate, but so--
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1:19:23: Maria, I have a question, if we do nothing with the rule at this
point, telemedicine would just be subject to basically the same rules that Medicare
apply to, right?
1:19:37: No.
1:19:38: So would it be allowed?
1:19:42: It would allowed--
1:19:43: And with the CMS billing--
1:19:49: The CPT codes with--that's one question is, you know, would
it be allowed with HCPCS code also? We have adopted the CPT code and the AMA
designates specific codes for telemedicine, can you use other codes, now we're
getting into the appropriateness--
1:20:10: Riot, right, exactly--
1:20:10: --because a code, this--so if we don't say anything about
codes, I would be perfectly happy.
1:20:19: But the point of telemedicine is in the market and they can bill
according to the national guidelines--
1:20:28: There's one, there's an unknown, however, the facility,
whether to pay or bill at the facility or non-facility rate, look--
1:20:34: Exactly, there's no standard for that--
1:20:35: Looking at our data, looks like most people are paying at the
non-facility rate, but there's nothing in the rule to provide guidance--
1:20:44: Yeah.
1:20:44: --at all, it just--
1:20:45: --Same thing with that telehealth transmission code, the
T1014, again it looks like the vast majority of health plans, they don't pay for that, I
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think it's a specific code for some Medicaid something, but I don't think in Oregon it's
paid either, but it's a valid code and so if somebody bills you that code a thousand
bucks, you may be forced to pay a thousand bucks because it's a valid code, and so
for that I think it might be beneficial to have something, to have a rule that, you
know, would specify insurers are not liable for that, or with the facility code, I think it
would be sensible to have a maximum payment amount because again it's a valid
code and the way the rules are generally written now, if there's no maximum
amount, the insurer has to pay 80 percent, and so we don't have an upward limit and
I think it would make sense to have an upward limit--
1:22:06: So when you're talking about maximum, are you talking about
a maximum for the HCPCS code or are you talking about a maximum for the data
transmission code?
1:22:15: For--I'm suggesting and these--this here and it's really--it's
not even suggesting, it's just an option, basically have a maximum for the facility
code, the Q3014, and basically state that the insurer is not liable for a transmission
fee. That seems to be the standard out there in the industry, so we don't, if we don't
have anything in the rule, it doesn't matter what the standard is out there because
we don't adopt the standard, you know, so that's why I do think it would be beneficial
to have a few things in the rule, but I totally agree, yeah, let's not go to
appropriateness of when it's appropriate and when it's not, and I think that's what a
lot of stakeholders--
1:23:20: Yeah, stakeholders--
1:23:20: --really have told us--
1:23:22: Yes. And in some sense we're adopting what's already
allowed under the rules with a couple of clarifications on how to deal with the non-
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facility versus the facility rate, getting rid of the T1014 code, and then giving a
maximum value to the Q3014 originating site code, so somebody gets paid for their
use of their facility as opposed to having it being open-ended.
1:23:50: Something else to consider is initial visits where kind of the
compensability is determined, they aren't enrolled in an MCO, they are typically not
enrolled in an MCO until the claim is accepted, but at that point you determine
(unintelligible)--
1:24:05: That's SAIF. There's a lot of self-insured employees that as
well--
1:24:10: Yeah (unintelligible)
1:24:13: Oh.
1:24:19: Is it time for a break?
1:24:20: Well, actually as soon as--well, I don't know if we have time to
complete this issue before the break, but we will be taking a break, I thought we
might actually have enough time to do our entire agenda without that, but I think it
would be the best thing, so-- Are you thinking it's time for a break, Ramona? We
can actually break now.
1:24:38: Well, I was, I wanted to talk to Jaye about something, like
(unintelligible) continue.
1:24:44: Okay. Well, you know, we were going to break at around
3:00, so why don't we break and get back together about--
1:24:50: (unintelligible)
1:24:51: That's right, we'll get back together at about 11 minutes after
3:00 we'll (unintelligible)
//
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(off the record)
1:25:00: Is we're back on the record. Actually we're probably always
on the record because one of the recorders is on and the telephone system is on, so
we're definitely on. Okay. I'll just kind of let people pick up where we left off in case
there's anything that you'd like to provide based upon your discussions or direction
of thoughts on telemedicine before I go through the bullet points here. Lisa Ann?
1:25:26: I was just going to say from our perspective we're not trying
to advocate anything in the clinical space, whether you should, whether you
shouldn't step on any MCO toes, no, just no, all we were saying is that if there are--
can be a standardized approached used in billing when it is determined at the
clinician's discretion that it's appropriate, it helps a little bit to wrap the tent around
the circus and have some kind of idea of what's going on out there, that's it.
1:25:59: Okay. Thank you, Lisa Ann. Okay. We did get, you know,
some advice on the definition of telemedicine, whether it's a little too narrow, that
being synchronous telemedicine service rendered by a realtime, et cetera, and so
we'll take that all into consideration as to whether we, you know, we should be a little
broader in our approach and talk about the asynchronous kind as well, but the
second bullet is clarify that providers may bill for telemedicine with CPT codes that
are listed in Appendix P of CPT 2020, so again this is just telling people what they
can already do--can already do under with the CPT codes, but they may not know
that they're able to do it and provide a little bit of direction, some help. Any concerns
about that?
1:26:52: Fred, Fred, it's Greg.
1:26:53: Hi, Greg.
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1:26:54: One thing that states have grappled with is, is most have
looked at Appendix B and some have adopted that, the one drawback from that at
this point until that is expanded is that it does not--there are lots of folks out there
doing tele-rehab now and those codes are not included in Appendix P, so I'm not
saying one way or another, I'm just pointing that out that that does preclude doing
any tele-rehab.
1:27:25: Well, correct me if I'm wrong, Juerg, but if we were to clarify
that they may bill for the telemedicine codes that are listed in Appendix P, we--that
that would be kind of a baseline that we could expand on that if that's what
everybody wanted us to do, but--
1:27:47: You know, I think that is one of the questions, should we
even mention Appendix P, which should we basically just say, you know, when you--
when you bill telemedicine services with a Hhic--with a CPT code, use modifier 95, if
you use a HCPCS code, you modifier GT, I think it is, that HCPCS modifier, and just
basically leave it at that, as opposed to if we make a reference to Appendix B--P, are
we basically now saying that, okay, it is limited to these codes, to these services,
and by doing that, now we're making a determination in the rule what would be
appropriate for telemedicine services, and I think if we left that out and just make the
reference to you have to identify the code with this modifier and for place of service
you have to use 02, that way we would not get into the appropriateness discussion
in the rule at all and just limit it to, okay, the provider then knows, okay, if I do
telemedicine services, I have to append modifier 80 and 95 to this code.
1:29:15: Is there a place of service code that would help identify if it
was provided at the worker was at a facility or they were in the safety office? Is that
what 02 says--
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1:29:29: 02 is what they should be billing, 02 is telling it that's a
telemedicine, yeah.
1:29:34: And they're at one of your sites, basically.
1:29:38: It's just, it's for the provider that's doing the services, so the
actual physician bills it out would append 95 to the actual CPT code and typically it's
only going to be an E&M code and then he puts or she puts 02 as the place of
service code. If--and that's only for that bill. If you're billing for the originating site,
which was discussed earlier, you don't use those codes because it's a specific code
just for the originating site, so it's telling you I'm an originating site, so when you're in
a pure play model of a rural versus urban setting where you have a rural hospital in
which a patient goes into a room and a setup and it's a full telemedicine suite, that
rural hospital would then bill the originating site fee without the 02 and the 95. The
physician that's based in your metropolitan city who's a neurologist and they can't
get them out in that rural area would then bill 95 the modifier on the CPT code he
used or she used as well as go to show that that was done the telemedicine visit, I
hope that makes sense.
1:30:49: Yes, it does, thanks.
1:30:56: Okay. I'll clarify that distant site providers must use
modifier 95 when billing for telemedicine services, Juerg just kind of went over that,
again require the use of 02 for place of service when billing for telemedicine services
by the distant site provider, require insurers to pay for telemedicine ser--this is a new
one here, require insurers to pay for telemedicine services at the non-facility rate.
When we looked at what limited data that we have on the medical billing data, it
looks like most insurers are paying at the non-facility rate, and the facility rate, as
many of you may know, is considerably lower in most cases, so the non-facility rate
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provides an equivalent reimbursement amount as you would for a regular brick and
mortar office visit, as I understand it. I would appreciate your input on that.
1:31:56: So it's--I think it's good that you're calling that out. Here's one
quest you may want to look at, we just covered this in Arizona, is that non--the
facility rate may be appropriate when you're doing the urban rule scenario I just
mentioned and you're billing your originating site fee as opposed to when you're not,
when you're just, there's no originating site fee because Medicare rule does show
non--excuse me, facility at the reimbursement in urban rural setting, they do not
allow urban-to-urban, and the way you're writing your rules allows that, as other
states have done as well, so there's some language I continue, Fred, that in an FHU
from Arizona that finds and outlines that scenario, so they want non-facility unless
you're billing originating site fee, and then it would be facility.
1:32:59: Okay, that there's a Q3014 originating site, isn't it, isn't that
the one? Is that the code--
1:33:06: Correct.
1:33:07: And there's two different rates, there's a facility and a non-
facility rate for that?
1:33:14: No--
1:33:15: No?
1:33:16: --we're talking about when you're using the non-facility and
facility rate, it's for the professional services delivered by the physician that's billing
the 95 code to--
1:33:24: Okay, okay, I'm sorry, now I understand.
1:33:28: Why would you pay a facility rate for the equivalent of an
office visit?
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1:33:34: It's the same thing as if a physician showed up to a hospital
under the E&M code.
1:33:42: Yeah, but it's not a hospital visit.
1:33:45: Yeah, I'm just--that's how Medicare has looked at it and how
they set that rule, I'm fine with not doing it all, I'm just telling you that that was
another scenario that the state looked at, I think you pay all non-facility, I just, but
Medicare set it up that way and you need to define it if you're going to do it because
if you don't, the default will be the Medicare regulation.
1:34:08: Right.
1:34:08: Yeah, I mean, what--
1:34:10: If it's not defined.
1:34:11: Why would the--
1:34:12: And we saw that happen (unintelligible)
1:34:16: Why would the distant site provider be punished when the
patient goes to hospital as opposed to doing it from his or her own living room, I
mean, the distant site provider--
1:34:32: I don't disagree with you, I don't disagree with you at all, I
don't think they should be, there's investment in the infrastructure, investment in the
software, there really shouldn't be, that's just if--it's because that was a Medicare
regulation--
1:34:46: Yeah, it's a different--
1:34:46: --It's how Medicare (unintelligible)
1:34:47: It's a different model and we appreciate you, you know,
pointing it out to us--
1:34:51: Yes.
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1:34:54: I think that, this is Sam, I think it's cleaner just to have it non-
facility across the board because if you start doing this stuff, you're going to have a
mess, I just--
1:35:04: I don't disagree, I just--I just want to make sure everybody
heard all the approaches.
1:35:10: Okay. Thanks, Greg. And then it goes on, require originating
providers when billing a facility fee to use HCPCS Code Q3014. Create a maximum
fee schedule amount for 3014.
1:35:27: I'm sorry--
1:35:28: Yeah, go ahead.
1:35:28: --make one point?
1:35:29: Sure.
1:35:30: So would it be worthwhile to point out that there's no other
service involved with the facility fee so that it's just the--
1:35:44: Because if there's a provider already and they're charging a
CPT code for that visit, they shouldn't be charging HCPCS.
1:35:52: Yeah.
1:35:53: Yeah.
1:35:54: So we should put that in any rule.
1:35:58: Yes.
1:36:03: And then it goes down, clarify that insurer are not required to
pay a telehealth transmission fee, which is the 1014.
1:36:10: Yes, yes.
1:36:12: Create a new rule in Division 9 titled--actually I guess that's
kind of its own concept, so everything above so far, all those kind of point-by-point,
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most of which are allowed under current or done under current practice, but this
would be putting it in rule, codifying it in rule. Any concerns, thoughts before we--
1:36:35: So the question I have here with this last bullet is basically
should we put all the telemedicine stuff into one rule or should we try to put things in
different places, for instance, we have a rule and/or section in the rules called
modifiers and so should we put, you know, modify 941GT, that lead to there or
should we just basically make a new rule called telemedicine and put everything
there so that everything for telemedicine is in one place, so it's more of an
organizational question, I guess--
1:37:19: I think I'd put it in a separate one because we have so many,
yes, points in here you're addressing--
1:37:27: Yeah, you can cross-reference--
1:37:29: Yeah, we would have to do that any--
1:37:31: But it wouldn't hurt to add the modifier in the modifier section,
I would say do it in your own section telemedicine but also throw in the modifier
section.
1:37:40: Yeah, or as Lisa Ann said, we could cross-reference, yeah--
1:37:41: Cross-reference, we just cross-reference--
1:37:45: Yeah.
1:37:47: And to clarify the intent of the first point, that by defining
telemedicine as synchronous telemedicine, we're saying that asynchronous is not
payable--
1:37:59: No, we're not saying that--
1:38:01: No, not addressed.
1:38:02: We're just saying that so, for example, the requirement to use
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modify 95 or GT if it's a HCPCS code, that requirement applies to synchronous
telemedicine, so this is not to asynchronous, so again the radiologist who gets a disk
basically provides asynchronous med services and that provider doesn't have to do
a modifier 95, they would use the modifier 26 for professional services as opposed
to technical, but basically that that's what the definition really would be--mean.
1:38:53: Okay, and all the other restrictions would apply to the
asynchronous, all the other rules that we talked about would apply to asynchronous
as well. That facility codes and facility (unintelligible) and all that.
1:39:10: I thought we were only be (unintelligible) for realtime, I
thought asynchronous was off the table.
1:39:16: Well, again it's what is asynchronous?
1:39:21: Well, it just depends on what you're talking about, I mean, I
mean, people are paying for that today anytime that a physician is reviewing X,
(unintelligible) diagnostics and stuff like that, so all we're saying is that it wouldn't be
changing what is being done today I guess is going to be status quo in the
asynchronous realm, we're only trying to put some sort of structure and guidance in
a situation where it would be asynchronous, I believe that's we're saying, we're not
saying no one's off the table, however that's being handled today and is payment
decisions that are being made today, the way it's being done today would still
continue, we're not saying all of a sudden doctors aren't allowed to look at X-rays
and asynchronous matter and get paid for it, that's not what we're saying--
1:40:02: They're not billing for telemedicine (unintelligible)--
1:40:05: Right, right, right, they're billing in a way that they would do it
today, right, exactly.
1:40:09: Okay.
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1:40:14: So any other thoughts on organization, whether we ought to
have a dedicated rule, any concerns about having a dedicated rule and then just
perhaps putting in cross-references or occasional references to the right modifier
and the right location, that kind of thing?
1:40:28: Negative.
1:40:33: Okay. With that I guess we're ready to move on to our next
issue, which is issue number four. Affects Rule 20 in the Division 9, the Oregon
medical payment rules, the criterion that DCBS uses to determine exemption from
the hospital cost-to-charge ratio for rural non-critical access hospitals is no longer
available. Under ORS 656.248(13) it provides that the Director may exclude
hospitals defined in another statute from imposition of a fee schedule upon a
determination of economic necessity. It's got a little typo there, it should be 436-009,
Rule 20, Section (5), Subsection (k), prescribes the test for the exemption. All rural
hospitals having a financial flexibility index at or below the median for all critical
access hospitals nationwide qualify for the exemption.
The 59 hospitals in Oregon fall into three categories, 23 urban
hospitals that are paid at their cost-to-charge ratio, 25 rural critical access hospitals
that are exempt from the cost-to-charge ratio, and 11 rural non-critical access
hospitals whose exemption status is determined each year by examining their
financial records. Hospitals that are exempt from the cost-to-charge ratio are paid
as billed.
There has been an average of 2.5 exempt rural non-critical access
hospitals from October 2011 through 2018, ranging from a low of one to a high of
four hospitals. Currently one of the 11 hospitals in this category is exempt on this
basis. The exemption status for these 11 hospitals is determined by comparing
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each hospital's financial flexibility index as calculated by DCBS, that's our larger
department, with a median financial flexibility index of all critical access hospitals in
the United States, which is calculated by a third-party contractor, Optum. Per this
agreement, each year DCBS provides Oregon hospital financial records to Optum
and Optum provides DCBS with the median financial flexibility index of all critical
access hospitals nationwide. Optum is no longer collecting these hospital financial
records or calculating the financial flexibility index of hospitals in other states.
Therefore, DCBS can no longer use the median financial flexibility index of all critical
access hospital nationwide to determine the exemption status for these 11 rural non-
critical access hospitals. DCBS is able to calculate the median financial flexibility
index of all Oregon critical access hospitals.
The following table shows how many rural non-critical access hospitals
were excluded from the cost-to-charge ratio using the national medium--median and
how many would have been excluded had we used the Oregon-only median
financial flexibility index. And you can see the little table at the bottom of page five.
So had the exemption status been determined using the median financial flexibility
index of all Oregon critical access hospitals, the average number of exempt rural
non-critical access hospitals would have been 3.6. So that's a little higher than it
was bef--under the national median.
So options would be exclude all rural hospitals from the cost-to-charge
ratio or exclude a fixed number of rural critical access hospitals; for example,
hospitals with the lowest three financial flexibility indexes. Eliminate the exemption
for all rural non-critical access hospitals. Or use the median financial flexibility index
of Oregon critical access hospitals only to determine which rural non-critical access
hospitals are excluded from the cost-to-charge ratio. Or some other option that we
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don't actually have identified, so with that I'd like to open it up for your input and
direction on what we should do in the absence of that national median data. I know
that was a mouthful, it certainly was for me. Concerns about using Oregon to
establish the median?
1:45:13: This is Dan from SAIF Corporation, seems like option four is
the closest to what we're currently doing, and either options two or four would not
work (unintelligible) option four being the closest and the most objective since it
fluctuates from year to year based on the number of hospitals.
1:45:36: Thanks, Dan. Anyone else? Okay. With that, thank you very
much, and we'll move right along.
Issue number five, we're still in the Oregon medical fee and payment
rules, Division 9, affect--this time affecting Rule 30, Section (2), Subsection (a), all
original medical provider bills must be submitted on an appropriate billing form that is
filled out completely and be accompanied by chart notes documenting services that
have been billed. Under Rule 22(a), insurers are required to return incomplete bills
to the provider within 20 days. Since a rule change in 2013, this rule inadvertently
no longer requires chart notes to make billings complete. This rule does not list a
completed billing form, as required.
Some background. Rule 32(a) provides that insurers must date stamp
medical bills, chart notes, and other medical documentation upon receipt. Bills not
submitted according to Rule 10 Subsection--or Section (1), Subsection (b), and
subsection--Section (2), must be returned to the medical provider within 20 days of
the receipt of the bill with a written explanation describing why the bill was returned
and what needs to be corrected. A request for chart notes on EDI billings must be
made to the medical provider within 20 days of the receipt of the bill. And then
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under Rule 10, again Section (1), (3), and (7), it lists the instructions for medical
providers regarding what billing form to use, how to fill out the billing form, and that
chart notes must accompany the bill to make it complete. It is not clear why Rule
32(a) refers to Section (2) of Rule 10, since that section refers to billing timelines, so
options would be make the following revision to Rule 30, Section (2), and if you see
in the draft wording there, there is a replacement of the reference to Section (2) of
Rule 10 to make it Section (3) and in addition of reference to Section (7) of Rule 10.
Again this is kind of a technical fix, I guess, Juerg, would it be safe to say this is
borderline housekeeping, I don't know.
1:47:53: That's the point, I don't think any is going to be opposed.
1:47:56: Okay. I guess sometimes what we think are housekeeping
actually has unforeseen consequences, but is there anything here that you think
might have some such an unforeseen consequence? With that, I'll just keep moving
right along.
Section--or issue number six affecting Rule 40 in Division 9 and it
affects Appendix B, the physician fee schedule. Effective April 1, 2019 the
Department increased the maximum payment amounts for evaluation and
management, or E&M, services by five percent. However, fees for arbiter and
physician reviewer services, which are similar to E&M services, were not raised.
Providers use Oregon-specific codes when billing for arbiter exams, and it lists them
out there, and also for file reviews, so they're all listed, and reports. When
performing a Director-required exam, such as a physician review for a treatment
dispute, providers use OSC, those are Oregon-specific codes, again P1 through P5
for billing. Prior to the 2019 increase in maximum payment amounts for E&M
services, the Department increased the maximum allowable payment amount for
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E&M, arbiter, and physician reviewer services by an average of three percent
effective April 1, 2016. The Department projects that a five-percent increase of the
maximum fee schedule amounts for arbiter and physician reviewer services would
increase the medical costs to the Workers' Compensation system by $62,760. So
an option to consider would be to increase the maximum fee schedule amounts for
arbiter and Director-required exams, file reviews, and reports by five percent, so
appreciate your feedback on that. Any concerns? Anyone on the phone, concerns?
1:50:00: Nope.
1:50:02: Okay. Thank you. On to issue number seven then.
1:50:05: Well--
1:50:06: Go ahead. Oh, another what?
1:50:10: Nope.
1:50:11: No concerns, okay. Rule 60, this is issue number seven
affecting Rule 60 in Division 9. A stakeholder, an MCO, is proposing three new
Oregon-specific codes be added to the Oregon medical fee schedule outlined in
Division 9 of Chapter 436 of the Oregon Administrative Rules, and then you can see
they're RECRW being one of the codes, another one it spells out VIDEO, and
another one is D0091. So there are two sets of nationally-recognized billing codes
to be used by healthcare providers in the United States the providers treating
Oregon workers may use to codify the services provided; AMA CPT codes and CMS
HCPCS codes are the ones. Although above sets of billing codes are quite
comprehensive, there are certain services, in particular as they relate to the
treatment of Workers' Compensation payments, that may not be coded correctly with
a CP or HCPCS code. For such services WCD has created Oregon-specific codes
listed in Rule 60, Section (2), there's a long table there.
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Since the Department has no data regarding billing or payment
amounts for the proposed codes, WCD not--will not be able to assign a maximum
payment amount to any of the proposed codes. The stakeholder proposes three
new OSC's. The RECRW, this R--this Oregon-specific code would be designated
for records review provided by a non-treating physician. Currently the closest CPT
code for this purpose would be 99358, which is a prolonged evaluation and
management service before and/or after direct patient care first hour. This code
assumes that the provider has seen or will see the patient; however, there are times
a provider is requesting new records to provide expert opinion or insight into a case
without an associated physical exam of the worker. While this is not common, in
those instances where it does occur, having a specific code for this service allows it
to be quickly identified as uniquely different from other records review. So I think
maybe we'll--maybe we could address these one at a time, your thoughts on
RECRW for a records review provided by a non-treating physician. Any concerns?
1:52:41: This is Jessica. So you're saying this is only when it's
requested by the insurer, so it's not just a--I know I've seen disputes where a
provider will do a record review and then they'll bill the insurer for that without it
being requested.
1:53:00: I'm not sure, does it say anywhere in here that it was
requested by the insurer--
1:53:01: It says times a provider is requested to review records.
1:53:05: Oh, okay.
1:53:05: So that would be the limit on it.
1:53:09: (unintelligible) we did put that in our (unintelligible) was
requested that this was proposed by Majoris and our intent was if it's requested by
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the insurer of the MCO.
1:53:25: Okay, so under options, I have--I put the description records
review by non-treating physician, so should we add records review requested by
insurer or--
1:53:42: Yes.
1:53:42: --or MCO, is that crucial or--
1:53:45: Yes.
1:53:46: --for the, yeah, DO, it's...
1:53:50: One of the issues we run into in our medical audit is there
have been just a couple of providers, one in particular, who for something like a
closing exam or a PCE exam they had bill records review on top of it when it's
considered by those as part of the PCE, and so that's why you want to add
something on there they're just going to add (unintelligible) PCE.
1:54:22: Thank you very much, Dee. Any addition--any additional
thoughts on RECRW? The next proposal was for VIDEO. There is no standard
CPT code specifically for review of video, video review is distinctly different from
other records review and the ability to identify the frequency with which a provider is
requested to review video or that video review is required in overall case
management assist with valuable trending analysis, as with RECRW, having a code
that directly relates to the services being rendered increases transparency in billing
and payment data and provides for consistency across all medical providers, so your
thoughts on this particular code, VIDEO?
1:55:14: I would say that we also wouldn't want to add in there if it's
been requested by the insurer or MCO.
1:55:22: And in that case, should we add for Director-initiated exams
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so if there's an arbiter, would you like to keep those separate? Because if there's a
physician review that the MRT would request like, say, there might be some video
out there, can the doctor bill separately for that or would that not be included in this,
like would that be part of the physician review billing of those OSP--
1:55:49: (unintelligible) billing also considering record review or video
review because if so then I don't think they should be able to bill separately for that if
it's encompassed within--
1:56:00: Yeah, I think those are already, those kinds of things are
contemplated within the arbiter and the code itself kind of.
1:56:14: And finally there was D0091, having access to the expertise
of an addictionologist is highly valuable in managing the medical care for injured
workers on opioids for chronic pain; however, it is very difficult to find an
addictionologist willing to treat Workers' Compensation. Consults usually involve a
number of different elements, including extensive records review, physical exam
reports, responses to letters, and urine drug screening. The standard is to have
each of these services billed individually, which increases the risk the consults are
not billed or reimbursed consistently. Having a single code to represent the entire
consult would circumvent this issue and ensure the provider receives adequate and
appropriate reimbursement. This MCO has partnered with two addictionologists in
the past 10 years and both have indicated a preference for this type of approach.
So your thoughts on having a D0091, which is services by an addictionologist
consultant consistent--consisting of an extensive records review, a physical exam,
reports, responses to letters, and urine drug screening.
1:57:23: Can we limit that to consults arranged by an MCO in the
description?
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1:57:31: Sure. It's going to be out of our own code, so we can--
1:57:35: Yeah, and, you know, the other two in order because
otherwise they would be just paid as billed or 80 percent is billed or something, right,
if there's not a contract (unintelligible)
1:57:49: Correct, they--
1:57:50: So they should put in there that, you know, only applicable
through MCO contracts?
1:58:05: I'm not sure about that. I have to think about it--
1:58:10: Or when requested by insurer or MCO on an MCO-involved
claim?
1:58:15: Can the--can the insurance company request that?
1:58:20: The record review or video review, they do.
1:58:34: Yes, we do, they can, because we don't always know there's
video until the carrier tells us, you know, we have video and we'd like to have it
reviewed.
1:58:43: Well, on this one, though, on the addictionologist one--
1:58:45: Oh, that, no, the addictionologist one I think you could limit to
the MCO--
1:58:50: Okay, that's--
1:58:53: --because that's part of our protocol for, you know, certain
opioid (unintelligible)
1:58:59: Are you limiting the ability for anybody that's not in an MCO
that has that opportunity?
1:59:05: They could still send them to an addictionologist, this is just--
1:59:06: Well, that would be put in rule then that it has to be under the
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MCO--
1:59:10: Because we're using a specific code so we bundle them and
we're paying sort of a premium to that provider because we--they're hard to find and
we're saying, whether you do some of this or all of this, you're going to get this code
because they're very, as you know, very difficult cases to deal with, so--and it's part
of an overall protocol, so people, I mean, they can send people to an
addictionologist and ask for all these services, but then their reimbursement fee
schedule, we just like to bundle them and have it all under one umbrella.
1:59:51: So the service is requested by the MCO.
2:00:02: Like you said with the second question, the bill (unintelligible)
this really is MCO or self-insured, keeping that code available to them also to
(unintelligible) so--
2:00:16: Well, they, I mean, that code is an umbrella for a number of
different codes, so they can still ask for those services--
2:00:23: But we're--what we're saying is they by that (unintelligible)
they can use that code--
2:00:28: Yeah, well, because if--
2:00:29: (unintelligible) written (unintelligible)--
2:00:31: Yeah, because they're--
2:00:32: (unintelligible) that seems a little exclusionary, but--
2:00:34: Well, except I think the code is meaningless to a non-MCO--
2:00:41: MCO claim--
2:00:41: --claim because the bundle of services, we want to correct
me if I'm wrong, the bundle of services is specific to (unintelligible)--
2:00:49: Specific to our the MCO, yeah, contract with providers--
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2:00:55: It's specific to our protocol--
2:00:57: So it just allows the billing to be bundled.
2:01:02: So basically by limiting it to MCO-enrolled claims, we're just
making sure that the insurer doesn't get presented with a huge bill because we
can't--
2:01:19: Right.
2:01:20: We can't put a payment amount to or a fee schedule amount
to it because we have no payer (unintelligible)--
2:01:25: It prevents them getting abused and there's other codes that
they can use to bill the same services.
2:01:32: So if there are other codes to be used with the same
subsystem, why do we need--
2:01:34: Well, actually the records review it isn't quite the same, I'm
wrong, there are no codes specific to those things--
2:01:39: It's not for the records review and part of it is to help ensure
that the addictionologist gets paid for all his services because they--it's not their
area, they don't do a lot of Work Comp, and so then they will forget to bill all those
codes but because they are providing a valuable service we want to make sure they
do get reimbursed for that.
2:02:10: And it's at the request of the MCO.
2:02:12: Correct.
2:02:21: Not to belabor this, but to Dr. Cohen's point, so if a physician
refers someone to the addictionologist and they're not an MCO-enrolled worker, you
were saying the addictionologist doesn't necessarily know how to bill for each
component of the service they provide.
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2:02:40: Well, in that case they would bill for the services that they did
get asked to provide, so say another provide made that referral because they're
worried about the prescriptions they're writing or trying to think of what--how else
that might get used, but they would ask for something specific like did they see the
worker and also do the drug screening, for example, and so the addictionologist
would bill for whatever services were being requested specifically for that patient.
2:03:09: And again this is designed as a premium to the
addictionologist so that they know they're going to get a certain premium amount for
handling these difficult cases, and even if they don't have to do one case of it,
they're still going to get reimbursed in this umbrella rate.
2:03:41: Additional advice, thoughts, concerns about this one? Okay.
Thank you and thank you, Lisa and Ramona, from Majoris for speaking to those
issues.
The next issue we've already covered because it's the one on
interpreters billing for no-show. Yeah. And so the final issue that we do have on our
agenda is issue number nine and this affects the managed care rules, Division 15,
Rule 30, Section (6), not all providers that are willing and able to accept managed
care organization-enrolled patients are allowed on MCO panels. A stakeholder
requested that this issue be discussed at the next--at this rulemaking advisory
committee meeting. The stakeholder stated MCO's are utilizing exclusionary
contracts with large multistate corporate PT clinics and refuse to contract with any
independent private practices. They cite geographical saturation. However, will
automatically enroll and credential any new clinic from the larger chains within a
three-mile proximity despite our efforts to join since 2015. When asked how they
assess for value, quality control, and cost saving, they have no answer. Feels very
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antirust and anti-competition, and that's the end of the quote from the customer.
Under current rules there are no remedies for providers who are not
granted paneled member status with MCO's. In prior advisory committee meetings
discussions about this subject, a majority of committee members were against--or
was against requiring MCOs to credential any willing provider. Under Rule 30,
Section (6), Subsection (a), an MCO must have an adequate number but not less
than three of medical service providers from each provider category, for the
purposes of these rules the categories include acupuncturist, chiropractic physician,
dentist, naturopathic physician, optometric physician, osteopathic physician, medical
physician, and podiatric physician. The worker also must be able to choose from at
least three physical therapists and three psychologists. Above number of minimum
three providers in each category providers applies to each geographical service
area, regardless of the population size of each area. So an option would be to
consider different numbers of providers in each category of providers based on the
population size of each geographical service area, make no change, or something
else entirely, so with this I'd just like to open it up for your input and would like to
hear from you.
2:06:31: Well, in looking at our data, first, let me--Dolores
(unintelligible) our last day with Caremark, thank you, Caremark (unintelligible)
submitted a letter opposing this and I would echo most of her sentiments about the
history and construction of MCO networks. She commented about the cost to the
participating physical therapists, but there's also costs to the MCO for credentialing
and managing the provider network, so throwing open the door to everyone
significantly increases the cost, and because we spend a great amount of resources
on educating and training providers on how to navigate the system, it also would
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greatly increase our cost in managing the providers and I think decrease the quality
of care, but in looking at our network composition, 56 percent of our network
participants are independents, 30 percent are hospital-based, and only 14 percent
are national networks, and of those it's, you know, a smattering from this one and
that one and that one, there's not any one big, you know, national contract of which
at least our PT network is comprised. I'm also not hearing anything about workers
access to care, which is the purpose of the MCO and, you know, that's the focus that
it's not necessarily provider's access to patients, but a worker's access to quality and
appropriate care.
2:08:16: Thank you, Ramona.
2:08:19: So I can address the access to care, especially from a
chiropractor standpoint, so I'm in a city of 26,000 people, there's no chiropractors
that are beholden to MCOs there (unintelligible) Wilsonville, which is 16, 17 miles
away, and we have a hard--a high Hispanic population of Woodburn that doesn't
have access to transportation up to Wilsonville all the time, a lot of times they
carpool to their jobs and when they're hurt they don't have access to anything, so
they have to ride bikes or take public transit to whatever facility they have, most of
the medical doctors in Woodburn are on MCO panels and most of the medical
doctors in Woodburn will not treat Workers' Comp patients, so what's the point of
(unintelligible) an MCO panel if (unintelligible) participate in Workers' Comp, and so
access is very limited but I also know in our patient population they will not go rock
the boat anywhere because they're afraid of losing their job, they're afraid of losing
their livelihood, they're afraid of losing, you know, potentially their citizen ability, and
so I know that it's an issue at least in our profession, I don't know how many are
enrolled in Salem, but, I mean, we have six chiropractors and only 26,000 people in
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Woodburn (unintelligible) panel.
2:09:51: Do you know if they've applied to--
2:09:52: I know a lot of them have, but, I mean, that was years ago,
they just give up, and so there's more access and far--as far as an entire profession
goes (unintelligible) we did a survey of our profession probably eight years ago as
far as how many want to take care of Workers' Comp and just, you know, our
association, I'd say less than 50 percent are willing to do it because part of the
statutory restrictions and part of it's MCO (unintelligible) so I know that's an issue
with our profession (unintelligible) so can I ask what the definition of a geographic
region is?
2:10:33: It's defined by the state, there's 15 of them in the--in the
rules, and they're separated by ZIP codes, and some are broadly geographic, they're
southeast Oregon, they're, I mean, the pattern of travel is just such that you're going
to have to go a long way to find medical (unintelligible) others are much smaller,
but--and I can't speak for the other MCOs, but I know that when we do get
applications, we look at locations within that geographic service area, so if it's in
Portland we want to be sure that we have access in southwest and southeast and
northeast and Vancouver and, you know, so that it's spread around, which is why I
was asking if providers have applied in Woodburn because that would be an area,
because it is distinct from Wilsonville or Salem as a community and so we do have
providers in that area, so that's I think our provider relations department to look at
and reach out.
2:11:43: Thank you, both.
2:11:44: I see this from I've got kind of a unique perspective, I've got--
represent clinics that continually try and get on MCO panels and are denied due to
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the restrictions, but by the same token I represent a network that is complying with
certain legal constructs on a federal level that--and to me there's kind of probably a
sweet spot in there as far as patient access goes and that one recommendation that
you might want to look into is Medicare Advantage plans, CMS has promulgated
network adequacy standards for Medicare Advantage plans and they might be--the
current Work Comp requirements might support them or they might be deficient, I'm
not sure, but I've had to look at them for the geo-access pieces for my network and I
know we can--we can comply with both the minimums and the maximums, so it
might be worth just looking at whether or not the Medicare network adequacy
requirements, how they compare to the state requirements for Work Comp.
2:12:57: Okay. Thank you, Rich--
2:12:57: Although there are some significant difference in that
Medicare Advantage plans know how many participants they have and in Workers'
Comp you don't know what the MCO patient population is until they have an injury,
and so you sort of take a best guess that, you know, 10 percent of injured workers
might have an injury, of those how many need to see an orthopedist and how many
doc--you know, are just urgent care, how many will reach the threshold to be
enrolled in the MCO, so it's a little bit apples and oranges, but I think it's reasonable
to look at that, but just with that, you know, caution that we just, we have different
measurements of patient populations and Workers' Comp is kind of a crapshoot.
2:13:44: Thank you. As to the actual option put before you all,
consider different numbers providers in each category of providers based upon the
population size of each geographical service area. That was just an option to put on
the table, but do you have any feedback for us on that trying to tailor the numbers
based upon population size?
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2:14:13? I think it goes back to my previous comment that the
population of an area is not necessarily indicative of the population of injured
workers. Those are applies and oranges. And, I mean, it would depend on the
industries in those areas, it depends on the age, the retirement level in those areas,
you know, certain areas have more retirees moving in, they have more service
industries and less manufacturing, you know, or logging and those kinds of things,
so just to use--I mean, I think, you know, the MCOs are--have requirements to have
people seen within a certain period of time and they're required to provide services
that are timely, convenient, and appropriate for the worker, and I--you know, with the
exception of maybe these underreported things that you're talking about where if
it's--if it's an immigrant or, you know, someone who for whatever reason has fears
about making waves, trust me, we hear plenty of people that are needing health
access and care, so, you know, I think there are properly constructed requirements
on the MCO to ensure that workers receive the appropriate care and in a timely
fashion.
2:15:43: While they might be apples and oranges, they're both fruit.
2:15:46: Yeah, no, I think that we're looking at that (unintelligible)--
2:15:47: And what I would say is, is that if one rule applies to a major
population with a high density in it and the same rule applies to a rural population
with a low density even with the 30 and 60 mile rules, et cetera, it's still one rule
applied to two very different demographic areas, and to the extent that Medicare
Advantage does work off the demographic kind of model, yes, Medicare is only
about 10 percent of the total population of the country, but by state compact
everybody's got to have Workers' Compensation insurance, so to me, yes, there are
differences, but it does make some sense to me in response to that that there should
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be a geo-access look at it, not just three providers per GSA or something like that,
that there the density of the population matters as much as the distance and that's
the way Medicare Advantage actually makes their calculations, as do we for our
criteria as well.
2:17:03: Thanks, Mitch.
2:17:06: I'd like to know on the bullet number two if that is actually, you
know, a practice that would, because what happened you say, you know, you only
have 14 percent or whatever of national chains, but is it the situation where
somebody has been requesting to be part of this panel for, you know, years and
years, they don't get on, but then let the national chain may already have an MCO in
place or have a--
2:17:35: A contract.
2:17:35: --a contract in place that when they get another, you know,
franchise put in that they're automatically enveloped in there, is that--
2:17:43: That would likely be the case because the physical therapists
tend to operate in various offices and so if--
2:17:51: They're already credentialed.
2:17:53: Yeah, and so if they add a location and they're not added to
the contract, you have a disconnect in the continuity of care, so that is likely the case
that we would add new clinics as they come in, and we're also, in that case we're not
diluting the benefit to that existing participating provider, which is, is something that
we try to look at, there has to be a benefit to our providers--
2:18:20: And that makes sense, I just (unintelligible) on the same
franchise came in (unintelligible) was because it's something that's (unintelligible)
2:18:35: What's the financial impact if you increased the numbers of
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providers on the MCO if the (unintelligible) providers (unintelligible) gets increased,
how does that, what's the (unintelligible)
2:18:50: Well, it depends on how much, I--you know, my guess would
be based on our counts and, you know, especially in the major metropolitan areas,
that it probably wouldn't have any impact, I think we probably would meet any of
those criteria on our patient (unintelligible) but it would depend on, on what you're
talking about and so...
2:19:17: Are the--are the categories, let's say that there's three
because I think see mention of that a couple times, there's three in an area, we're
talking about remote area, is it a requirement that you have three or is it just--
2:19:30: It's a requirement that we have three and if we don't, I mean,
let's say there's four there, two of them don't want a contract, then we have to allow
the worker to treat out of network so they would basically have access to all of the
providers in that area with a minimum of three are unwilling or unable to contract, so
it comes (unintelligible) and outlying areas because (unintelligible) already meet
those and now you increased those, right, you're basically, you're (unintelligible)
yeah, right, I mean, that's, so I think you have to be really careful if you're going to
do that, I (unintelligible)--
2:20:09: Yeah, more workers could treat outside the MCO, if you
made it four, five, then, right, right, then it'd be harder to meet the threshold, and so--
2:20:17: I'd like to point out we don't say increase the number of
providers, we say consider different numbers of providers--
(Crosstalk not transcribed.)
2:20:34: No, I'm definitely not excluding that possibility because there
are areas out there in Eastern Oregon where three, it's a ludicrous number, yes, I
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mean, you know, and so I do think that would be something to consider, no, I'm
definitely not, not saying at all that, oh, yeah, we should just increase the number,
no, that's not at all what I'm saying--
2:21:03: Okay.
2:21:06: Do you want patient access (unintelligible) acceptable
(unintelligible)
2:21:10: Well, particularly for physical therapy, yeah, I mean, certainly
there are access issues among primary care particularly, they just really don't want
to mess around with Workers' Comp and that's a constant struggle for us, so we're
trying some different things with bid levels, you know, trying to pilot some things and
see what we can do differently with those, but with physical therapy, that really has
not been an access issue, Lisa, have you had any (unintelligible) no, I mean, I don't
think, I would have to go back and look, but I certainly don't recall any disputes or
appeals to that end and we usually hear about it from Stan if someone's, you know,
complaining that they can't see a provider, because it will rise pretty quickly so that,
you know, I called everybody on the list and no one will see me and, you know, or I
can't drive that far or those kind of, so I don't have any data to suggest that we don't
have adequate access, and again I can only speak for Majoris, I can't speak for any
of the other MCO's.
2:22:19: So if you have a number of complaints saying I've called
everybody on the list and they're not willing to see me, how often do you modify that
list and take those unwilling providers off it?
2:22:30: That is a constant project for provider relations that when we
get that information, we call and verify it with the provider's office and then we say,
okay, are you going to see your own patients or are you just not seeing patients or
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under what conditions will you see patients and then, you know, we modify the list
that way, but I can guarantee you that it's never ever correct, because they just
change this constantly, but if we see areas where that's, you know, really a constant
and people aren't getting seen, that's when we start looking at mid-level
(unintelligible) trying to find other ways to access care for injured workers.
2:23:14: And Ramona already mentioned it, but I want to draw your
attention to another letter of advice that came from Dolores Russell from MHN
Caremark Comp, there's copies of her letter over on the side table as well, so I
guess I'll ask if you have any additional thoughts for us on this one. And--
2:23:40: There'll be time to opine on this in writing following the
meeting, Fred--
2:23:45: There will, actually, although I'm going to ask in just a
moment for to see if there's anything, you know, anything new that people want to
talk about, but I would say and, Juerg, correct me if I'm wrong, but maybe if
everyone here, if they have additional thoughts, could provide either, you know, just
an email to me or you may also telephone in your comments and I'll commit them to
writing, probably would send it back to you so that we can make sure that we
actually agree they're really your comments and not my interpretation of your
comments, but within two weeks, would that be okay? So if you can get them to us
within two weeks from today, I think we'll be good, and that'll probably take us right
to the 1st of December, so those two weeks are not extraordinarily rich in terms of
actual work time because you've got Thanksgiving in there, et cetera, but--and with
that, I'd like to see if there's any--you know, this is the agenda we put together and
we put it together, and I'll encourage you if possible in the future to be kind of
watching for a summertime memo from me that just says we want volunteers to the
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committee and we want agenda topics because the sooner we get the topics and
can get them on and do research, et cetera, the more likely we can actually get them
out to everyone in advance and then have them well-researched by the time that you
get them, but is there anything else that you'd like to talk about before we leave
today and while we still have the chance?
2:25:19: I have one thing just--
2:25:20: Right.
2:25:21: --I wanted for general conversation, I don't think
(unintelligible) specific to this meeting, about agenda topics and just rulemaking in
general. It'd be really wonderful if the Department could like have a running
calendar that would maybe post issues that people have brought in, I don't care if I
know who it is, but just the issues themselves that are being percolated up to your
attention for potential rulemaking, because then that might sort of inform us about
things that we should be thinking about differently. I think SAIF, we have a
tendency, we have our big pie in the sky issues, but just from a practical day-to-day,
we get used to the rules as they are and we put our processes in place of language
in our letters, et cetera, et cetera, and so we're not really thinking about some of
those, so it would be helpful if as the Department is collecting ideas that, and I don't
know, I would think that other people would find that useful as well--
2:26:28: It also helps with data collection if it's not something that
we're already tracking that we can start and come prepared with some valid
information--
2:26:38: Just a thought.
2:26:39: Yeah, I'll take that to the, forward to the, you know, the
people who work in my unit, the other policy analysts and our policy manager.
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How--I guess one question I would have is how well researched and vetted do you
expect them to be or could they, would they just go--
2:26:53: At all.
2:26:54: Not at all? Just--
2:26:55: No, just ideas--
2:26:57: Ideas.
2:26:57: --because, I mean, I guess we could fully expect to not every
idea that comes to you will see a place on the rulemaking agenda, but that idea
might (unintelligible) something else.
2:27:15: Right. Okay. That's very interesting, creative, thanks.
Additional thoughts. Okay. Okay, then if within the next two weeks you could get us
any additional thoughts about the agenda items or don't limit yourself to that, it's
always good to get your foot in the door if you have other ideas, so you've been a
really good group and I appreciate all your time and, sure enough, we did almost use
up our three hours that I didn't think we would, but, you know, I'm glad we did justice,
I hope we did justice to the issues, and with that I'll let you go and thank you very
much.
(WHEREUPON, the proceedings were adjourned.)
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CERTIFICATION OF TRANSCRIPT
I, Stephen Wright, as the transcriber of the oral proceedings at the November 18,
2019 hearing before Administrative Rules Coordinator Bruyns, certify this transcript
to be true, accurate, and complete.
Dated this 4th day of December, 2019.