The Department of Industrial Relations and its Division of Workers Compensation (DIR/DWC) announced the afternoon of January 4, 2013, new regulations implementing provisions of Senate Bill 863, including the amended official medical fee schedule for ASCs.
According to the DIR/DWC details of these new regulations include:
Hospital outpatient departments and ambulatory surgical centers fee schedule
The statute amended the official medical fee schedule for hospital outpatient departments and ambulatory surgical centers, reducing the facility fee for ambulatory surgical center services to 80 percent of what Medicare bills for the same services in a hospital outpatient. The regulation is effective Jan. 1, 2013.
Utilization Review, Independent Medical Review
For injuries on or after Jan. 1, 2013, and effective July 1, 2013 for all dates of injury, medical treatment disputes will be resolved by physicians through an efficient process known as independent medical review (IMR), rather than through the often cumbersome and costly adjudication system. If utilization review denies, delays or modifies a treating physician’s request for a specific course of medical treatment for the reason that the treatment is not medically necessary, the injured employee will have the right to request a review of that decision by IMR conducted by a physician. The physician review will be expeditious and based upon evidence-based standards to ensure that injured employees receive timely and appropriate medical treatment.
Qualified Medical Evaluator Regulations and PDRS
The new regulations amend existing rules to clarify that independent medical review is the sole process for resolving disputes regarding ongoing medical treatment issues; limits the number of offices from which a Qualified Medical Evaluator (QME) may conduct evaluations; streamlines the application process for chiropractors; allows for factual corrections of a comprehensive medical-legal report from a QME panel; and amends a number of forms.
Independent Bill Review
Medical service billing disputes for dates of service on or after Jan. 1, 2013, will be resolved through a non-judicial process of independent bill review (IBR). The IBR applies to any medical service bill where the fee is determined by a fee schedule adopted by the DWC. If the medical provider disagrees with the amount paid by a claims administrator on a properly documented bill following a second review, he or she can request an IBR. This regulation will eliminate unnecessary, costly litigation.
Electronic document filing and lien filing fee
Any lien for reasonable medical expenses incurred by or on behalf of the injured employee (except disputes subject to independent medical review or independent bill review) and filed on or after Jan. 1, 2013, is subject to a lien filing fee of $150. For those liens filed before Jan. 1, 2013, there will be a $100 activation fee which must be paid prior to Jan. 1, 2014, or the lien will be subject to dismissal by operation of law.
Self-Insurance and Annual Actuarial Reports
These new regulations will implement SB 863’s requirement for all private self-insured employers and groups to obtain an actuarial report to more accurately establish the organization’s California workers’ compensation liability exposure. The regulations will further define new methods in how the OSIP establishes security deposit collateral requirements based on this additional information.
Interpreter Services
SB 863 amended Labor Code section 4600(g) to state that an injured worker is entitled to the services of a “qualified interpreter” at medical appointments if the injured worker is not proficient in English. These regulations define the “qualified interpreter for purposes of medical treatment appointments” as “…an interpreter who has a documented and demonstrated proficiency in both English and the other language; a fundamental knowledge in both languages of health care terminology and concepts relevant to health care delivery systems; and education and training in interpreting ethics, conduct and confidentiality …” so that employers can furnish, and non-English-speaking injured employees can receive, interpreter services at medical treatment in accordance with the statute.
Supplemental Job Displacement Benefits
Makes modifications reflecting regulatory changes regarding offers of work, notifications and vouchers for retraining workers injured on the job.
Additional information regarding these changes can be found at the links provided above. The CASA Workers Compensation Fee Schedule Calculator has been updated and is listed on the CASA website.