Health Technologies Assessment Committee Issues Initial Rulings

on Lumbar Fusion, Implantable Infusion Pumps, Arthro Knee Surgery

The Health Technologies Assessment Committee has issued initial rulings on three important treatment modalities: lumbar fusion surgery, implantable infusion pumps, and knee arthroscopy for osteoarthritis.  They approved coverage of benefits for lumbar fusion, for specific circumstances, and rejected coverage for implantable infusion pumps and knee arthroscopy.  While the lumbar fusion decision is final, the other two decisions will be finalized at the October 12, 2008 meeting of the HTA.  You can find the Lumbar Fusion decision, Implantable Infusion Pumps, and Knee Arthroscopy at the HTA webpage.

Department Releases

Trucking Safety Report and Information

In time with ASSE-WSIA's Professional Development Conference on September 11, 2008, The Department of Labor & Industries' SHARP unit has published a report concerning trucking safety in Washington State.  You can find their REPORT here.  More important than the report itself, are steps you can take to help increase trucking and driver safety. Click here for important DRIVER SAFETY information.

Medicare & Medicaid Claim

Reporting Deadline Approaches

Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (which took effect January 1, 2008) requires all liability and workers' compensation insurance companies, self-insureds and others to review every open claim in their office and submit a 3 page, 45-part questionnaire form for every eligible file.  Those forms are due at CMS (Center for Medicare & Medicaid) by July 1, 2009.  As required by the MMSEA, ‘‘applicable plans,’’ must: (1) Determine whether a claimant is entitled to Medicare benefits; and, if so, (2) report the identity of such claimant and provide such other information as the Secretary may require to properly coordinate Medicare benefits with respect to such insurance arrangements in the form and manner (including frequency) as the Secretary may specify after the claim is resolved through a settlement, judgment, award or other payment (regardless of whether or not there is a determination or admission of liability). The penalty for failure to timely comply is a staggering $1,000 per day, per claim! Beware, time is running out!  WSIA is attempting to work with the Department of Labor & Industries to determine whether our SIEDRS submittals could be forwarded to CMS, or whether each self-insured employer would be required to submit the data (and form for each claim).  You can find out more by going HERE.

Federal Law May Have Impact in

Washington Regarding Medicare Benefits

While Washington state has been fairly insolated from the Medicare Secondary Payer Act, mostly due to the fact that we do not have compromise and release and cannot settle out the medical portion of our claims, a provision in a recent federal law might impact self-insurers here in Washington.  WSIA is STILL soliciting feedback from a number of sources to get an idea on how this might apply on our claims.  We await responses from the Department and from UWC, the federal organization we belong to that lobbies on workers' compensation and unemployment issues.  You can be certain we will share that information with you as soon as it becomes available.   Here's the text of their email to us:

On 12/29/2007, President Bush signed the "Medicare, Medicaid, and SCHIP Extension Act of 2007". The bill was sponsored by Senator Chuck Grassley (D-IA) and was passed in the House (12/19) and Senate (12/18) before the signing by the President. The bill passed unanimously in the Senate and 411-3 in the House. Grassley has long been an advocate for increased Medicare Secondary Payer enforcement and the passage of this bill into law has ramifications for Liability Insurance, Self Insurance, No Fault Insurance, and Workers' Compensation Insurance programs nationwide.

Of major importance to liability, self, no fault, and workers' compensation insurers is Section 111 ("Medicare Secondary Payer"), paragraph 8 ("Required Submission of Information by or on behalf of Liability Insurance (including Self-Insurance), No Fault Insurance, and Workers' Compensation Laws and Plans"), items (A)-(H). Here are a couple key sections of the law:

(A) REQUIREMENT - On or after the first day of the first calendar quarter beginning after the date that is 18 months after the date of the enactment of this paragraph (the law was passed on 12/20/07, making the following requirements begin July 1st, 2009), an applicable plan shall- (i) determine whether a claimant (including an individual whose claim is unresolved) is entitled to benefits under the program under this title on any basis; and (ii) if the claimant is determined to be so entitled, submit information described in subparagraph (B) with respect to the claimant to the Secretary in a form and manner (including frequency) specified by the Secretary.

(B) Required Information - The information described in this subparagraph is -

(i) the identity of the claimant for which the determination under subparagraph (A) was made: and

(ii) such other information as the Secretary shall specify in order to enable the Secretary to make appropriate determination concerning coordination of benefits, including any applicable recovery of claim.

(C) TIMING - Information shall be submitted under subparagraph (A)(ii) within a time specified by the Secretary after the claim is resolved through a settlement, judgment, award, or other payment (regardless of whether or not there is a determination or admission of liability).

(E) ENFORCEMENT

(i) In General - An applicable plan that fails to comply with the requirements under subparagraph (A) with respect to any claimant shall be subject to a civil money penalty of $1000 for each day of noncompliance with respect to each claimant (in addition to any other penalties prescribed by law and in addition to any other Medicare secondary payer claim under this title with respect to an individual).

What does it all mean?

Beginning on 7/1/2009; Liability Insurers, Self-Insurers, No Fault Insurers, and Workers' Compensation Insurers must determine Medicare beneficiary status on all claims and report those claims involving a Medicare beneficiary to the Secretary at the time of settlement, judgment, or award. If the reporting is not done in a timely manner, the Secretary may enforce a civil money penalty of $1000 per day per claim. Beyond the reporting requirements and financial penalties, this now provides Medicare huge amounts of previously difficult to collect primary payer data on liability, self-insured, no-fault, and WC claims which can be utilized to enforce their Secondary Payer rights. It will be very easy for Medicare to review settlements, judgments, and awards to determine if their interests were adequately considered in the settlement. Workers' Compensation has faced a similar situation (on a smaller scale) since 2002 with Medicare Set-Aside Arrangements. The scope of this law is much broader than MSAs though and adds liability and no-fault settlements into the process, with stiff financial penalties for non-compliance.

What can be expected?

The Secretary has two issues to address in this law, (1) what data to collect and (2) what timeframe to receive the information post-settlement, judgment, or award. The timing of the collection of data (post-settlement, judgment, or award) suggests that a copy of the the settlement agreement, judgment or award will be required submission to the Secretary. Since the intent is to enforce Medicare's Secondary Payer rights, it is reasonable to assume injury information, diagnosis codes, and primary payer data will be required. The language is broad enough to allow for the collection of medical information to determine if the settlement adequately protected Medicare's interest. It is likely that the timeframe will be shortly after the date of settlement, judgment, or award, but may be more frequent.

If you are a self-insured employer or TPA and have dealt with this issue in other states, please contact Dave Kaplan at dave.kaplan@wsiassn.org or by phone at 800-736-7296.  Thank you!

Department Adopts New Fee Schedule,

Limitations on Massage Therapy Reimbursement

The Department of Labor & Industries adopted the new RBRVS converstion factor that took effect July 1, 2008.  In addition to the conversion factor change, the Department adopted a rule change relative to massage therapy reimbursement. The effect of the rule change is to limit massage therapy reimbursement to 75% of the fee schedule for physical therapy and occupational therapy.  You can find the text of that new rule HERE.

Department Provides Updates & Corrections

to July 1, 2008 Medical Aid Rules & Fee Schedule

The Department has released a link to the changes and corrections in their July 1, 2008 Medical Aid Rules & Fee Schedule.  You can find those updates and changes HERE. Several Payment Policies were inadvertently published with errors. These corrections are effective July 1, 2008.
• Page 48, Professional Section: Technical component in an ASC is determined by the ASC Fee Schedule not the Professional Fee Schedule as stated.
• Page: 57, Professional Section: The Radiology Reporting Requirements was inadvertently left off. A separate formal written report is required before the professional component will be paid.
• Page 90, Professional Section: Code 1108M, IME Standard exam, had a combined bullet point.
• Page 92, Professional Section: Code 1129M, Extensive file review by examiner, was worded in such a way as to appear that it did not apply to self insured employers.
• Page 92, Professional Section: Code 1131M, Out of state exam, the description was inadvertently omitted.
• Page 140, Professional Section: Some items were inadvertently left off the Interpreter Maintenance of Boundaries area.
• Page 141, Professional Section: Some items were omitted from the Interpreter Prohibited Conduct area.
We want to thank everyone who brought these issues to our attention. We strive to make the Medical Aid Rules and Fees Schedules reflect the correct policies of L&I. We are sorry for any inconvenience that our omissions may have caused. We welcome any questions, comments or suggestions that anyone may have concerning the Medical Aid Rules and Fee Schedules.
To get the complete text of the above corrections, please see the Payment Policy Corrections Table, under the Updates & Corrections Tab, within the 2008 Fee Schedules located on the fee schedules web site: http://feeschedules.Lni.wa.gov. All entries have a posting date of July 25, 2008 and are effective July 1, 2008.

Department Publishes

Helpful Leave Guide

With the adoption of yet more leave laws by the Legislature, the Department of Labor & Industries has developed a table listing all of the leave laws, and what the requirements are.  You can find the leave listing table at http://www.lni.wa.gov/WorkplaceRights/files/FamilyLeaveLawsTable.pdf.  For more detailed information on each type of leave, go HERE.  Coordination of leave benefits with workers' compensation benefits will become an even bigger issue in the future, so watch the WSIA website for more information.

Department Finalizing

Hospitalization Rules

The Department is in the process of finalizing changes to the core safety rules, the most notable change being the reporting of even one employee going to the hospital for medical treatment.  The rule requires reporting the hospitalization within 8 hours of the incident.  Click HERE to see the rule language.  WSIA will be submitting comments to the Department for consideration.  HOWEVER, it's important to note that the change has already taken effect on the "expedited rule-making process".  Objections to the expedited rule-making process must be received to the Department no later than October 10, 2008.  Barring a strong objection or problem with the rule, the rule will become final on that date.

Department Reiterates Prior Policy on

Payment of LEP, Time Loss Benefits to Terminated Employees

On September 4, 2008 the Department issued a memo "clarifying" when Time Loss or Loss of Earning Power was to be paid to a worker that was terminated for cause.  You can find that memo HERE.  The controversy over this issue deals with the last phrase in the memo: "Termination for cause must be for actions occurring during the light duty employment and not retroactively (i.e. the worker failed a drug test that was prior to returning to work)."  Many employers and attorneys have expressed that is not what RCW 51.32.090(4) states, and that was not the law's intent.  If you have thoughts on the Department's interpretation of this law, please email them to WSIA Executive Director Dave Kaplan at dave.kaplan@wsiassn.org.

Department Receives a Petition for

Psychiatric ARNP's to Initiate Claims

The Department of Labor & Industries has received a petition for rule-making from an ARNP asking to allow psychiatric ARNP's to initiate a claim.  All ARNP's (and Physicians Assistants, for that matter), were given the authority by the Legislature to initiate claims and to certify time loss.  However, ARNP's that are credentialled to work on psychiatric issues have been unable to treat or certify for psychiatric conditions associated with the injured worker's physical ailments.  The rule change would clarify that they could certify/treat such psychiatric conditions.  Do you have comments in regard to this issue? Please contact WSIA Executive Director Dave Kaplan at dave.kaplan@wsiassn.org and share your thoughts.  And continue to watch the FYI online newsletter for more information, if actual rule language changes are proposed.

Department Announces Rules

Development Schedule for Second Half of 2008

As required by law, the Department of Labor & Industries has posted it's proposed rule-making schedule for the last half of 2008.  You can find out what issues they intend to tackle by going to
http://www.lni.wa.gov/LawRule/Files/pdfs/RulesAgenda.pdf.

Requesting Self-Insured and

Requesting State Fund Claims Files

In response to changes in public disclosure law, the Department of Labor & Industries has changed the way they process and respond to requests for prior industrial insurance claims files.  You will need to submit TWO requests: one to Norm Voiles for information on self insured claims (faxed to 360-902-6900), and then requests for State Fund claims histories to Paula Clayton (faxed to 360-902-6970.)  If you have questions on the status of State Fund claims information requests, you can call 360-902-5656.  Most State Fund requests will be handled within 10 business days.

Return to Work Workshop

Set for October 8 - 9 2008

There is a Return to Work Toolkit workshop scheduled for October 8-9, 2009 at the Doubletree Suites Hotel in Tukwila.  The workshop is geared for professionals who are working with the RTW process such as RTW coordinators, human resources personnel, claims adjusters, VRC's and nurse case managers.  The interactive class is limited to 20 participants so you will want to register as soon as possible.  For more information about the workshop, click INFO.  To register for the workshop, click REGISTER.

Department Announces

Inactivation of Provider Numbers

The Department of Labor & Industries announced that all provider numbers for Dr. Brian Buchea (Ferndale) have been made inactive.  According to a voicemail on his office machine, Dr. Buchea retired his medical practice on July 29, 2008.

as of 9/15/2008