The Louisiana Association of Self-Insured Employers (LASIE) held its 25th annual conference at the Golden Nugget Casino in Lake Charles, LA from November 2nd-4th. In addition to celebrating LASIE’s quarter-century of service to the self-insured community, the program emphasized several areas of reform. Given the national picture and our neighboring states, it was no surprise that opioid abuse and Louisiana’s outpatient billing rules emerged as key areas of discussion.
Guilbeau on outpatient billing – “ninety percent of infinity is infinity”
Louisiana’s statute governing outpatient billing for workers’ comp procedures is a continuous source of complaint from employers and insurers, who contend that payers are charged “90 percent of infinity” since “the mean of usual and customary” fees are not specific enough to stop providers at outpatient surgery centers from picking an arbitrary (and often very high) fee.
Speaking on the issue in his presentation on Thursday, John Kocke, of CoreCare Management, explained, “When they wrote the fee schedule [in 1994], there was a list of approved procedures for an outpatient setting, it’s a pretty short list. And it says that the Office of Workers’ Compensation can expand on this list to its rule-making authority, but I’ve never seen an updated list and I doubt the OWC has ever tried to update it. Now they’re even doing lumbar fusions on an outpatient basis. What’s really fascinating about that is that those procedures are not approved by most insurance carriers or by Medicare for outpatient.”
Kocke and his fellow speakers Keith Kenney of Gulf South Risk Services and Joe Guilbeau of Juge Napolitano spent much time hammering home this concept – that workers’ comp is the subject of cost shifting from other payors like Medicare and group health.
In an effort to stop such cost-shifting, Kocke offered employers a game plan. Noting that operating room charges are based on the complexity of the surgery, Kocke explained that some outpatient hospitals will exaggerate the difficulty in order to increase the price per minute but that there are resources available to attack charges.
“One of the things we can do to determine if a charge that appears outrageous is actually reasonable is to compare charges to reimbursements for that procedure at that hospital. CMS is a treasure trove of information because every hospital that accepts Medicare has to report [those data]. It gives you a starting point,” Kocke explained. “The other way to attack this is to look at bundling and unbundling [of CPT codes]. Our fee schedule says that charges should not be unbundled and that they should charge in the most expeditious way possible – the least expensive way for the carrier.”
By Kocke’s method, employers and carriers can assess Medicare’s bundling of charges and contest the unbundling of the CPT codes for a particular procedure and confront the provider with the numbers. “Now, this really does you no good if you’re a carrier that is risk averse and unwilling to engage in litigation – you’re on the hook for 90 percent.”
Joe Guilbeau picked up where Kocke left off on the legal side, saying that payors are “getting gouged by OWC’s failure to cap outpatient services” and urging attendees not to simply pay the 90 percent to avoid a fight.
Arguing that so-called “Chargemasters,” which contain proprietary information for specific procedures for specific hospitals, are often not in line with the mean of usual and customary charges, Guilbeau stated: “These hospitals aren’t run by the sisters of charity anymore, times have changed […] ninety percent of infinity is infinity […] no one expects you to pay the Chargemaster rate for the hospital until someone comes along like an uninsured patient or a workers’ compensation payor. If you continue to pay 90 percent of the charges, you’re feeding the dragon and making it worse,” Guilbeau said.
Opioids raised up as the largest impediment to return to work
Later in the conference, opioids emerged as another key area where either Office of Workers’ Compensation or legislative action should focus. RADM Pamela Schweitzer (Chief Pharmacist Officer of the United States Public Health Service, with a temporary promotion to the Assistant Surgeon General), Dr. Graves Owen of the Texas Pain Institute, and Dr. Michael Salas of the Renown Regional Medical Center discussed this in a session called “Are Pain Management Prescribing Practices Increasing Chronic Pain?”
Dr. Owen started by dispelling a myth about pain management: “You have to ask yourself, when did they start the opioids? Often it’s the occupational medicine doctor, so by the time they get to us, they are already on these medications,” he said. “So what are the risk factors for addiction at that point? Family or personal history, age under 45 years, nicotine use, and then all of the behavioral issues like impulse control, OCD, depression […] In a chronic pain population, we can have anywhere from a third to two thirds of our patients diagnosed with personality disorders.”
In addition to offering such a perspective of chronic pain in practice, the speakers also drew a distinction between chronic pain (pain lasting more than three to six months) and chronic pain syndrome. Chronic pain syndrome, according to Dr. Owen, is “someone with chronic pain who cannot function” and is “disabled in their perception, they’re not working and they’re usually on a lot of opioids.”
He also noted that he believes that many chronic pain patients are using opioids to cope with behavioral issues, even though the number of chronic pain patients that are actually addicted is between two and six percent. “So if you really want to get people back to work, you have to address these unstable behavioral issues. That doesn’t mean that you have to take ownership of them as part of the claim – we don’t know whether they occurred before the injury or not. Often carriers are unwilling to offer psychotherapy, but I think this is something we need to work with so that the help is there but the carrier isn’t entirely responsible for that diagnosis.” Dr. Owen cited Germany as an example, where injured workers that are out of work for more than a few weeks are referred to treatment for behavioral health.
Once business was complete each day, LASIE held several social events to celebrate the 25th anniversary of the organization, all in keeping with the “Rock On” theme, including a karaoke event on Wednesday and a blowout at the BrickHouse in Lake Charles featuring Bag of Donuts.
Editor’s Note: LCI Workers’ Comp, the sole sponsor of Louisiana Comp Blog, is a LASIE member and sponsored a portion of the conference events.