The November meeting of the Workers’ Compensation Advisory Council (WCAC) was held yesterday in Baton Rouge. As a new administration and the requisite holiday languor loom over a variety of regulatory initiatives, Council members focused on specific details that could aid two major ongoing problems – streamlining the 1010/1009/1008 processes, and the challenges of the Medical Director post – but no votes were taken.
The meeting was dominated by discussion surrounding a current proposal (document at the bottom of this page) to amend Louisiana Administrative Code 40:I:2715, which governs the 1010, 1009 and 1008 processes. OWCA Director Patrick Robinson explained that, as it stands, the submissions are not achieving the goal of increasing efficiency and expediting treatment decisions.
Director Robinson began the day by discussing the impetus for amending the rules, based on his meetings with various stakeholders.
Regarding Form 1010 and 1010A, Robinson identified the first problem as a back and forth between the payor and the provider when the payor believes sufficient information to be lacking. “Give the opportunity to provide additional information, but after that, if you still think there’s not enough information, make a decision. Don’t just keep it going back and forth and allow for this unilateral suspension,” Robinson said. “The other issue [on the 1010 side] is…some [payors] are running things through a PBM, which aren’t necessarily using the 1010s, and then [pharmaceuticals] are being denied at the PBM level. In speaking with the pharmacists, they have great concern with the paperwork involved about doing a 1010 for every single script that comes through for a 30 day fill,” he continued.
With the 1009 process, the key issue is an “overload of records” submitted to the Medical Director. According to Robinson, the problem is particularly common amongst claimant representatives, who may submit all or nearly all of their client’s medical records in an effort to be thorough. “When we get a submission from a doctor, it’s usually fifty pages or less…attorneys don’t have that knowledge and, out of an abundance of caution, will submit everything, sometimes up to hundreds of pages,” Robinson explained. “A fifty page review takes an hour – a five hundred page review takes a day and a half.”
Finally, at the 1008 level, Robinson stated that the issue revolves around preparation of relevant documentation, so that all parties involved know what evidence the Medical Director used to make a decision and what evidence the workers’ comp judge is considering. He advocated for the creation of an “official record” of the 1009 process in a particular claim and emphasized the need for consensus on the introduction of new evidence.
Discussion of the extensive amendments followed Director Robinson’s delineation of the identified needs, but given the fact that nearly all aspects of state government are in transition as Louisiana elects a new Governor this weekend, no vote was taken on the proposal. However, Council members from both sides indicated that it might help solve some of the 1009/1008 issues if the Medical Director was permitted to make phone calls to providers. That was not allowed in the initial statutory changes creating the position, because the MD is semi-judicial in nature and such communications could be considered ex parte. The parties generally agreed that if it would expedite the review process, and a notation was made in the official record that the MD had spoken to a provider, then the change would be recommended.
In the same vein, other rules surrounding the position are still tying up the process of hiring a new MD. In particular, Robinson stated that he would like to see the removal of a provision requiring the MD to have no clinical practice. He also indicated that, because the Medical Advisory Council influences such a significant number of policy decisions in workers’ comp, it would be worth making some of those meetings public to increase access and transparency, especially as the formulary question remains under consideration at the OWCA.
Further updates regarding the OWCA’s other initiatives were also offered up for the Council and the public’s information, including the fee schedule changes designed to increase the per diem and decrease the prevalence of outpatient upcharging by creating a Louisiana-specific conversion factor to Medicare reimbursements. That is expected to make further progress in the new year.
To conclude the meeting, Robinson confirmed that he would likely be leaving his post as OWCA Director and returning to his judgeship in Shreveport. He thanked the Council members and stakeholders, saying that he has a much broader perspective on the complexities of the system now that he has worked as top comp regulator.
There will be no WCAC meeting in December, barring extenuating circumstances. The dates for 2016 meetings will be published on the Louisiana Workforce Commission website once they are confirmed.