Essential Updates: Comp Medical News

Welcome to the first installment of the monthly Comp Medical News essential update series. On the first Wednesday of each month, Comp Blog will keep you informed of the most important national stories related to medicine and workers’ comp, with special focus on medical treatment guidelines and medical management.

 First, the last month saw several major stories on the regulatory and governmental front:

OWC Director Wes Hataway supports hospital fee schedule changes

Wes Hataway expressed the OWC’s desire to see changes made to the state’s hospital fee schedule. This could occur either in the 2015 legislative session or may be accomplished by administrative rule changes. Leaders representing both workers’ comp carriers, and hospitals that treat workers’ comp patients, are frustrated by the nearly twenty year old current hospital fee schedule, which provides for reimbursement levels that are often discordant with modern medical technology. Also at issue is the rate for outpatient procedures, often referred to as the “90% rule” which sets reimbursement at 90% of billed charges, with no distinct guidance on proper initial charges. By contrast, the per diem rate for inpatient procedures under-compensates hospitals.

Read the feature from WorkCompCentral (paid content) here.

New York medical treatment guidelines deemed within the Workers’ Compensation Board’s authority

The highest court in New York state ruled recently that the the New York Workers’ Compensation Board was within its rights to list preauthorized medical procedures. The case involved an employee for the Board who was injured in a work-related car accident in 1996 and deemed permanently partially disabled. The Board denied her acupuncture treatments after the implementation of the state’s medical treatment guidelines in December 2010, claiming that the treating physician had not objectively proven that such treatment was necessary under the guidelines. The appellate division ruled in a 4-3 decision that the board “acted within its legislatively conferred authority when it devised a list of pre-approved medical care deemed in advance to be medically necessary for specified conditions.”

Read full coverage from Business Insurance here.

Arkansas Workers’ Compensation Commission proposes the adoption of the Official Disability Guidelines and associated ODG formulary

The Arkansas WCC has posted an administrative rule proposing that the state adopt the Official Disability Guidelines and its drug formulary, to be effective January 1st, 2015. The rule is currently open for public comment until December 29th. The implementation of the ODG formulary will be phased in for claims with an injury date on or after July 1st, 2015 and for legacy claims, would apply after July 1st, 2016.

Access the proposed rule here. Read coverage from WorkCompCentral here.

Medicare is cracking down on non-emergency ambulance transportation

Beginning this week seniors living in Pennsylvania, New Jersey and South Carolina will need prior approval from Medicare before they can get an ambulance to take them to cancer or dialysis treatments. The change is part of a three-year pilot to combat extraordinarily high rates of fraudulent billing by ambulance companies in those states and could extend to others. The crackdown comes on the heels of a 2010 inspector general report which indicated that 20 percent of the agency’s spending on non-emergency ambulance trips was improper.

Read the story from Healthcare Finance here.

 Second, the business side of medicine was on in full force:

The EEOC is challenging some wellness programs offered by employers on the grounds that they violate the Americans with Disabilities Act

The Equal Employment Opportunity Commission, filed suit against Honeywell International in October charging, among other things, that the company’s wellness program isn’t actually voluntary, as it sets extremely high financial penalties for employees who refuse to undergo medical testing. It’s the third lawsuit filed by the EEOC in 2014 that takes aim at wellness programs, and it highlights a lack of clarity in the standards these programs must meet in order to comply with both the Affordable Care Act (AKA “Obamacare”) and the Americans with Disabilities Act. Large employers, many of whom supported the ACA because it encouraged incentive-based wellness programs, have threatened to throw their weight behind legislative efforts to repeal or radically alter the law unless the EEOC backs down.

Read the story from Workers’ Comp Institute 360 here.

ICD-10 gains ground on social media with #ICD10Matters

Advocates for the impending switch to ICD-10 medical classification codes, which would bring U.S. healthcare in line with international coding standards, have been swarming on Twitter, using the hashtag #ICD10Matters to build awareness and support for the changeover. The movement, which is a few months old, recently flared up again to counter a campaign by the Texas branch of the American Medical Association asking members to lobby Congress to delay the deadline for ICD-10 compliance, currently set for Oct. 1, 2015.

Read full coverage from Healthcare Finance here.

 Lastly, two notable editorials about medical care in workers’ comp offer some valuable perspective on both the industry and the plight of the injured worker:

Tom Sebold, Vice President of GENEX, discusses the top three myths of medical bill review

Read Sebold’s thoughts via WorkCompWire here.

Mary Ann Porucznik, with the American Academy of Orthopaedic Surgeons, asks: Do treatment guidelines threaten the patient-physician relationship?

Read Porucznik’s criticism of guideline production and physician burden of proof, especially relevant to the NY Comp Board story above, here.


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