At the October meeting of the Workers’ Compensation Advisory Council (WCAC) yesterday, members addressed concerns about UR review, reimbursement for surgical implants, the pending status of a new OWC Medical Director, and the upcoming public hearing for the 200+ page update of the Medical Treatment Schedule.
Utilization review standards have been an issue in the carrier community since the Wilson v. Broadmoor decision back in March, in which an out-of-state UR doctor’s review was deemed incompetent evidence. In the meeting yesterday Council member Denis Juge questioned whether or not the OWC ought to promulgate rules or issue clarification on the matter. Greg Hubachek, another Council member, (whose law partner Greg Unger successfully represented the injured worker in the case) stated that the UR opinion in the Wilson case was especially unsatisfactory. “The report itself was not competent evidence,” Hubachek explained. “The reason that it wasn’t competent was because it was a really bad UR report…and the judge gave it no weight and shouldn’t have given it any weight.”
Of particular concern to nearly all Council members in reference to out-of-state UR was improper standards. Dr. Henry Eiserloh, an orthopaedic surgeon by trade, explained, “When I get patients with an out-of-state review, the problem becomes their lack of familiarity with our Guidelines. And when you read them they reference ODG or whatever, and those are rules we don’t play by. If there’s like a 1-800 number and it says ‘call this to talk to the peer review physician,’ I call the adjuster and just tell them: ‘No, I don’t have time for this, I’m in accordance with the guidelines.’ I thought that was the reason we had all these meetings in the first place, to streamline the process.”
Other Council members confirmed that domestic carriers almost unilaterally use exclusively Louisiana doctors for UR, and OWC Director Patrick Robinson explained that defining “what constitutes practicing medicine” is likely not under the authority of his administration anyway.
Further in the medical realm, Robinson confirmed that Dr. Ian Gardner, an occupational medicine physician, will be the new lead Medical Director for the OWCA. However, the associate position remains vacant and, because Dr. Gardner will not be available to start until January, the agency is “reviewing contracts for private companies to fill that need.” Robinson also explained that certain “boundaries of the statute” regarding the MD position make it especially difficult to fill.
Regarding the highly anticipated update of the Medical Treatment Schedule, Robinson reminded the parties assembled that the public hearing will take place on October 28th at 9:30 AM at the OWC (on the fourth floor of the Louisiana Workforce Commission campus). By way of preface, Robinson explained that the MTS update is still based on Colorado’s standards, but that there could be a “gradual veering away from” them. However, complications associated with such a departure include prominently the fact that the OWCA lacks dedicated staff to perform updates. The responsibility would likely fall on the Medical Director and his or her associate, which would be in addition to their duties in the 1009 process.
Attendees also heard two guest presentations. The first was from Michelle Sorrels, Co-Chair of the Kids’ Chance scholarship program Committee in Baton Rouge about National Kids’ Chance Awareness Week from November 2nd-6th. Sorrells encouraged workers’ comp professionals to hold fundraising events in their offices and to donate.
The second was delivered by Jennifer Brescher of Cypress Pointe Surgical Hospital in Hammond. Brescher sought to clear up confusion regarding the reimbursement of surgical implants, which she said is a problem for many facilities but especially Cypress Pointe, which is small scale in nature. According to Brescher, Cypress Pointe and other surgical hospitals do not keep surgical implants in stock, but rather, have the vendor in the OR to administer the correct implants in each case, which are then sent to the comp carrier for reimbursement as a handwritten invoice. However, “the majority of carriers that are processing these claims omit these invoices and pay us without reimbursement for the implants. And then we have to turn around and do reconsideration and appeals. If you go through [the statute], it doesn’t specify whether invoices have to be typed or handwritten…We’ve really only had this problem in the last couple of years.” Brescher went on to explain that some carriers will try to match a bulk invoice from the implant vendor to the individual case, which is not accurate. She went on to encourage adjusters and carriers to recognize the way that implants work in small surgical centers and accept the invoices as delivered.
The next WCAC meeting will be held at the LABI Conference Center on November 19th.
Image Credit: LexisNexis Workers’ Compensation eNewsletter California edition.