At the 2019 California Self-Insurer Association Annual Conference, George Parisotto, Administrative Director from California Division of Workers’ Compensation discussed their ongoing activities.
Medical Treatment Utilization Schedule
The MTUS guidelines are an independent guideline that contains definitions and evidence based treatment guidelines. They include the ACOEM guidelines but can go beyond them. They are constantly looking to update their guidelines and the regulations provide a methodology to easily make adjustments based on the latest evidence based treatment guidelines. Recent updates include October 2018 traumatic brain injury guidelines and April 2019 updates on a variety of issues including post-traumatic mental health.
Physicians can now have free access to these guidelines by registering on the Reed Group web site to view the CA MTUS-ACOEM Edition guidelines.
MTUS Formulary and Drug List
The formulary applies to all drugs dispensed on or after January 01, 2018 and applies to all accident dates. It applies only to drugs dispensed for outpatient use at home or outside a clinical setting. The ACOEM guidelines are the foundation of the formulary. Certain drugs are considered “exempt” from review if the drugs are filled according to MTUS guidelines. Prospective review is required for drugs that are not exempt from review. The formulary also contains ancillary formulary rules around things like physician dispensing, generic/brand dispensing, compound drugs, and off-label use.
Independent Medical Review
Workers that apply for IMR are represented 85% of the time. This is definitely an attorney driven process. They receive about 250,000 IMR applications per year. This is substantially higher than they anticipated when the law was passed. These numbers have held steady at this level since the law was passed. The IMR process is very efficient and operates well within the timelines provided in the statute. In spite of this, they get frequent complaints that the IRM process is delaying medical treatment. 90% of IMR decisions are upheld on appeal and this has head steadily for years. Most IMR requests have to do with medications as they involve half of all IMR reviews. They hope that the drug formulary will result in less IMR reviews as physicians follow the pharmacy treatment guidelines.
Independent Bill Review
They do not see much activity in this area. It is only used in a dispute over the amount of the bill, not the appropriateness of the treatment. The thought is most of these disputes never reach this level. They see less than 2,000 of these requests per year. About 1/3 of these reviews result in additional payments to the medical providers.
Mandatory electronic reporting of UR data by claims administrators is now required. The doctors first report must also be submitted electronically to both the DWC and the claims administrator.
Utilization Review – SB 1160
DWC approval of UR plan is required. URAC accreditation is required for UR plans that deny requests for authorization effective July 01, 2018. Certain non-profit, public sector internal UR programs may be exempted from accreditation.
Claims administrators cannot refer matters to a UR entity in which the claims administrator has a financial interest unless there is prior written disclosure to the employer of the financial relationship. Utilization Review Organizations are prohibited from offering financial incentives to physicians based on the number of UR denial or modification decisions they issue.
Effective 01/01/2018 prospective UR is not required for treatment within the first 30 days after the date of accident if the treatment is on an accepted body part, consistent with the MTUS, rendered by a MPN or HCO physician, and the bills are submitted timely. Surgery, psychological treatment, advanced radiology services and injections are exempt from this UR fast track.
DWC is looking to revise their regulations around audits of UR programs focusing on a larger sample population and claims where there was a UR denial. These revised regulations will include more robust penalties and will not allow abatement of the penalty.
Qualified Medical Evaluators
Proposed QME regulations were received by the DWC in December 2018. There are significant concerns that QME reviewers are not appropriately following MTUS guidelines and formularies. They are considering discipline procedures to remove physicians from the QME list if they do not follow the guidelines. The rates being paid to QME’s is also being reviewed and they are considering going to flat rates for these exams.
The medical fee schedule is supposed to update annually. The pharmacy fee schedule will be revised very soon based on recently published guidelines. They also set fee schedules for copy services, interpreters, and home health services.
They are moving to a complaint-based audit schedules which will include looking more at issues like denial of claims. These regulations will be changing and those changes will be published in the near future.
Liens filed by providers who are criminally charged with fraud are automatically stayed pending disposition of the criminal case. If convicted the stay remains in place. Providers convicted of medical fraud are also suspended from practicing in the workers’ compensation system. All liens must certify that they are not subject to IBR and that the lien claimant is eligible to file that lien. This has helped reduce the overall volume of liens in the system.