Regulatory and Legislative Updates

Fee Schedule Changes

California

The California Division of Workers’ Compensation adjusted their Physician and Non-Physician Practitioner Fee Schedule and their Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule to conform to changes in the Medicare payment system as required by law. Both orders are effective for services rendered on or after July 1, 2016. The physician/non-physician practitioner order adopts the following Medicare changes:

  • CMS Medicare National Physician Fee Schedule Relative Value File (RVU file) RVU16C July 1, 2016 quarterly update
  • National Correct Coding Initiative Physician/Practitioner Services CCI Edits July 1, 2016 quarterly update
  • National Correct Coding Initiative Medically Unlikely Edits July 1, 2016 quarterly update

The DMEPOS order includes all changes identified in CMS Change Request number 9642 and adopts the Medicare DMEPOS quarterly update for calendar year 2016.

Louisiana

The Louisiana Supreme Court released a much anticipated decision further clarifying their interpretation of the $750 limit for non-emergency medical treatment of injured workers without the mutual consent of the workers’ compensation payer and the injured employee. The decision also provides further guidance to payers on how the $750 limit for non-emergency medical care in statute is viewed by the Court, particularly in the case of physician dispensed medications.

Montana

The Montana Department of Labor and Industry adopted updated rules governing their professional fee schedule, which covers several ancillary categories. The fee schedule update mostly includes an increased conversion factor for several ancillary service categories along with the associated rate adjustments and is effective for services provided on or after July 1, 2016. Pharmacy services are ​not affected by the update.

New York

The New York Workers’ Compensation Board posted a list of modifications to their Durable Medical Equipment (DME) fee schedule. The schedule is based on Medicaid, and the changes only impact nine Healthcare Common Procedure Coding System (HCPCS) codes. These changes apply to dates of service on or after July 1, 2016.

Rhode Island

The Rhode Island Division of Workers’ Compensation, through their vendor, posted updated fee schedules applicable to dates of service on or after July 15, 2016. The updates include reimbursement rate increases for many listed ancillary service/item codes and updated procedure coding. Individually listed fee schedule codes should be reviewed for a detailed assessment. Pharmacy reimbursement has not been changed at this time.

South Dakota

The South Dakota Department of Labor and Regulation, Division of Labor and Management adopted updates to their rules governing fee schedules for professional services (CPT codes). This includes updating the Relative Values for Physicians publication source edition and increasing the conversion factors. The rule changes took effect June 28, 2016. Reimbursement rules for Durable Medical Equipment (DME) and pharmacy have not been changed at this time.

Washington

The Washington Department of Labor & Industries adopted and posted updated fee schedules and billing/payment policies for services performed on or after July 1, 2016. The most notable changes ​relate to reimbursement for many listed Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS) and state-specific codes.

Wyoming

The Medical Case Management Unit of the Wyoming Division of Workers’ Compensation posted bulletins containing updated guidelines and policies regarding coverage for and payment of ​transcutaneous electrical nerve stimulation (TENS) devices, home oxygen therapy, and active/passive cooling and heating devices.

Federal

The bill processing vendor for the U.S. Department of Labor (DOL), Office of Workers’ Compensation Programs (OWCP) announced significant reductions to reimbursement for both generic and compounded medications under the Division of Federal Employees' Compensation (DFEC) program. The reimbursement for compound medications establishes two tiers based on ingredient count. These fee schedule reductions apply to services billed on or after July 1, 2016. Additionally, it was announced that, starting July 1, 2016, initial prescriptions for compounded medications should be for a period not to exceed 90 days. Initial prescriptions for periods greater than 90 days may be subject to further review for medical necessity.

Opioid Analgesics

Arizona

The Industrial Commission of Arizona adopted regulations to create ground rules for the use of and application of previously adopted treatment guidelines. The regulations were approved by the Governor’s Regulatory Review Council​ and will take effect October 1, 2016. The new rules outline the process that should be used when applying the guidelines, including voluntary preauthorization and decisions made by payers to approve or deny use of an opioid analgesic.

Massachusetts

The Massachusetts Department of Labor & Workforce Development posted a revised chronic pain guideline and a new opioid analgesic protocol. Similar to state-wide legislation passed earlier in the year, the new opioid analgesic protocol, which is specific to workers’ compensation, includes a 7-day initial prescribing limit which may be exceeded if deemed necessary in the professional medical judgment of the prescribing physician.

Minnesota

Originally adopted in June, 2015, The Minnesota Department of Labor & Industry (DLI) has revised their model contract related to their rules governing long-term treatment with opioid analgesic medication for workers' compensation injuries. Providers are not required to use the DLI model contract; however, if a prescriber uses this model contract, it is deemed to meet the requirements of the rules once completed and made part of the patient's medical record.

New Hampshire

Legislation was signed related to opioid analgesic prescribing and treatment from a state-wide perspective, not just limited to workers’ compensation or auto no-fault. While the bill, HB 1423, does not impart any immediate prescribing restrictions via statute, it does require various medical licensing boards to report proposed rules for the management of prescribing Schedule II, III and IV opioid analgesics for the treatment of pain to the Joint Legislative Committee on Administrative Rules, no later than September 1, 2016. The bill outlines what the rules should contain, including required use of treatment agreements, checking the state prescription drug monitoring program (PDMP) and limits on the days supply of medications.

New York

New York Governor Andrew Cuomo signed SB 8192, incorporating many of the recommendations that the New York Heroin and Opioid Task Force published in their final report released on June 9, 2016. Among other provisions, the legislation

  • Requires enhanced educational requirements regarding opioid analgesics and addiction issues for providers
  • Adds new requirements for health insurance plans to offer benefits for in-patient substance abuse treatment at state-licensed facilities that are within the payer’s network
  • Imparts new statutory limitations on prescribing of opioid analgesics, and
  • States that a practitioner may not prescribe more than an initial 7-day supply of any Schedule II, III or IV opioid analgesics when treating acute pain. Subsequent refills are subject to the current prescribing limitations of 30 days.

Vermont

Continuing a trend, legislation was signed in Vermont related to opioid analgesic prescribing and treatment, addressing the state-wide, cross-industry concern. Among other provisions, SB 243 adds “acute pain” to the list of treatments that the various licensing boards shall address via development of evidence-based standards, strengthens use of the state’s prescription drug monitoring program (PDMP) and allows the Commissioner of Health to engage in rule-making on the prescribing and dispensing of opioid analgesics, including the ability to restrict initial prescribing time frames. Various effective dates are included in the legislation, depending on the specific area being addressed.