Rules Are Meant to be Broken – or At Least Updated. 2019 Rule Updates
2019 brings changes to two Rules that affect Colorado Workers’ Compensation. Rule 11 and Rule 16 have both been revised and the changes go into effect January 1, 2019. The changes to Rule 11and the DIME process are extensive. Below is a brief summary of the changes.
Rule 16 is undergoing a few changes. The rule has been reordered. Most of the changes are not substantive. It is strongly recommended that the new rule be referenced in dealing with any prior authorization or billing issue for specifics. The more substantive changes are highlighted below; however, the specifics of the rule should be reviewed in each situation.
- ‘Payer’ definition is the same, but the definition now states that use of third parties to pay bills does not relieve the carrier or self-insured employer of obligations under the rules.
- Recognized healthcare providers previously under 16-5 is now under 16-3.
- Required use of the medical treatment guidelines, previously under 16-3 is now under 16-4
- Notification requirements previously under 16-9 is now under 16-5.
- Prior authorization previously under 16-10 is now under 16-6
- Contest of prior authorization previously under 16-11 is now under 16-7.
* In conjunction with 16-11 in the new rule governing payment of medical benefits, contest for payment of prior authorization for non-medical reasons now contains examples of non-medical reasons including: no claim has been filed, compensability is not been established, the provider is not authorized, insurance coverage is at issue, typographic, gender or date errors on the bill, failure to submit medical documentation and unrecognized CPT codes.
- Required use of the medical fee schedule previously under 16-4 is now under 16-8 and specifically sets forth the payment for build services without an established value under the medical fee schedule require prior authorization.
- Required billing forms and accompanying documentation previously under 16-7 is now under 16-9 and has been added to somewhat.
- Required medical documentation previously under 16-8 is now under 16-10 and sets forth in greater detail specifically what Form 164 should look like from the doctor’s office.
- Payment of medical benefits previously under 16-12 is now under16-11.
- Dispute resolution process previously under 16-13 is now under 16-12.
- On-site review of hospital or other medical charges previously under 16-14 is folded into 16-10 regarding required medical record documentation.
The following is a brief summary of the Rule 11 changes:
- No real change for years.
- Doctors’ reluctance to continue to do DIMEs due to reimbursement and increased complexity.
- January 1, 2019
- DOWC says there is some leeway for the first month.
Overview of changes
- 3 tiers based on DOI, and number of body parts
- $1,000 = DOI < 2 years and < 3 regions marked on the application
- $1,400 = DOI > 2 years but < 5 years and 3 – 4 body regions marked
- $2,000 = DOI > 5 years and ≥ 5 or more body regions marked
- FAL – includes objection to the FAL, notice proposal and application for DIME
- Request for Appointment to the DIME
- Notice and Proposal and Application for DIME
- DIME Examiner Summary Sheet
- Notice of DIME Negotiations
- Follow-up DIME
- DIME Physician Summary Disclosure Form
- Notice of Reschedule or Termination of DIME
- Notice of Agreement to Limit the Scope of the DIME
- DIME Report Template
Time-frames – font color corresponds to responsible party. Key to color below list.
- FAL = 30 Days After Receipt of MMI (calendar 30 days after report for safety)
- Notice and Proposal and Application for DIME = 30 Days After Filing of FAL
- Claimant Files for Indigency = 15 Days After Filing the Notice and Proposal and Application for DIME
- Attempt to Negotiate DIME = 30 Days After Notice and Proposal and Application (Notice of Negotiation Form to be filed within 30 Days)
- DOWC Issues Panel = 5 days
- Summary Disclosure Request = 5 Business Days
- Requesting Party Strike If No Disclosure Request = 5 Business Days
- Non-Requesting Party Strike = 5 Business Days
- DOWC Send DIME Confirmation = 5 Business Days
- Pay For and Schedule DIME = 14 Days
- Schedule DIME = Between 35 – 75 Days After DIME Confirmation
- Complete Copy of Medical Records to Claimant = 14 Days from DIME Confirmation
- Claimant submits additional Medical Records to Carrier = 10 Days After Medical Packet From Carrier
- Completed Packet Provided to DIME = 14 Days Before Exam
- Claimant Notifies Carrier of Need for Interpreter = 14 Days Before Examination
- Carrier is Responsible for Paying for the Interpreter
- After DIME = 20 Days After Examination a Report is Generated
Key = Respondent duty = Claimant duty = Either Party’s duty
- New Rule applies to any Notice and Proposal with a certificate of service after 1/1/19
- Applies to any follow-up DIME after 1/1/19
- Applies to 24-month DIMEs
- Body Parts?
- The checklist proports to control body parts considered
- PALJs likely to address
- DIMEs still not confined to specific body parts
- DIME Cancellation
- Very tight cancellation time-frames with fixed penalties
The above summaries of Rule 11 and 16 are not intended to be used as legal advice. They are an outline of the changes to those Rules effective January 1, 2019. Please contact an attorney at Lee & Brown for case specific legal recommendations.