The Division of Workers’ Compensation seems to be on a constant mission to tweak various workers’ compensation rules of procedure. Some of these changes are directed at situations that clearly need attention, while others are less clear. This year is no different. There have been several rule changes from the Division of Workers’ Compensation that take effect at the first of the year or have already taken effect. I will try to break down the rule changes as briefly and clearly as I can.
Rule 2: Workers’ Compensation Insurance Premium and Payroll Surcharge EFFECTIVE 7/1/20
As you may or may not be aware, an approved rate reduction in “loss costs” occurred this year. Loss costs are the average cost of lost wages and medical payments paid to or on behalf of the injured worker. This is a component of an employer’s premium calculation. Rule 2 changes do not have anything to do with claim handling and, therefore, do not require coverage.
Rule 16: Utilization Standards EFFECTIVE 1/1/21
16-2 Standard Terminology for Rules 16, 17 and 18
Believe it or not some of the terminology throughout the rules did not match. Here are some housecleaning efforts.
16-2(E): You may not have known this, but a “certified medical interpreter” had a specific definition. They were individuals with certification from the Certification Commission for Healthcare Interpreters or the National Board of Certification for Medical interpreters. 16-2E struck the definition of a Certified Medical Interpreters. If you recall, several years ago there were concerns raised that medical conditions referenced by the injured worker were not making it into reports based on language barriers. This requirement had the unintended consequence of making it hard to find a certified medical interpreter, hence the change.
16-2G: There has been inconsistency throughout the rules in that some rules used “business days” for time measurement while others simply used “days.” This particular change clarifies that “day” is a calendar day unless otherwise noted. So now day means day unless the rules says business day, or some other type of day. This really does clarify things.
16-2H: If I used the term designated provider list in the workers’ compensation setting what you think it would mean? If you struggled for an answer other than the doctor list the employer provides to an injured worker join the club. Well never fear, this change clarifies that “designated provider list” means the physician list as required under Section 8-43-404(5)(A)(1), C.R.S.
16-2N & Q: This rule change better defines a non-physician provider to include a surgical assistant. It also defines a “Physician Provider” as someone who is board licensed in their area of practice. For instance, a physician provider would need to be licensed by the Colorado Medical Board, a dental provider would have to be licensed by the Colorado Dental Board, etc. It is recommended to simply review this rule if the question is encountered.
16-3A: This requires that any provider not listed in 16-2 as a “Physician Provider” requires prior authorization to provide services for a work injury.
16-3B, C & D: This now requires that all providers have a referral from a physician provider managing the claim (or NP/PA working under that physician provider). It used to be that only non-physician providers had to have a referral from a physician provider, but now it is everybody.
16-6: This rule deals with a provider’s notification to treat an injured worker. It basically sets forth the way in which a provider advises a payer of the treatment to get paid for that treatment. This year’s change requires the payer’s response time to a notification to treat. It goes from 5 business days to 7 calendar days. Although this makes the rule more uniform, in certain circumstances, such as determining a holiday that would otherwise not be included as a business day, this could make it difficult to respond to such a request.
16-7: Prior Authorization issues are always difficult. This section of Rule 16 changes the payer’s response time from 7 business days to 10 calendar days. Once again, while making the rule more uniform in certain circumstances, such as determining a holiday that would otherwise not be included as a business day, this could make it difficult to respond to such a request.
16-7-1: Deals with prior authorization denials – when a denial is made based upon a medical report that predates the request. Under this change, an IME or report from an ATP used to deny a prior authorization request based solely on relatedness to the injury cannot be older than one year from the date of the prior authorization request. Further, such a report can only be used if there is not an admission of liability filed admitting the relatedness of the requested treatment, or a final order has not been entered finding that the specific medical condition is related to the admitted injury. Otherwise, the IME report or ATP opinion must be after the prior authorization request. The thinking behind this rule change is that a stale report cannot be used to deny prior authorization request. One wonders what happens when the request is for the same treatment over and over. Can the requests get stale too?
16-7-2: This section deals with appeals of a prior authorization denial. Now the requesting party has 10 days from the date of the denial to appeal the denial. By the same token the payer has 10 days from the date of the appeal to issue a final decision.
16-9A & B: This section deals with required medical record documentation to get paid. This rule was modified so that a claimant’s functional response to treatment no longer needs to be documented. There is also no longer a requirement that the documentation reference specifics for a treatment plan.
16-10A: This section deals with payment requirements for medical bills. There was a suggested change that would have no longer required bills be submitted by a provider but could be submitted by anybody. Fortunately, over these suggested changes that would have allowed submission by the attorney or party, the rule remains that the submission must be made by the provider.
16-10-2A: This section deals with denying payment of billed treatment for non-medical reasons. This change to this section now allows for denial for non-medical reasons for improper use of a CPT code.
16-10-2C: When denial for non-medical reasons the payer’s denial does not have to be made within 30 days of receipt of the bill.
16-10-4: this section deals with appealing billed treatment that has been denied. The billing party has 60 days from the date of the written notice to request reconsideration to appeal. The appeal now has to have the specific code being appealed.
Rule 18 Medical Fee Schedule EFFECTIVE 1/1/21
18-4(I): Telemedicine: This provides guidelines and requirements for telemedicine. Telemedicine must comply with requirements found under the Colorado Medical Practices Act and the Colorado Mental Medical Board and the Colorado Board of Psychologist Examiners. A physician-patient relationship must be established for telemedicine to occur. The same documentation required of an in-person evaluation is required of telemedicine.
18-9D: App-Based Interventions: This new subsection allows the provider to write an order for an app-based intervention for the injured worker. For instance, as part of biofeedback perhaps the apps Hello Mind or Mindspring could be prescribed. For more physiologic app, perhaps some sort of activity tracker would be prescribed. Such an order is to have a designated time frame for use and must be payable by invoice and billed directly to the payer the maximum allowable charges $25 a month and the maximum duration is three months per order. Anything over this amount requires prior authorization.
If you have any questions about the updated Rules, or any employment or workers’ compensation related question, please contact Lee & Brown, LLC.