JULY 2016
The Regulatory Bulletin is a select compilation of workers' compensation legislative and regulatory changes that directly impact the client programs administered by Xerox and Bunch CareSolutions, A Xerox Company.
State Reimbursement News
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Florida State Reporting Testing for Revision F

Summary: 
Florida's Division of Workers' Compensation has implemented an updated process for electronic billing. This Florida billing rule series,  69L-7, F.A.C., describes the billing information each health care provider type is responsible for reporting for reimbursement  and how the information is to be reported. The Reference Material Rule series  69L-8, F.A.C. lists the coding reference materials to be used in conjunction with the billing and reporting responsibilities discussed in the billing rule, to properly describe and report services rendered. 

This information is made available to assist health care providers in properly reporting and submitting an accurately completed medical claim form to expedite the authorization of medically necessary care and ensure the timely processing of medical claims for reimbursement. Carriers and bill review processors are required to begin electronic testing to be sure that the process will be complete.

Potential Impact: 
We are scheduled to begin Revision F conversion testing on July 17, 2016, and testing will be completed no later than Aug. 30, 2016. Programming is in the 1300 release and we are on track to begin testing as per the schedule. Testing will be completed when the submitted bills have been accepted by Florida's Medical Data System and pass visual comparison to paper bills and all test scenarios have been completed.
  
Sources: 
Workers' Compensation Medical Reimbursement and Utilization Review, 69L-7.750, F.A.C.


Compounded Medication Safety: Best Practice
 


by  Dr. Gary Rischitelli, MD, JD, MPH, FACOEM, Medical Director

Medical Treatment Guidelines for Compounded Medications
Compounded medications continue to be a costly and frequently unnecessary expense in the treatment provided to injured workers in some jurisdictions. Their inappropriate use is largely driven by the substantial profits associated with compounding and dispensing fees, therefore states continue to explore methods to control the cost of compounded medications by regulating billing and fees through mandatory fee schedules. Regulating compounding fees to reasonable levels may be the most effective means to reduce unnecessary use and control excessive costs, but application of evidence-based medical treatment guidelines plays an important role in promoting the appropriate use of these medications.

Compounding "is a practice in which a licensed pharmacist, a licensed physician, or, in the case of an outsourcing facility, a person under the supervision of a licensed pharmacist, combines, mixes, or alters ingredients of a drug to create a medication tailored to the needs of an individual patient ." (FDA, 2015)

In rare circumstances, compounding may be appropriate to meet the needs of specific patients who:
  • require medications that are not otherwise commercially available, 
  • might be allergic to inactive ingredients in FDA-approved drugs,
  • may need a different dosage strength, or
  • may need a different route of administration. (ODG, 2016)
Compounded medications are not regulated by the FDA but instead by the local state pharmacy board and state law governing the practice of pharmacy. The FDA does not prohibit or otherwise restrict pharmacy-compounded products, in recognition of the important medical need met by traditional compounding in specific cases. The large scale production and labeling of some so-called "compound meds," however, blurs the distinction between medications created for a specific clinical need in a specific patient and medications produced for mass profit. (FDA, 2015)

The Official Disability Guidelines (ODG) state that compounded medications are not recommended as a first-line therapy, and that commercially available, FDA-approved drug should be given an adequate trial. If commercially available medications are ineffective, contraindicated or require a different route of administration, then compounded drugs that use FDA-approved ingredients may be considered.  These compounded products must actually be medications and include at least one component that is an FDA-approved prescription drug.  The ingredients that are FDA-approved drugs should have been made in an FDA-registered facility. The compounded product should not simply be a copy of a commercially available FDA-approved drug product sold at a higher price because of the compounding fees.

Topical analgesics are the most frequent class of compounded agents encountered in the treatment of injured workers due to the high proportion of musculoskeletal conditions. They are largely experimental and unproven with few randomized controlled trials to determine efficacy or safety. There is little evidence to support their use above standard therapies or over-the-counter topical agents. 

In summary, there is little to no research to support the use of many these agents and they are not recommended as a first-line therapy. Commercially available, FDA-approved drugs should be given adequate trials at appropriate doses and for sufficient time to assess clinical response. (ODG, 2016) In the absence of the substantial profits associated with compounding and dispensing fees, compounded medications would probably be rarely encountered in the care of injured workers.

Sources: 
FDA Compliance Policy Guides, Section 460.200 Pharmacy Compounding (Accessed June 30, 2016); Official Disability Guidelines (ODG), Work Loss Data Institute, 2016

Updates on States Supporting the Use of Medical Marijuana
Ohio Supports the Legalization of Medical Marijuana
 
Summary: 
Ohio passed House Bill 523, legalizing medical marijuana for 22 qualifying medical conditions. Qualifying conditions include HIV/AIDS; hepatitis C; cancer; epilepsy and other seizure disorders; pain that is chronic and severe; intractable pain; PTSD; spinal cord disease or injury; multiple sclerosis; and more.  This bill will become effective on Sept. 8, 2016.
 
The bill comes with many stipulations including:
  • the implementation of medical marijuana control programs and advisory committees
  • regulation on the location of medical marijuana cultivators and dispensaries
  • an electronic database which will monitor medical marijuana from its seed source dispensing
  • requirement that users register with the Ohio State Pharmacy Board
  • requirement that prescribers engage in continuing education related to cannabis before they can begin recommending medical marijuana
Currently, Ohio does not have the governmental framework to provide medical marijuana, as the cultivators have not been set up nor can individuals grow or smoke medical marijuana within the state. Until in-state cultivators are established, individuals must go out of state and bring legally acquired medical marijuana back with them, and only in the form of oils, tinctures, plant material, edibles, vapor, or any other future form approved by the state board of pharmacy.  

For employers, companies will not encounter legal repercussion from terminating employees under the influence of medical marijuana, and can deny workers' compensation to those injured on the job if they are taking medical marijuana. Employees cannot sue employers for termination or any other discipline resulting from the use of marijuana.
 
Potential Impact: 
We will work closely with our TPAs and insurance clients in identifying at-risk behaviors through the use of our Comprehensive Initial Assessment (CIA) tools for case-managed claims.  

Source:
From Our Managed Care Desk
New Forms Posted on the Georgia State Board of Workers' Compensation (SBWC) Website
 
Summary: 
The Georgia SBWC has posted the 2016 revised forms to their website. The Bill of Rights
(BOR), English and Spanish, were revised. The revised BORs must be posted and in use by
Oct. 1, 2016, at all Georgia employer worksites, both Georgia Managed Care Organization
(MCO) and non-MCO. The BORs were just revised last July, after which we redistributed to our Georgia panel clients' worksites in Q3 2015.
 
Potential Impact: 
We will roll out the July 2016 version of the BORs to all Georgia panel accounts. For employers whose Georgia panels are not managed by our team, the BORs are available on the SBWC web link or by contacting your account manager. All Georgia employers must be using the new forms by Oct. 1, 2016.  

Source:
From Our Clinical Desk on Utilization Review and Case Management

Tennessee Updates Case Management Regulations

Case management rules have changed under Tennessee's Chapter 088-02-07, General Rules of the Workers Compensation Program for Case Management. The proposed rules for case management would, for the first time, expressly stipulate a list of actions that are verboten for a case manager,  and penalties may be assessed if the nurse case manager does not follow the new rules.  Case managers would not be allowed to:
  • Present an employee with a panel of physicians.
  • Determine whether a case is work-related.
  • Question the physician or employee regarding compensability issues. 
  • Conduct or assist parties in claims negotiation, investigation or any other activity unrelated to worker rehabilitation.
  • Advise the employee about any legal matter involving settlement options or procedures, recovery of money, claims evaluation or the applicability of the state workers' compensation statute to the employee's claim.
  • Accept compensation or a reward from any source as the result of a settlement.
  • Discuss what a worker's impairment rating should be.
  • Reschedule medical appointments without first discussing the rescheduling with the injured worker.
  • Refuse to provide parties to the claim with case management reports.
  • Assist in recording an injured worker's activity for the purposes of disproving a claim.
  • Deny or authorize treatment for the purpose of guaranteeing prepayment or pre-certification.
An amended provision introduces a set of guidelines, but not a requirement, under which employers and insurers are "encouraged" to provide case management services, including  situations in which  the worker has suffered a catastrophic injury, has anticipated medical expenses exceeding $10,000, is hospitalized on an inpatient basis, or lost more than three months of work time.

If "case management is undertaken" in a catastrophic-injury case, according to the proposed rule, the employer or insured must assign a case manager within seven days of receiving notice of the injury.

Potential Impact: 
Tennessee's Division of Workers Compensation will post updates on the state's website and we will check regularly on the implementation of the new rules, as well as provide staff education on the changes and licensing support for nursing licensure, registration and renewals.

Sources:
Other News Heard This Month
Louisiana Takes Action on Physician Medication Dispensing
 
Summary: 
The Louisiana Supreme Court clarified its interpretation of RS 23:1142 and the $750 limit for non-emergency medical treatment without mutual consent. A recent ruling in Louisiana's Supreme Court supported the employer's and carrier's reimbursement refusal rights for more than $750 on physicians dispensing medication from their offices. Recommendations on upholding this refusal require the employer/carrier to notify the physician that there will be no reimbursement for office dispensed medications when there is a pharmacy available after the initial $750 has been paid for the unauthorized charges.

This ruling directs payers on how the $750 limit for non-emergency medical care in LSA-R.S. 23:1142 is for physician-dispensed medications and may add in additional rationale for compounded medications and other pharmacy care when there is a lack of mutual consent for the care that exceeds the $750 limit. 
 
Potential Impact: 
We will work with our bill review specialists to ensure consistent application of the fee schedule for repricing of medications. We recommend that any questions regarding how the ruling may affect current company policies and procedures should be directed to your legal counsel.

Source:
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BR16946
This information has been compiled by Xerox to update clients on recent changes in selected workers' compensation legislation. The information contained in this document is a summary based on interpretations of such legislation as of the date of this publication and is not intended to be considered as legal advice. Xerox assumes no obligation to provide updates to the information contained in this document. The information contained herein does not represent the provisions of legislation in their entirety. Readers should refer to the state legislative bills for more information on such workers' compensation legislation.