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Policy Matters Brief March 18, 2020

March 18, 2020 · Policy Matters team

California proposed medical treatment guideline updates
The California Division of Workers’ Compensation has proposed further updates to their Medical Treatment Utilization Schedule guidelines, which incorporate the latest published guidelines from the American College of Occupational and Environmental Medicine (ACOEM) for the following:

  • Occupational Interstitial Lung Disease Guideline (ACOEM November 8, 2019)
  • Knee Disorders Guideline (ACOEM December 3, 2019)
  • Workplace Mental Health Guideline: Depressive Disorders (ACOEM February 13, 2020)

A public hearing is scheduled for March 30. Comments may be submitted no later than that date.

Kentucky proposed medical fee schedule updates
The Kentucky Department of Workers’ Claims (DWC) is undergoing the bi-annual process to update their “Schedule of Fees for Physicians,” as required by statute -- a preliminary draft of updates is available to interested stakeholders. Informal stakeholder sessions were held on February 28, 2020 to receive a presentation from FAIR Health (the fee schedule vendor used by DWC) on how the proposed updates were developed and to receive comments and questions from stakeholders in attendance.

Currently, rates in the fee schedule are determined based on the 45th percentile of FAIR Health charge benchmarks for services performed in Kentucky. DWC is proposing to remove certain clinical treatment information in the fee schedule, citing this information should be addressed by the state’s medical treatment guidelines, which are expected to be adopted later this year.

Initial written comments were accepted until March 3, 2020. The rule-making process to formally propose and adopt any updates should play out over the next few months. Further information can be obtained by contacting Pamela Knight (

Michigan draft auto no-fault reform UR regulations
The Michigan Department of Insurance and Financial Services (DIFS) is in the process of adopting regulations to implement 2019 auto no-fault reform legislation. Draft rules currently in progress relate to establishing utilization review (UR) standards, as required by the reform law.

The draft rules have gone through modifications based on feedback solicited by DIFS from groups representing small businesses, notably providers. The original draft was pared down to focus on UR; whereas, previously, it had included other less-relevant language governing areas such as fee schedules and provider billing forms. Areas addressed include the overall UR process (which includes both bill review and medical review), including acquisition of records, determinations and appeals. Under the latest proposed draft, insurers would be required to obtain certification of their UR program from DIFS and may also contract with a medical review organization to perform UR activities on their behalf.

The latest draft is still subject to further review and revision. A hearing will be held on April 10, 2020 and written comments will be received until 5:00 p.m. that day. Current status of this rule-making can be tracked, and related documents can be viewed, through the state’s Administrative Rulemaking System here.

Washington expands workers’ compensation coverage policy for COVID-19
Washington Governor Jay Inslee, and Joel Sacks, director of the state’s Department of Labor & Industries (L&I), announced that L&I has changed its policy on workers’ compensation coverage for health care workers and first responders who are quarantined by a physician or public health officer. This effort is to ensure workers’ comp protections for those who are on the front lines of the COVID-19 (coronavirus) outbreak. The expanded coverage takes effect immediately and covers eligible workers already under quarantine.

Under the policy, L&I will provide benefits to these workers during the time they’re quarantined after being exposed to COVID-19 on the job. Coverage can include medical testing and treatment expenses if a worker becomes ill or injured and time-loss payments for those who cannot work if they are sick or quarantined. The policy also applies to others who may have accepted claims for exposure to COVID-19, such as those who are not considered health care workers but are working in facilities with documented exposures.

Current L&I rules already provide for workers’ comp coverage if health care providers and first responders become sick in connection with their job duties. Workers can file a workers’ comp claim up to two years after being exposed to a disease at work.

New York updates formulary drug list
On Monday, March 9, 2020, the New York Workers’ Compensation Board (WCB) published a notification of the emergency adoption of an amendment to the Drug Formulary under 12 NYCRR 441.2. The emergency notice indicates a change to the Formulary Drug List by modifying various medications on the list and drug application within formulary. The emergency adoption becomes effective immediately and like previous drug list changes, will be finalized by the adoption of a permanent rule within the next 90 days.

Of specific interest, is the addition of a WCB web page that specifically outlines what drugs were added or modified via a new ‘formulary changes landing page’. This new page and modifications to the drug list can be found here.

Additionally, the WCB published a revised and all-inclusive drug list, which can be found here. Optum Workers’ Comp and Auto No-fault has currently incorporated these drug list revisions into our pharmacy processes and we urge our clients to review the changes and notify their adjusters, claims examiners and First Level review entities to ensure smooth implementation of any necessary changes.

PTSD and presumption bills continue to advance
As many of the state legislative sessions begin to pick up speed, many states continue to consider or push forward bills related to PTSD and cancer presumptions for first responders. Generally, those bills that consider PTSD add to existing state workers’ compensation laws by presuming that PTSD claims for first responders are related to various traumas witnessed as part of job duties.

Most cancer presumption legislation focuses specifically on providing firefighters and/or fire inspectors with a presumption for certain types of cancer related to job place exposure. In 2019 over twelve states passed some form of PTSD or cancer presumption for first responders, and so far in 2020, the our Public Policy and Regulatory Affairs team continues to track over a dozen similar bills.

Louisiana adopts revised pain treatment guidelines
Seeking better ways to control opioid utilization in workers’ compensation, the Louisiana Workers’ Compensation Administration (WCA) formally adopted revised chronic pain treatment guidelines. A form of pain guidelines for treating chronic pain has been in place at the WCA for several years, and these latest changes are the most sweeping changes in recent years.

The revisions to the Medical Treatment Guidelines (MTGs) outline recommendations for the usage of opioids, benzodiazepines, skeletal muscle relaxants and topicals. The revised MTGs add treatment recommendations for specific drugs as well as guidelines for drug classes.

Two specific guidelines stand out among the revised rules. First, the guidelines strongly recommend that long-acting opioids should not be used when treating acute pain. Second, the guidelines indicate that usage of compounds, outside of those topical medications recommended by the guidelines, is not recommended and should be reviewed for medical necessity.

The revised guidelines were effective upon publication, February 20, 2020. The WCA should be posting the revised guidelines on their website shortly and they can be found here.

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