Policy Matters Brief October 12, 2020
California DWC updates drug formulary
The California Division of Workers’ Compensation (DWC) issued an order updating their Medical Treatment Utilization Schedule (MTUS) Drug List (drug formulary) effective November 1, 2020. The update order adopts changes to the drug list based on the American College of Occupational and Environmental Medicine (ACOEM) Practice Guidelines, including new drug recommendations addressed in the Depressive Disorders Guideline. More information, including a copy of the new v.7 of the drug list, can be viewed on the DWC’s website, here.
California DWC adds to medical treatment guidelines
The California Division of Workers’ Compensation adopted an update to the evidence-based treatment guidelines portion of their Medical Treatment Utilization Schedule (MTUS), effective for medical treatment services rendered on or after October 26, 2020. This change incorporates, by reference, the American College of Occupational and Environmental Medicine’s (ACOEM’s) most recent Antiemetics Guideline (ACOEM March 27, 2020). Antiemetic drugs are administered to prevent and treat nausea and vomiting during the perioperative period, among other conditions. The Antiemetics Guideline is applicable as a supplement to conditions addressed in other MTUS guidelines associated with nausea and vomiting.
Florida changes EDI prefix list
The Florida Division of Workers’ Compensation has published a revised/expanded list of valid medical license prefixes, which is used for medical EDI state reporting. The past version(s) of the list were often viewed as incomplete – not all state-approved license prefixes, as established by the Florida Department of Health, were included in the DWC list. This caused confusion in certain prescriber vs. treating doctor reporting for prescribed and dispensed medications.
To alleviate confusion between the two separate lists, DWC recently emailed EDI submitters indicating that changes have been made to the Revision F Valid License Prefix document to now include Unlicensed Medical Doctor Training (prefix TRN). The new list can be found on the DWC website.
Michigan workers’ comp proposed topical medication reimbursement change
The Michigan Workers’ Compensation Agency recently updated proposed changes to health care services rules to address pharmacy reimbursement. The additional proposal amends existing language limiting reimbursement for commercially manufactured topical medications, which are over-the-counter (OTC) or contain OTC ingredients, to expand it to apply to all commercially-manufactured topical medications, even those requiring a prescription. Maximum reimbursement would be set at “acquisition cost” plus a single dispensing fee of $8.50. In addition, newly proposed language states that a provider would only be reimbursed one dispense fee per topical medication in a 10-day period.
New York adopts regulation amendments to modify definitions and billing form requirements
The New York Workers’ Compensation Board adopted amendments to existing regulations that modify definitions and billing form requirements. The amendments change the term “physicians” to “treating provider” to comply with the Expanded Provider Law and allows payers to designate a single mailing address for filing medical reports. Additionally, the adopted changes move forward the WCB CMS-1500 Project related to use of the CMS-1500 form for medical billing, including use and submittal of the CMS-1500 form in an electronic format.
The adopted rules are expected to be posted on October 14, 2020 and become effective immediately. More information on the modified rules and the CMS-1500 project can be found, here.
Oregon WCD adopts temporary workers’ comp COVID-19 rule
The Oregon Workers’ Compensation Division (WCD) adopted a temporary rule concerning claims for COVID-19 or SARS-CoV-2 exposure. The rule explains that under existing regulations, insurers must conduct a “reasonable investigation” before denying any claim. It also describes what a reasonable investigation must include when the claim is for COVID-19 or exposure to SARS-CoV-2 on and after October 1, 2020. As of that date, if an insurer has reported to the WCD five or more claims for COVID-19 or exposure to SARS-CoV-2, regardless of whether those claims have been accepted or denied, the WCD will audit the insurer’s files for all claims denied by the insurer for COVID-19 or exposure to SARS-CoV-2. This applies to denials that became final according to operation of law by the date of audit.
Texas proposes modifications to Medical Fee Dispute Request Resolution
The Texas Division of Workers’ Compensation has proposed specific modifications to the existing Medical Fee Dispute Request Resolution (MFDR). In their proposal, the Division looks to permit providers and payers to submit requests for MFDR, and associated responses, in an electronic format, as well as retain continued use of the paper format. The proposed changes allow submittal of MFDRs in an electronic format as defined as “transmission of information by facsimile, electronic mail, electronic data interchange or any other similar method but does not include telephone communications.” A copy of the proposed rule changes can be found here. Comments are due no later than November 9, 2020.