Policy Matters Brief April 20, 2022
Connecticut adopts new 2022 workers’ compensation hospital and ASC fee schedule
The Connecticut Workers’ Compensation Commission (WCC) has adopted and published the new 2022 fee schedule for hospital and ambulatory surgical center treatment with changes to the CPT and HCPCS codes and reimbursement changes associated with these codes.
Key changes include:
- Hospital inpatient reimbursement rate of 174% of Medicare
- Hospital outpatient and hospital based ASC rate of 201% of Medicare
- Non-hospital rate of 196% of the hospital based rate of Medicare
- Updates to the most current CPT and HCPCS codes
Connecticut does not publish their fee schedule for free public access, rather interested stakeholders can purchase the fee schedule on the WCC website. The fee schedule is effective for dates of service on or after April 1, 2022 regardless of the date of injury.
New York issues revisions for use of certain provider forms
As part of the New York Workers’ Compensation Board ebilling – CMS-1500 – project, they frequently issue updates on forms, formats and processes to assist stakeholders with system programing and development. Recent updates from the WCB include revisions to certain provider forms and the data elements required on these forms. Per the WCB:
- As of June 16, 2022, the injured worker’s full nine-digit social security number (SSN) will no longer be required on the C-8.1 and the C-8.4 forms. Instead, impacted stakeholders should only use the last four digits of the SSN for these forms.
- On May 2, 2022, an updated Request for Further Action by Insurer/Employer (Form RFA-2) and current C-8.1 and C-8.4 forms will be published and ready for use.
- As of July 1, 2022, both payers and providers must utilize the new forms and billing processes as required by the CMS-1500 project, which include the usage of the proper CARC and RARC codes by payers when responding to a bill submitted by the provider.
Phase 3 (of 3 Phases) of the CMS-1500 project is set to take effect on July 1, 2022. More information about the project can be found on the NY-WCB website.
Indiana workers’ compensation law medical reimbursement, billing and bill review amendments
Indiana legislation, House Bill 1153, has been signed into law and amends various workers’ compensation and occupational disease law provisions. The bill includes two medical service related amendments that take effect January 1, 2023.
- Medical services amendments add ambulatory outpatient surgical centers into the definition of "medical service facility" making it subject to the facility fee schedule limitations and “pecuniary liability” provisions, which tie partly to Medicare rates.
Under the law, when a reimbursement agreement has not been reached through negotiations, reimbursement is to be based on 200% of the amount that would be paid to the medical service facility under the facility's Medicare reimbursement rate.
- New statutorily-required medical provider billing forms and bill review timeframes with new response and payment timeframes that differ depending on how the provider bill was submitted (paper or electronically).
- A medical service provider shall only submit the following forms for payment by a payer: CMS 1450 (UB-04), CMS 1500 (HCFA-1500) and American Dental Association (ADA) claim form.
- Required payment or denial timeframes:
- Bill submitted electronically: Within 30 days of receipt
- Bill submitted on paper: Within 45 days of receipt
- Same timeframes for payers to respond and notify provider of deficiencies in a submitted bill.
- If a payer fails to pay or deny a clean bill in the time required, then subsequently pay it, they will be required to pay interest.
New Jersey legislation to expand auto insurance medical fee schedules
New legislation in New Jersey (if passed and signed into law) will expand the scope of existing state auto insurance medical fee schedules to cover certain ambulatory surgical center (ASC) services. Per S 2392, ASC-provided services not listed on the Physicians' and ASC Fee Schedules requires reimbursement at a rate of 300% of the Medicare Part B payment rate for the service, for the same area, provided that the services are reimbursable pursuant to current CMS guidelines. Unlisted medical supplies utilized in conjunction with services that are not currently listed on the fee schedules would be reimbursable at invoice cost plus 20%.
S 2392 is currently in the Senate. For more details on it and other auto no-fault bills or regulations we are tracking, visit our Legislative and Regulatory Tracker webpage (select “Auto” as the category in the dropdown menu).
Utah legislation loosens physician dispensing restrictions
Utah House Bill 301 was signed into law in late March and takes effect on May 4, 2022. The bill includes new requirements and loosens practice restrictions around physician dispensing. The bill permits a “dispensing practitioner” (specified physicians, surgeons, advanced practice registered nurses, or physician assistants) who practices at a “licensed dispensing practice” to dispense for a condition that is not expected to last longer than 30 days and for which the patient has been evaluated by the physician on the same day they dispense the drug.
However, under these new exemptions, HB 301 states that a dispensing practitioner may not make a claim against workers' compensation or automobile insurance for a drug dispensed for outpatient use unless the dispensing practitioner is contracted with a pharmacy network established by the claim payer. Additionally, a dispensing practitioner may not dispense a controlled substance, a drug or drug class designated by the Division of Occupational and Professional Licensing as not to be dispensed, gabapentin, or a drug that exceeds a 30-day supply.
For more details on HB 301 or other bills we are tracking related to physician dispensing, visit our Legislative and Regulatory Tracker webpage (select “Physician Dispensing” as the topic in the dropdown menu).
Washington expands workers’ comp COVID-19 presumption scope
Recently-enacted legislation in Washington, Senate Bill 5875, expands the scope of the existing COVID-19 workers’ compensation presumption law for “frontline employees.” The Bill adds to the definition of “frontline employee”: “employees employed by the department of licensing who are assigned to review, process, approve, and issue driver licenses to the general public, if the employee has in-person interaction with the general public as part of their job duties or has in-person interaction with other employees.”
SB 5875 becomes effective on June 9, 2022. For more information on the various COVID-19 workers’ compensation presumption policies across the country, review the presumptions map toward the bottom of our COVID-19 Information & Resources webpage.