Policy Matters Brief - October 5, 2022

October 5, 2022 · Public Policy & Regulatory Affairs Team

New York WCB posts updated provider medical billing FAQs

As of July 1, 2022, it became mandatory for medical service providers in New York to use the CMS-1500 form and provide accompanying medical narrative by:

Completing the state prescribed medical report template or

Including the medical narrative attachment either at the top or prominently displayed on, the medical narrative that accompanies the CMS-1500 form

The Workers’ Compensation Board recently published the updated fact sheet, Treating Workers’ Comp Patients: Three Musts for Medical Reports, which details various requirements and provides additional information and resources.

Certain health care providers, including occupational therapists, physical therapists, and acupuncturists, should report on work status only.
Physician assistants should always report on work status and ongoing degree of disability, and may do so independently. When reporting on causal relationship and initial degree of disability, they must do so under the supervision of a physician.

Visit the Medical Narrative Requirements section of the Board’s website to view the complete chart. For CMS-1500 feedback and questions, email CMS1500@wcb.ny.gov. For clinical feedback and questions, email provider@wcb.ny.gov.

Colorado workers’ comp. fee schedule and utilization standards rules updated

The Colorado Division of Workers’ Compensation (DWC) adopted updates to the rules governing utilization standards and fee schedules, effective January 1, 2023.

Utilization standards rule change highlights:

Permits a payer to limit the approval of initial treatments to the number or duration specified in the treatment guidelines without a medical review
Identifies the new field and code submission requirements for resubmission of medical and facility bills and appeals

Fee schedule rule change highlights:

Introduced a new prior authorization requirement for certain drugs for which a “significantly lower-cost” therapeutic equivalent is available
Increased reimbursement amounts for prescription topical compounds and over-the-counter (OTC) topical medications
Simplified OTC topical reimbursement language
Updated medical and ancillary related billing codes, modifiers, status codes and reimbursement sources – including coverage limitations
Updated reimbursement values for a variety of medical and ancillary services/items (mostly increases)

The adopted pharmacy prior authorization language differs from what was originally proposed and requires prior authorization for any non-steroidal anti-inflammatory drug (NSAID), muscle relaxant, or topical agent for which a significantly lower-cost therapeutic equivalent is available, including commercially or OTC, even in a different strength/dosage. “Significantly lower cost” means the therapeutic equivalent costs at least $100 less, for the same number of days’ supply. The originally proposed language did not limit the type of drugs and had a $50 threshold.

“Prior authorization” under the relevant DWC rule means, “a guarantee of payment for treatment requested in accordance with [Rule 16].” Prior authorization may be requested using the “Authorized Treating Provider’s Request for Prior Authorization” (Form WC 188) or alternatively, is to be clearly labeled as a Prior Authorization request.

California workers’ comp mental health social worker legislation passed

California Senate Bill 1002, a bill addressing inclusion of clinical social workers in the treatment of injured workers, has been passed by both chambers of the legislature. The bill:

Adds the services of licensed clinical social worker (LCSW) as treatment an employer is reasonably required to provide
Provides that that an LCSW may treat or evaluate an injured worker only upon referral from a physician
Authorizes medical provider networks to add LCSWs to their physician providers listings

The stated intent of the Legislature with this change is to authorize qualified LCSWs to assess, evaluate, and treat the behavioral and mental health needs of injured workers within the workers' compensation system.

For more information on this and other legislation or regulations we are tracking related to provider networks, view our Legislative and Regulatory Tracker (select “Provider Choice, Networks or MCOs” as the Topic in the dropdown menu).

Michigan legislation introduced to modify auto fee schedule law

Michigan House Bill 6371 has been introduced to modify the 2019 auto no-fault reform law’s fee schedule provisions. If enacted, this legislation would provide that, a physician, hospital, clinic, or other person that renders treatment or rehabilitative occupational training to an injured person for an accidental bodily injury that is covered by personal protection insurance is not eligible for payment or reimbursement under the auto no-fault law for more than the maximum charge that applies to the treatment or training under the state’s workers’ compensation fee schedules.

Following several other bills, HB 6371 is just the latest attempt to modify the reform law’s fee schedule provisions. Concerns have been raised about the adequacy and practicality of the reform law’s reimbursement provisions, particularly as it relates to services where there is no Medicare reimbursement benchmark.

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