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The latest legislative and regulatory activity that impacts you and the services we provide

Policy Matters Brief - October 30, 2024

October 30, 2024 · Public Policy & Regulatory Affairs Team

California Workers’ Compensation Hospital Outpatient Departments and Ambulatory Surgical Centers Fee Schedule Adjusted

The California Division of Workers’ Compensation (DWC) recently posted an order adjusting the Hospital Outpatient Departments and Ambulatory Surgical Centers section of its Official Medical Fee Schedule (OMFS) to conform to quarterly changes. More specifically, the adjustment order updates Addenda A and B to the CMS Medicare Hospital Outpatient Prospective System (OPPS) for services rendered on or after October 1, 2024.

Details can be found here.

California Updates Workers’ Compensation Drug Formulary

The Division also recently issued an order updating its MTUS Drug Formulary List, effective November 1, 2024. The new Drug Formulary List (v.12) is based upon the American College of Occupational and Environmental Medicine (ACOEM) Guidelines, which have been updated to synergize with recently revised California Medical Treatment Utilization Schedule (MTUS) standards on anxiety disorder treatment and opioid prescribing.

The updated guidelines and drug list can be accessed here.

Colorado Workers’ Compensation Medical Fee Schedule Adopted

Effective January 1, 2025, the Colorado Division of Workers’ Compensation (DWC) amended its Rule 18 – Medical Fee Schedule - to establish maximum fees for workers’ compensation healthcare services.

The revised Rule 18 features substantive amendments to the fee schedule (such as updates to reimbursement sources and coding); simplifies physician dispensing limitations; adds gabapentin to the list of drugs that cannot be dispensed by a physician.

Details can be found here.

Colorado Workers’ Compensation eBilling Regulations Adopted

On September 27, the Colorado DOWC also adopted file regulations to establish eBilling requirements. The new rules impart new eBilling rules for all workers’ compensation related medical and pharmacy claims/bills. The rule requires providers or their designee(s) with certain claim(s) volume to submit bills electronically and requires payers or their designee(s) to be able to receive and process any submitted electronic bill as of January 1, 2026.

More details can be found here.

Minnesota Ambulatory Surgical Center calculation of payment updated

The Minnesota Division of Workers’ Compensation (DWC) recently provided notice that its calculation of payment for covered workers’ compensation surgical procedures and ancillary services provided by an Ambulatory Surgical Center (ASC) on or after October 1, 2024 has been updated. For surgeries or ancillary services performed by an ASC, calculation of payment is now based on the July 2024 Addenda AA, BB, and DD1 (updated June 28, 2024) of the Medicare Ambulatory Surgical Center Payment System (ASCPS).

Details can be found here.

New Mexico Proposed Rule – Payment to Providers

The State of New Mexico is considering amending existing provider and payer billing rules, specifically payments made to providers. In New Mexico, a payer is responsible for timely payments to providers within 30 days of receipt of a bill for service. Under the proposed rule amendments, penalties will be added to unpaid bills within 30 days of their receipt, which if adopted could include an interest rate 10% of the HCP FS rate, or $25.00 (whichever is greater).

Comments are being accepted until November 12, 2024. The proposed rule will take effect January 1, 2025. The rule and comment details can be found here.

Pennsylvania Legislation Passes PTSD Bill

Pennsylvania lawmakers recently sent a bill to Governor Shapiro that provides an option for first responders to receive benefits for work related post-traumatic stress disorder. Senate Bill 365 would enable first responders to claim a work-related injury for PTSD when the injury is related to exposure to a “qualified traumatic event.”

The application of PTSD as a workers’ compensation claim must be based upon an assessment and diagnosis from a psychologist or psychiatrist.

More information on the bill can be found here.

Additional Optum resources:

For more information on these policy developments and others we have been tracking this year, be sure to visit our Legislative and Regulatory Tracker. Bills or regulations can be filtered by insurance line, topic, status and jurisdiction.

If you have questions on these or any other public policy developments, please contact our team at OptumWC.PolicyMatters@optum.com.

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