State House Passes "Pay During Appeal" Bill;

Senate Hearing Likely Within the Next Week

The House of Representatives voted 62 to 32 on February 18, 2008 on E2SHB 3139 to pay benefits pending an employer appeal.  To see how your Representatives voted, go HERE.  To listen to the debate on the bill, go HERE.  A series of amendments were offered up by Representative Cary Condotta and Representative Bruce Chandler, but only one minor amendment was adopted.  Our fight now goes to the Senate for more reasoned thinking on potential amendments.

Department to Change

Abulatory Surgery Center Reimbursement Methodology

Currently Labor and Industries (L&I) pays Ambulatory Surgery Centers (ASC) using a modified Medicare Grouper 9 payment methodology.  Medicare’s methodology groups authorized services into 1 of 9 payment groups. L&I modified the methodology to better serve and accommodate the younger working population by adding 5 additional payment groups.

Payment Methodology Changes: Medicare at the direction of Congress developed a new payment methodology for ASCs based largely upon the Outpatient Hospital Prospective Payment System (OPPS).  In January 2008 the Medicare Grouper 9 ceased to exist and the new methodology for paying an ASC went into effect.  L&I is planning to implement the new payment method on July 1, 2008.

L&I will use the CMS list of procedures covered in an ASC plus additional procedures determined to be appropriate. L&I expanded the list that CMS established for allowed procedures in an ASC to better meet the needs of the working population. 

In the new system, payment to an ASC will be based primarily upon a discounted OPPS payment rate. The discount suggested by Medicare is 67% (up from the 62% initially proposed in the preliminary rule).  The ASC industry requested a discount rate of 75%. Washington State ASC industry representatives have strongly hinted at, but have not formally requested, a discount rate of 84%.

Medicare intends to implement the new payment methodology over the next 4 years beginning in January 2008.  They intend to blend the old methodology payments with the new methodology payments, gradually decreasing the old methodology until the entire system is operating under the new methodology.  Medicare has already indicated that the payments must be budget neutral and that no additional money will be allowed until 2010 at which time the rates will advance according to the increase in CPI.  Unlike Medicare, Labor and Industries is leaning toward fully implementing the new payment methodology as of July 1, 2008 to reduce the implementation (computer programming) costs.

Proposed ASC Discount Rates: The ASC industry had legislation (H.R. 1823, Ambulatory Surgical Center Medicare Payment Modernization Act of 2007) introduced in the House of Representatives in March 2007 specifying the 75% discount rate. Two of the 49 cosponsors on the House bill were from Washington State. In June 2007 Senator Maria Cantwell expressed concern about the impact of the 62% on the availability of health care services provided by ASCs, but did not specifically endorse the industry’s request of 75%.  Note - As of this date, L&I has not determined the department’s ASC discount rate.

If you would like additional information contact Bob Mayer or Morgan Wear at L&I.  Bob Mayer (360)902-5021 or email: MAYR235@LNI.WA.GOV or Morgan Wear (360)902-6820 or email: WEAV235@LNI.WA.GOV

New Department Rules Take Effect on

Incident Reporting Requirements and Linear Hearing Aid Replacment

The Department has announced adoption of new rules governing incident reporting, and linear hearing aid replacement.  The rules concerning incident replacement are designed to make the reporting requirements the same for various industries, rather than the multiple exceptions and differences previously in WAC.  To read the new incident reporting rules, go HERE.  The rules concerning the replacement of worn out linear hearing aids was announced via a policy change last summer/fall, but the Department decided it needed to put these policies in statutue.  To read the new linear hearing aid replacment policy, go HERE.

Health Technology Assessments Committee

Taking Public Comments on Interthecal Pumps (pain meds)

The Health Technology Assessments Committee is taking public comments on the questions regarding use of Interthecal Pumps (chronic non-cancer pain management).  This committee reviews these devices and makes recommendations to all state agencies that may utilize these technologies in the management of their health care related activities.  The Department of Labor & Industries is part of this review process. HTA has published the draft key questions for IT Pumps on our website at:  http://www.hta.hca.wa.gov/reviews/index.shtml.  HTA is accepting public comments until COB Wednesday, February 27, 2008.  Please read up on Interthecal Pumps HERE, then submit your thoughts back to WSIA or directly to the HTA.  Please copy WSIA on your questions.  Thank you!

Federal Law May Have Impact in

Washington Regarding Medicare Benefits

While Washington state has been fairly insolated from the Medicare Secondary Payer Act, mostly due to the fact that we do not have compromise and release and cannot settle out the medical portion of our claims, a provision in a recent federal law might impact self-insurers here in Washington.  WSIA is soliciting feedback from a number of sources to get an idea on how this might apply on our claims.  We await responses from the Department and from UWC, the federal organization we belong to that lobbies on workers' compensation and unemployment issues.  You can be certain we will share that information with you as soon as it becomes available.   Here's the text of their email to us:

On 12/29/2007, President Bush signed the "Medicare, Medicaid, and SCHIP Extension Act of 2007". The bill was sponsored by Senator Chuck Grassley (D-IA) and was passed in the House (12/19) and Senate (12/18) before the signing by the President. The bill passed unanimously in the Senate and 411-3 in the House. Grassley has long been an advocate for increased Medicare Secondary Payer enforcement and the passage of this bill into law has ramifications for Liability Insurance, Self Insurance, No Fault Insurance, and Workers' Compensation Insurance programs nationwide.

Of major importance to liability, self, no fault, and workers' compensation insurers is Section 111 ("Medicare Secondary Payer"), paragraph 8 ("Required Submission of Information by or on behalf of Liability Insurance (including Self-Insurance), No Fault Insurance, and Workers' Compensation Laws and Plans"), items (A)-(H). Here are a couple key sections of the law:

(A) REQUIREMENT - On or after the first day of the first calendar quarter beginning after the date that is 18 months after the date of the enactment of this paragraph (the law was passed on 12/20/07, making the following requirements begin July 1st, 2009), an applicable plan shall-

(i) determine whether a claimant (including an individual whose claim is unresolved) is entitled to benefits under the program under this title on any basis; and

(ii) if the claimant is determined to be so entitled, submit information described in subparagraph (B) with respect to the claimant to the Secretary in a form and manner (including frequency) specified by the Secretary.

(B) Required Information - The information described in this subparagraph is -

(i) the identity of the claimant for which the determination under subparagraph (A) was made: and

(ii) such other information as the Secretary shall specify in order to enable the Secretary to make appropriate determination concerning coordination of benefits, including any applicable recovery of claim.

(C) TIMING - Information shall be submitted under subparagraph (A)(ii) within a time specified by the Secretary after the claim is resolved through a settlement, judgment, award, or other payment (regardless of whether or not there is a determination or admission of liability).

(E) ENFORCEMENT

(i) In General - An applicable plan that fails to comply with the requirements under subparagraph (A) with respect to any claimant shall be subject to a civil money penalty of $1000 for each day of noncompliance with respect to each claimant (in addition to any other penalties prescribed by law and in addition to any other Medicare secondary payer claim under this title with respect to an individual).

What does it all mean?

Beginning on 7/1/2009; Liability Insurers, Self-Insurers, No Fault Insurers, and Workers' Compensation Insurers must determine Medicare beneficiary status on all claims and report those claims involving a Medicare beneficiary to the Secretary at the time of settlement, judgment, or award. If the reporting is not done in a timely manner, the Secretary may enforce a civil money penalty of $1000 per day per claim. Beyond the reporting requirements and financial penalties, this now provides Medicare huge amounts of previously difficult to collect primary payer data on liability, self-insured, no-fault, and WC claims which can be utilized to enforce their Secondary Payer rights. It will be very easy for Medicare to review settlements, judgments, and awards to determine if their interests were adequately considered in the settlement. Workers' Compensation has faced a similar situation (on a smaller scale) since 2002 with Medicare Set-Aside Arrangements. The scope of this law is much broader than MSAs though and adds liability and no-fault settlements into the process, with stiff financial penalties for non-compliance.

What can be expected?

The Secretary has two issues to address in this law, (1) what data to collect and (2) what timeframe to receive the information post-settlement, judgment, or award. The timing of the collection of data (post-settlement, judgment, or award) suggests that a copy of the the settlement agreement, judgment or award will be required submission to the Secretary. Since the intent is to enforce Medicare's Secondary Payer rights, it is reasonable to assume injury information, diagnosis codes, and primary payer data will be required. The language is broad enough to allow for the collection of medical information to determine if the settlement adequately protected Medicare's interest. It is likely that the timeframe will be shortly after the date of settlement, judgment, or award, but may be more frequent.

Department Announces Certified

Claims Administrator Testing Schedule for 2008

The Department of Labor & Industries has announced the dates for their Certified Claims Administrator testing.  The test dates are March 20, June 19, September 18, and December 18, 2008.  There is an application acceptance period for each exam.  It is now too late to apply for the March 20th test.  For the June 19 test, your application must be submitted between March 23 and May 4.  For the September 18 test, your application must be submitted between June 23 and August 3.  And for the December 18 test, your application must be submitted between September 22 and November 2.  You can find the application at the Department's website at http://www.lni.wa.gov/forms/pdf/207177af.pdf.  Also, as you know, WSIA provides a one-day review course the day before each of the Department test dates.  Review courses, offered only to employees of WSIA member organizations, will be held on March 19, June 18, September 17, and December 17 at a location in Olympia.  Watch the WSIA website's Training Programs & Conferences page for more details.

Clarification Regarding Claims Administrator Certification,

Continuing Education Requirements, and Deadlines

There has been a number of questions regarding the Continuing Education option, as an alternative to re-testing, for maintaining the state's Claims Administrator Certification.  Hopefully this will clarify and answer most of those questions.

If your certification expires before October 1, 2008 you MUST take the Certified Claims Administrator test.  There are no exceptions to that.  No grandfathering.  You MUST take the test again.  Once you are certified, you will have five years to either collect a minimum of 75 Continuing Education Credits (20 in claims processing/procedures; 20 in legal issues; 20 in medical issues; 2 in ethics; and 13 in elective topics), or take the test again.

There is a tiered structure for those people whose certification expires between October 1, 2008 and September 30, 2012.

If your certification expires between October 1, 2008 and March 31, 2009, you must earn a minimum of 30 credits (8 in claims processing/procedures; 8 in legal issues; 8 in medical issues; 1 in ethics; and 5 in elective topics).

If your certification expires between April 1, 2009 and September 30, 2009, you must earn a minimum of 35 credits (10 in claims processing/procedures; 10 in legal issues; 10 in medical issues; 1 in ethics; and 4 in elective topics).

If your certification expires between October 1, 2009 and March 31, 2010, you must earn a minimum of 40 credits (11 in claims processing/procedures; 11 in legal issues; 11 in medical issues; 1 in ethics; and 6 in elective topics).

If your certification expires between April 1, 2010 and September 30, 2010, you must earn a minimum of 45 credits (12 in claims processing/procedures; 12 in legal issues; 12 in medical issues; 2 in ethics; and 7 in elective topics).

If your certification expires between October 1, 2010 and March 31, 2011, you must earn a minimum of 50 credits (14 in claims processing/procedures; 14 in legal issues; 13 in medical issues; 2 in ethics; and 7 in elective topics).

If your certification expires between April 1, 2011 and September 30, 2011, you must earn a minimum of 55 credits (15 in claims processing/procedures; 15 in legal issues; 15 in medical issues; 2 in ethics; and 8 in elective topics).

If your certification expires between October 1, 2011 and March 31, 2012, you must earn a minimum of 60 credits (16 in claims processing/procedures; 16 in legal issues; 16 in medical issues; 2 in ethics; and 10 in elective topics).

If your certification expires between April 1, 2012 and September 30, 2012, you must earn a minimum of 65 credits (18 in claims processing/procedures; 18 in legal issues; 18 in medical issues; 2 in ethics; and 9 in elective topics).

The Department will assign credits to courses that are submitted by education providers.  A Committee meets monthly to review the submittals, and then makes recommendations for the number of credits to be awarded.  WSIA has already submitted all of our training programs for review, as well as a number of Region meetings, conferences, and non-WSIA programs.  We have yet to hear anything back on the number of credits to be awarded, but will post those as soon as we receive them.

The Department will maintain a web-based database for for Certified Claims Administrators to track and report their credit hours.

For more information, consult the rule at http://www.lni.wa.gov/rules/AO06/19/0619Adoption.pdf.

Trouble Finding a Medical Examiner?

New Department Search Feature Makes it Quick & Painless

Need help finding a medical examiner for a particular specialty?  The Department has added a search function to their list of approved examiners.  https://fortress.wa.gov/lni/imets/.

Updated Self-Insurance Section

Phone Contact Listing ... Including Team Assignments

Need an updated list of Self-Insurance section phone numbers?  Here’s the link to the latest and greatest list, http://www.lni.wa.gov/ClaimsIns/Files/SelfIns/SelfInsPhoneList.pdf, updated January 1, 2008 .  Note that the list now includes which adjudicator and which consultant work on which claims Team.  Check back at this link periodically for updated information.

Requesting Self-Insured and

Requesting State Fund Claims Files

In response to changes in public disclosure law, the Department of Labor & Industries has changed the way they process and respond to requests for prior industrial insurance claims files.  You will need to submit TWO requests: one to Norm Voiles for information on self insured claims (faxed to 360-902-6900), and then requests for State Fund claims histories to Paula Clayton (faxed to 360-902-6970.)  If you have questions on the status of State Fund claims information requests, you can call 360-902-5656.  Most State Fund requests will be handled within 10 business days.

You Pay for It, Use It!

DOSH Safety Materials Available for Your Use

The Department of Labor & Industries’ Division of Occupational Safety & Health has at least 27 downloadable safety videos, 75 industry fact sheets, 18 employee safety rule training kits, 85 online safety presentations, 52 construction industry toolbox talks, and over 2000 different safety, health, and risk management video titles for checkout in their safety library.  YOU pay for these services, so please take advantage of them.  You can find these materials at the DOSH webpage at the Department’s website at http://www.lni.wa.gov/safety/.

Electronic Filing of Claims Appeals

At the Board of Industrial Insurance Appeals

Did you know you can file your claims appeals electronically, online?  You can!  Go to the Board of Industrial Insurance Appeals website at www.biia.wa.gov and click on the E-filing logo.  Your appeal is submitted instantly, saving time and postage.  You are able to print a copy for your records, and a receipt showing that your submittal was received.  Give it a try!

as of 2/19/2008