Department Interprets Requiring Certified Claims Administrators

to Include Those Working from Home

The Department of Labor & Industries has interpreted WAC 296-15-350 (2)(b) [if claims are administered in more than one location, there must be at least one department-approved claims administrator in each location] to mean that, if a claim manager works claims from home, that would constitute a "location", and that claim manager should be certified.  If you have any other questions, please call Jeannie Parr directly at 360-902-6839.

New Vocational Rehabilitation Pilot Project Rules

Released by the Department

The Department of Labor & Industries has released the final version of the initial rules for the Vocational Rehabilitation Pilot Project.  While everyone has been utilizing Department guidelines until these rules take effect, the rules themselves will be the guidance on complying with the 2007 law as it passed the Legislature.  The new rules take effect March 31, 2008.  You can find the current Guidelines HERE.  You can find the Final Rules HERE.

Webinar on Psychological Disorders

in Workers' Compensation

For those of you looking for additional educational and continuing education opportunities, there is an interesting two-part, 1.5 hour each webinars offered by The LeClair Company on Psychological Disorders in Workers' Compensation.  The webinars are being held May 1st and 8th at 10:00am Pacific Time.  The webinars will cover: Is this psychological disorder caused by the event, is it related to the event or the treatment process, or is it an aggravation of a pre-existing condition?  What types of information will help me clarify issues associated with causation, work-relatedness and aggravation and how can I best gain that information?  When I believe I have valid information about the disorder and its relatedness to work, how do I address segregation and apportionment?  How can I develop a practical tool set that will help me organize my approach and the information I have generated?  For more information and registration, go HERE.

National Council of Self-Insurers Annual Conference

to be held June 1-4, 2008 in Naples, Florida

The National Council of Self-Insurers (of which WSIA is a member) is holding its annual conference June 1-4, 2008 at the Naples Grand Resort in Naples, Florida.  Information regarding the agenda, and registration materials can be found at the NCSI website at http://www.natcouncil.com/meet.html.  The National Council blocked a larger number of hotel rooms at the Naples Grande Resort & Club for the 2008 annual meeting than it has ever blocked for a meeting in Florida.  The block, however, has now been totally reserved.  The Council has reserved an additional block of rooms at the Edgewater Beach Hotel, a sister property of the Naples Grande.  The Edgewater Beach is an “all suites hotel” directly on the Gulf of Mexico.  The price per room is the same as the Naples Grande, $169 plus tax per night, with the resort fee being waived.  I suggest that you visit the web site of the Edgewater Beach Hotel, www.edgewaternaples.com  The drive from the Edgewater Beach to the Naples Grande is an easy four miles. Self-parking at both hotels is free.  The Edgewater Beach Hotel has a Group on-line booking system.  You may go to the following link to book your reservation:

https://reservations.ihotelier.com/crs/g_login.cfm?hotelID=3580

After clicking on the link, you will need to put in an attendee code of 8E2203 and then click on Attendee Log-In.

New Department Rules on Occupational Therapy,

Physical Therapy, and Massage Therapy Reimbursement Rates

The Department is in the process of updating its reimbursement rates for occupational therapy, physical therapy, and massage therapy services.  Most significant among the changes is setting the massage therapy rate at 75% of the rate charged for physical therapy.  The text of the draft rule can be found at the Department's website HERE.  There will be a public hearing on the rule change at 1:00pm, Wednesday, March 26th at the Department's headquarters in Tumwater.  Written comments are due back to the Department by April 2nd.  Send comments to Tom Davis at dato235@LNI.wa.gov.

Department to Update List of Examiners

and Registered IME Companies

2008 Examiner Update.  On February 21, 2008, requests for updated information was  mailed to all examiners whose last name begins with one of the following letters: A, D, G, J, M, P, S, V, and Y.  Examiners who are currently listed as temporarily unavailable on the approved examiner list will also be receiving a request for updated information.  Examiners who fail to comply with this required update by June 30, 2008, will be listed as temporarily unavailable to conduct IMEs.  Access to the “Approved IME Examiner Update (F245-051-000)” form is available on the website at www.imes.LNI.wa.gov.

2008 IME Firm Update.  During the month of March 2008, all IME firms are required to verify the information listed on the website “Find a Medical Examiner” is accurate.  Send an e-mail to winc235@LNI.wa.gov if your firm’s listing is correct.  Call 360-902-6815 if there are corrections that need to be made.  Some corrections may need to be submitted in writing

.  

New Link on IME website.   The assignment letter is being revised.  General instructions to approved examiners will be listed on the website until it can be incorporated in the next version of the Medical Examiners’ Handbook.

For more information contact Provider Review and Education at 360-902-6815.

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.

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.

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-

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/.

as of 3/4/2008