Sedgwick CMS 2009 Capabilities Overview

Transcription

Legislative Reforms
Sweep the Nation –
What You Need to Know
Presented by:
Darrell Brown, Senior Vice President
Sedgwick © 2012 Confidential – Do not disclose or distribute.
Legislation in the last 10 years
NY
CA
TX
FL
2
Commonalities
Networks
Utilization
review
Benefit
increases
Fee schedules
3
Legislative reform cycle
Balance
Slippage
Correction
Political
tension
Imbalance
4
Legislative changes
ME
MT
WA
WI
NE
CO
CA
MO
KS
MA
MD
IL
KY
NC
TN
OK
AZ
NY
MI
LA
MS
FL
5
Impact of 2010
Elections
Illinois and Kansas
• Illinois – Senate Bill 1349
IL

Allows employers to establish preferred provider
network (PPP)

Requires utilization of AMA Guidelines, 6th Edition

Assigns more weight to utilization review

Reduces medical fee schedule by 30%

Intoxication could be basis for denial

Fee schedule change from geo-zip to more Medicare
based
• Kansas – HB 2134
KS


Increases benefit caps

Permanent partial

Permanent total

Death benefits
Excludes coverage for employees at a companysponsored event, unless worker was ordered or coerced
to participate.
7
Montana and Oklahoma
• Montana - House Bill 334, Senate Bill 243, and
House Bill 71
MT

5 year limit on long-term benefits for injured workers
who are not permanently totally disabled.

Insurer designation of treating physician

Amended definition of course and scope to address offsite break and recreational or social activities.

Criteria for permanent partial disability

Allows settlements of medical benefits on accepted claim

Requires department to establish rules for use of
evidence-based guidelines.
• Oklahoma - Senate Bill 878
OK

Fee schedule - 120% of Medicare

Use of latest edition of ODG

Implement EDI by 7/1/2012

Reduces maximum number of TTD weeks from 300 to 156

Provides that no permanent disability for a body part
where there was no medical treatment.
8
Tennessee
• Tennessee – House Bill 1503 and Senate
Bill 923
TN

Redefines injury under workers’ compensation
(causes either disablement or death of the
employee).

Hearing loss, carpal tunnel syndrome or other
repetitive motion would not be considered
occupational diseases.

Presumption of treating physician’s opinion

Guarantees employers access to injured workers’
medical records.

Allows parties to mutually agree to settle future
medical - unless employee is permanently totally
disabled.
9
Washington
• Washington – Senate Bill 5566 and House
Bill 1869
WA

Allows for the settlement of claims

Establishes an industrial health care provider
network.

Mandates that injured workers seek treatment
from network for all but the first visit.

Requires L&I to identify best practice standards that
will be used to evaluate that the network provides
and removes those that fail to adhere to the best
practices and fail to deliver optimal outcomes to
patients.
10
Michigan
• Michigan – House Bill 5002

Provides that a personal injury is compensable if work causes,
contributes to or aggravates the condition of the employee so as to
create a condition that is “medically distinguishable” from the
employees’ prior condition.

Adds degenerative arthritis as a condition of the aging process that
may be compensable.

Adds a requirement that an employee’s perception of actual events be
reasonably grounded in reality, for a mental disability to be
compensable.

Allows employers to choose health care providers for injured
employees for 28 days from the start of medical care, rather than 10
days. Employee can then choose to be treated by his or her own
physician.

Provides that a limitation of wage earning capacity occurs only if an
employee is unable to perform all jobs paying the maximum wages in
work suitable to his or her qualification and training.

Provides that an employee terminated from reasonable employment
due to the fault of the employee is considered to have voluntarily
removed himself/herself from the work force and is not entitled to
wage loss benefits.

Changes the amount the weekly benefits can be reduced if the
employee received Social Security retirement benefit payments before
the date of the injury or work-related disease.
MI
11
North Carolina
NC

Medical compensation amended to include
attendant care services.

Defines “suitable employment” offer

Employee may be disqualified from receiving
compensation if certain misrepresentations were
made at time of hire.

TTD benefits are capped at 500 weeks from the first
date of disability unless employee makes application
to the Industrial Commission that total loss of
earning capacity has been sustained.
12
2012 legislation
ME
WI
NE
MO
CO
OK
AZ
MS
LA
FL
13
Florida and Oklahoma
• Florida – HB 5203

FL
Abolishes the state Bureau of Rehabilitation and
Reemployment Services and allows the state to contract
the rehabilitation of injured workers out of private
vocational counselors.
• Oklahoma

OK
Oklahoma has been considering “opt-out” legislation
since 2010 when House Bill 2881 was introduced. This
bill would have allowed businesses to opt-out of the
state workers’ compensation system as can be done in
Texas. The bill was re-filed as House Bill 1286 in 2011,
but again did not pass.
14
Missouri and Maine
• Missouri - House Bill 1540
MO

Addressed the decision in Richard Robinson, et al v. Cheryl Hooker (by
providing that effective August 28, 2012 an employee will not be liable for
a co-employee’s workplace injury or death “for which compensation is
recoverable under the workers’ compensation laws.”

Provides for the inclusion of occupational exposure claims within the
exclusive remedy provision of the Missouri Workers ’ Compensation act.
• Maine – Legislative Docket 1913
ME

Eliminates requirement that an employer/insurer continue paying
benefits to an employee during an appeal of a hearing officer decree by
the employee.

Increases the percent of the state weekly average calculation from 90% to
100% for the maximum benefit level computation.

Adds presumption that work is unavailable for a person participating in a
rehabilitation plan ordered by the Workers’ Compensation Board for as
long as the employee continues to participate in vocational rehabilitation.

Changes time from which the statute of limitations for filing a petition
begins from 2 years from the date an employer is required to file a first
report of injury to the actual date of injury.
15
Wisconsin and Mississippi
• Wisconsin – SB 409
WI

Raises maximum compensation rate for permanent partial disability by $10 per week to $312 for
injuries after 4/2/12 and additional $10 for injuries after 1/1/13.

Changes provisions on compensation for permanent disfigurement to restrict compensation to
cases in which an employee suffers “an actual wage loss due to the disfigurement.”

Provides that the Work Injury Supplemental Benefit Fund, rather than employers or insurers, will be
liable for benefits or treatment expenses for injuries before April 1, 2006.

Permits the Department of Workforce Development (DWD) to bring an action in tort against a third
party for damages due to an injury which must be paid by the Work Injury Supplemental Benefit
Fund.
• Mississippi - SB 2576


MS




Requires that the Workers’ Compensation Act by law not be presumed to favor one party over
another.
Requires the claimant, in certain cases, to file medical proof of the direct causal connection
between the work performed and the alleged work-related injury or occupational disease within 60
days after the filing of a petition to controvert.
Allows employers and carriers to seek apportionment for any pre-existing condition, regardless of
whether the pre-existing condition was considered occupationally disabling.
Provides that compensation is not payable if the proximate cause of the injury is the use of illegal
drugs or the taking of a valid prescription medication contrary to the prescriber’s instructions
and/or contrary to label warnings.
Increases the maximum amount the commission may award the employee for serious facial or head
disfigurement from $2,000 to $5,000.
Increases the maximum amount the commission may award as maintenance compensation from
$10 per week to $25 per week up to a maximum of 52 weeks.
16
Louisiana
LA

Requires that workers’ compensation cases are to be decided on
their merits and not to be liberally construed in favor of the
employee.

Reduces the period for paying the first week of temporary
disability benefits from six weeks to two weeks.

Mandates electronic data interchange (EDI) by December 31, 2013.

Increases the lump sum one-time payment for catastrophic
injuries from $30,000 to $50,000,in addition to any other benefits
owed.


Increases benefits for burial expenses from $7,500 to $8,500.
Clarifies how and when utilization review companies can be used
and procedures for when an independent medical exam is
requested.
17
Arizona
• Arizona – SB 1016, HB 2155 & HB 2368

Allows employees to received benefits through electronic
fund transfer or prepaid debit card.

Permits IME physicians to access data from the state’s
prescription drug-monitoring drug database and to
disclose that information to the employee, employer,
insurance carrier and the commission.

Permits the board to release data from prescription drugmonitoring database to IME physicians.

Requires the commission to develop and implement
state-specific, evidence-based treatment guidelines by
December 31, 2014.
AZ
18
Colorado
• Colorado – HB 1003
CO

Requires an employer report to the division and its
carrier within 10 days all contraction of occupational
disease or injuries resulting in more than three days
or three shifts loss of time from work. Fatalities
must be reported immediately.
19
Nebraska
• Nebraska – Legislative Bill 738
NE

Increases the maximum workers’ compensation
burial benefits from $6,000 to $10,000 payable
to eligible dependents.
20
California
• California SB 863
CA

Permanent impairment

Medical Provider Network

Independent bill review (IBR)

Independent medical review (IMR)

Fee schedules

Liens

Return to work
21
On the horizon
OK
TN
FL
22
What actions the risk management community should take:
Activism
Vigilance
Understanding
Data
Operationalize
Measurement
Training
23
Thank you for attending this webcast.
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24

Sedgwick CMS 2009 Capabilities Overview

Transcription

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