2nd Quarter 2008 by oof19312

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									                                                                                                                                                     2nd Quarter 2008
                                                                                                                                                    2nd Quarter 2007




                         AIG Domestic Claims and Health Direct are pleased to bring you this quarterly newsletter on the
                      most recent legislation and regulation on workers' compensation medical management for your state(s).
                                                                 Legislative and Regulatory Activity
       Legislation                                                    Synopsis                                                   Status & Last Action Date         Effective Date
Alaska
Guides to Evaluation of        The Alaska Workers’ Compensation Board selected the American Medical Association’s                Bulletin issued on 1/15/08.        3/31/08
Permanent Impairment           Guides to the Evaluation of Permanent Impairment, Sixth Edition as the authority for all
                               permanent partial impairment determinations and ratings.


California
California Code of         Proposed substantive and non-substantive modifications to the regulations governing qualified         Public hearings held on 1/14/08    N/A
Regulations §§1-159        medical evaluators (QME) and agreed medical evaluators (AME) which among other things:                and 1/17/08. Comment period
                               Outlines QME eligibility, application requirements, and standards for reappointment.              ended on 1/17/08.
Qualified Medical              Addresses various reasons for QME disciplinary action.
Evaluators                     Requires all QMEs and AMEs, knowing of a conflict of interest, to send written notification
                               to the injured employee, the employer or insurer (or their representatives) within 5 business
                               days of becoming aware of the conflict and allows for disqualification if either party objects.
                               Prevents QMEs with shared business interests from serving on the same panel.
                               Changes the list of physician specialties including merging specialties to reduce travel by
                               injured workers.
                               Describes how parties should apply to the DWC’s Medical Unit to request the issuance of a
                               QME panel, in order to select a QME to perform a comprehensive medical legal evaluation
                               and report.



                                                                                             1
        Legislation                                                   Synopsis                                                   Status & Last Action Date            Effective Date
California Code of            Governs the exchange of information between the parties and the QME.
Regulations §§1-159           Describes certain rights injured workers must be advised of by the QME.
                              Mandates new reporting requirements for QMEs and AMEs when providing an opinion on a
Qualified Medical             disputed medical treatment issue to apply, and be consistent with the evidence-based medicine
Evaluators                    standards established in the medical treatment utilization schedule.
(Cont.)                       Establishes a new set of forms for use with the proposed regulations.
                              Further information regarding the proposed regulations may be viewed at:
                              http://www.dir.ca.gov/dwc/DWCPropRegs/qme_regulations/qme_regulations.htm S
                              synopsis
California Code of         Updated treating physician regulations and forms were posted to an online forum for public            Comment period ended on               N/A
Regulations §§9785 and     comment, which:                                                                                       5/18/08.
9792.6                        Allow all physicians who treat an injured worker, including the primary physician and any
                              referral physicians, to submit reports directly to the claims administrator.
Treating Physician            Facilitate the mandatory utilization review process by requiring the use of a new request for
Regulations                   authorization form (DWC Form RFA) for all requested workers’ compensation treatment.
                              Revise the treating physician progress report (DWC Form PR-2) and the functional
                              improvement report (DWC Form FIR).
                              Authorize use of an optional proof of service form (DWC Form PSMR) to verify the mailing
                              date of a medical report.

California Code of            Proposed amendments update the vocational rehabilitation regulations, the supplemental job         Public hearings scheduled for         N/A
Regulations §§10116 to        displacement regulations, and the return-to-work regulations by revising specific forms to         7/14/08 and 7/15/08. Comment
10133.58                      allow the Division of Workers’ Compensation to implement the first stage of the Electronic         period ends on 7/15/08.
                              Adjudication Management System and store claim data electronically.
Retraining and Return to      Further information regarding the proposed regulations may be viewed at:
Work Regulations              http://www.dir.ca.gov/dwc/DWCPropRegs/EAMS_regulations/EAMS_regulations.htm

AB550                         Establishes the Integrated 24-Hour Occupational Medical Care pilot project through 1/1/13 for      Bill revised on 5/19/08. No           N/A
                              the purpose of demonstrating and evaluating the effectiveness of providing medical treatment       longer applicable.
                              for work-related injuries through the same medical care delivery system which delivers
                              treatment and services for non-occupational injuries and illnesses.

SB1338                        Proposed legislation would eliminate the 12/31/09 sunset provision contained in the Labor          Passed in the Senate. Referred to     N/A
                              Code section which permits an employee to pre-designate his/her physician for treatment of a       the Assembly on 5/27/08.
                              work-related injury.

AB2081                     Proposed legislation would, among other things:                                                       Passed in the Assembly. Passed        N/A
                              Prohibit a claims adjuster from offering, delivering, receiving or accepting any rebate, refund,   in the Senate Labor and Industrial
                              commission, preference, patronage dividend, discount or other consideration to induce a            Relations Committee, as amended,
                              referral for utilization review services to any entity with which it contracts to provide such     and referred to the Senate
                              services.                                                                                          Judiciary Committee on 6/11/08.
                              Require utilization review entities to provide an annual report to the employer and the Division
                              of Workers’ Compensation of the number of denials that were overturned either through the
                              QME/AME process or by an administrative law judge.
                              Further information regarding the legislation may be viewed at:
                              http://www.leginfo.ca.gov/pub/07-08/bill/asm/ab_2051-
                              2100/ab_2081_bill_20080612_amended_sen_v96.pdf

                                                                                             2
      Legislation                                                    Synopsis                                                   Status & Last Action Date            Effective Date
AB2091                       Proposed legislation expands the annual medical access study conducted by the Administrative       Passed in the Assembly. Referred      N/A
                             Director of the Division of Workers’ Compensation to include prescription drugs and                to the Senate Committee on Labor
                             pharmacy services information.                                                                     and Industrial Relations on
                                                                                                                                5/29/08.

AB2351                       Proposed legislation would require retrospective utilization reviews that modify, delay, or deny   Referred to the Assembly              N/A
                             services to be communicated to the claimant or their designee within 30 working days of            Insurance Committee and failed
                             receipt of the information that is reasonably necessary to make the determination.                 passage on 4/30/08.



AB2969                     Proposed legislation would require any physician who conducts workers’ compensation medical          Passed in the Assembly. Referred      N/A
                           utilization review to be licensed in the state of California.                                        to the Senate Labor and Industrial
                                                                                                                                Relations Committee on 5/29/08.

Delaware
Delaware Administrative   Workers’ compensation regulations implementing SB1, which, among other things:                        Final rules published in the          5/23/08
Code                        Establish a healthcare payment system providing maximum acceptable charges for services             Delaware Register on 6/1/08.
                            performed by health care professionals, hospitals, ambulatory surgical treatment centers,
Workers’ Compensation       laboratories, pharmacies, and durable medical equipment providers.
Regulations                 Require payment within 30 days of the insurance carrier’s receipt of a clean claim.
                            Establish guidelines implementing best practice standards for treatment of carpal tunnel
                            syndrome, chronic pain, cumulative trauma disorder, and lower back and shoulder injuries.
                            Create a presumption in favor of the provider that any services performed conforming to the
                            treatment guidelines are reasonable and necessary.
                            Create a utilization review procedure for prompt and efficient review of challenged healthcare
                            procedures (currently limited to care subject to the treatment guidelines developed by the
                            Health Care Advisory Panel) and adopt a utilization review form to be used during the process.
                            Require biennial registration with the Office of Workers’ Compensation for any person
                            conducting utilization review.
                            Adopt forms to be used by employees, employers, insurance carriers and healthcare providers
                            to better facilitate communication.
                            Further information regarding the regulations may be viewed at:
                            http://regulations.delaware.gov/register/june2008/final/11%20DE%20Reg%201661%2006-01-
                            08.htm#P9_165


Florida
SB2548                    Proposed legislation would, among other things:                                                       Died in the Senate.                   N/A
                             Require carriers to give an employee more than one opportunity to change physicians for
                             medical treatment.
                             Revise the requirements for obtaining an independent medical examination and redefine the
                             term to exclude evaluations by an expert medical advisor.
                             Repeal the medical expert advisor procedure currently used by compensation claim judges.
                             Delete qualified rehabilitation providers from the list of persons entitled to request medical
                             information from an authorized health care provider treating an injured employee.
                             Further information about the proposed legislation may be viewed at:
                             http://www.flsenate.gov/data/session/2008/Senate/bills/billtext/pdf/s2548.pdf

                                                                                           3
      Legislation                                                  Synopsis                                                  Status & Last Action Date        Effective Date
Georgia
Medical Fee Schedule       The Georgia State Board of Workers’ Compensation issued revisions to its Medical Fee              Posted to the State Board of      4/1/08
                           Schedule including:                                                                               Workers’ Compensation website.
                           o A recalculation of all maximum allowable reimbursements.
                           o Updated CPT codes and a 10% increase in hourly rates for home health services.
                           o Implementation of the MS-DRG codes.
                           Further information about the revisions may be viewed at:
                           http://sbwc.georgia.gov/00/channel_modifieddate/0,2096,11394008_34361078,00.html

Hawaii
HB763                      Provides for the optional use of evidence-based treatment guidelines in accordance with the       Died in the Senate.               N/A
                           most current edition of ODG Treatment in Workers’ Compensation issued by the Work Loss
                           Data Institute or other medical guidelines approved by the Director.
                           Creates a rebuttable presumption that services performed, in accordance with the evidence-
                           based guidelines, are medically necessary and correct, and allows the physician to treat the
                           claimant without providing a treatment plan.
                           Requires the provider to send a treatment plan to the employer 14 days prior to the start of
                           treatment for injuries not covered by the evidence-based guidelines. The treatment plan must
                           describe projected commencement and termination dates of treatment, diagnosis, frequency of
                           treatment, modalities and procedures to be used, an estimated total cost of services, and
                           provides a mechanism for the employer to dispute the treatment plan.
                           Amends the laws relating to Independent Medical Examinations and provides that:
                           o All physicians selected to perform IMEs be licensed in Hawaii, hold an active professional
                                and occupational license for five consecutive years prior to the IME, and be subject to
                                peer review.
                           o The employer and employee will mutually agree on the examiner and, if the parties cannot
                                agree, a mechanism to allow for resolution of the dispute.
                           o The employee and the employee’s physician can record the IME and ask questions
                                relating to the examiner’s experience and overall qualifications.

HB1386 (See also SB1472)   Amends the current law relating to guidelines on frequency of treatment and utilization and       Died in the House.                N/A
                           mandates (not optional) that all treatment be in accordance with the ODG treatment guidelines
                           issued by the Work Loss Data Institute.
                           Creates a rebuttable presumption that services performed in accordance with the evidence-
                           based guidelines are medically necessary and correct, and allows the physician to treat the
                           claimant without providing a treatment plan.
                           Requires the provider to send a treatment plan to the employer 14 days prior to the start of
                           treatment for injuries not covered by the evidence-based guidelines. The treatment plan must
                           describe the reason for deviating from the guidelines, projected commencement and
                           termination dates of treatment, diagnosis, frequency of treatment, modalities and procedures to
                           be used, and an estimated total cost of services.
                           Specifies that all treatment plans must be based on evidence-based medical treatment
                           guidelines generally recognized by the medical community. It also provides a dispute
                           mechanism if the employer questions the treatment plan.
                           Limits psychiatric evaluation or psychological testing with resultant reports to four hours,
                           unless the physician submits prior documentation indicating the necessity for additional time.



                                                                                         4
        Legislation                                                      Synopsis                                                 Status & Last Action Date         Effective Date
HB1380 (See also SB              Proposed legislation would disallow a workers’ compensation claim for a mental illness or        Died in the House.                 N/A
1466)                            injury, or the physical manifestations brought on by mental illness or injury, resulting from
                                 personnel actions (e.g., layoff, counseling, work evaluations or criticism, job transfer,
                                 retirement, demotion, suspension or transfer) taken in good faith by an employer.

Idaho
Idaho Administrative Code     Final rule adopts the Resource-Based Relative Value Scale as the standard in determining the        Adopted on 4/2/08.                 4/2/08
17.02.08                      acceptable charge for medical services provided under the workers’ compensation law by
                              providers other than hospitals and Ambulatory Surgery Centers (ASCs) and:
Medical Fee Schedule             Provides a standard for determining the acceptable charge for large hospitals at 85 percent of
                                 the appropriate inpatient charge, and 90 percent of the appropriate inpatient charge for small
                                 hospitals.
                                 Provides a standard for determining the acceptable charge for ASCs, and hospital outpatient
                                 charges at 80 percent of the appropriate charge.
                                 Imposes a 30 percent penalty against a payor if a medical provider prevails on his/her motion
                                 for payment to serve as compensation to the medical provider for costs and expenses associated
                                 with the payment dispute resolution process.
                                 Further information regarding the final rule may be viewed at:
                                 http://adm.idaho.gov/adminrules/rules/idapa17/0208.pdf

Illinois
 50 Illinois Administrative   Proposed amendments to the Workers’ Compensation Medical Fee Schedule would:                        Public hearings held on 3/26/08    N/A
 Code § 7110.90                  Adopt maximum payment rates for medical services payable under the Ambulatory Surgical           and 4/2/08. Comment period
                                 Treatment Center schedule and the Hospital Outpatient schedule.                                  ended on 4/21/08. An additional
Medical Fee Schedule             Add a separate Rehabilitation Hospital schedule to the Medical Fee Schedule (currently           45-day comment period is
                                 reimbursed under the Hospital Inpatient Schedule) by establishing a maximum per diem             expected.
                                 reimbursement rate for all services performed in freestanding rehabilitation hospitals.
                                 Adopt the Medicare Severity Diagnosis Related Group (MS-DRG) classification system by
                                 1/1/09 for the Hospital Inpatient schedule.
                                 Further information on the proposed amendments may be viewed at:
                                 http://www.iwcc.il.gov/news.htm#FSPR

HB5659                           Proposed changes to the Illinois Workers’ Compensation Act would, among other things,            Re-referred to the House Rules     N/A
                                 require the current edition of the American Medical Association (AMA) Guides for the             Committee on 3/14/08.
                                 Evaluation of Permanent Impairment to be applied in determining the level of disability.
                                 Further information on the proposed legislation may be viewed at:
                                 http://www.ilga.gov/legislation/BillStatus.asp?DocNum=5659&GAID=9&DocTypeID=HB&L
                                 egId=37236&SessionID=51&GA=95

Iowa
SF424                         Proposed legislation eliminates employer-directed medical care and:                                 Died in the Senate.                N/A
                                 Provides that an employee may choose a provider of medical services at the employer’s
                                 expense, and specifically prohibits the employer and the insurer from making any suggestions
                                 or otherwise attempting to influence the injured employee’s choice of treating physician.
                                 Allows for alternate care upon application and hearing by the Workers’ Compensation
                                 Commissioner if either the employer or employee is dissatisfied with the care offered or
                                 provided.

                                                                                              5
        Legislation                                                      Synopsis                                                    Status & Last Action Date         Effective Date
Iowa Administrative Code       Emergency regulatory amendment adopting the American Medical Association’s Guides to the              Published in the Iowa              4/2/08
§876 -- 2.4 (85, 86)           Evaluation of Permanent Impairment, Fifth Edition as the reference for determining permanent          Administrative Bulletin on
                               partial disabilities for injured workers.                                                             4/23/08.
Emergency Rule                 Further information on the emergency regulation may be viewed at:
                               http://web.legis.state.ia.us/Rules/Current/Bulletin/IAB080423.pdf
AMA Guides to the
Evaluation of Permanent
Impairment

Kentucky
Kentucky Administrative     Proposed amendment to the regulation governing workers’ compensation managed health care                 Public hearing held on 9/21/07.    N/A
Regulation §25:110          plans which:
                               Modifies the definition of gatekeeper physician.
Managed Health Care Plans      Requires, as part of the plan qualification, that a complete list of health care providers is given
                               to the injured employee.
                               Mandates that the list of participating employers or carriers in the plan, their date of
                               enrollment, and date of termination, if applicable, be provided to the Office of Workers’
                               Claims.
                               Modifies the annual reporting requirements.
                               Further information regarding the regulation may be viewed at:
                               http://www.labor.ky.gov/NR/rdonlyres/55E74FBE-A98E-4403-94A4-
                               462B23888824/0/803KAR25110.pdf

Kentucky Administrative     Proposed amendment to the selection of physician, treatment plan, and medical services statement         Public hearing held on 9/21/07.    N/A
Regulation §25:096          regulation:
                               Includes a provision in the employee’s physician selection section that the employee must
Selection of Physicians,       choose a gatekeeper physician from the list provided by the employer if a managed health care
Treatment Plans, and           plan is utilized.
Statements for Medical         Modifies the procedure for changing a designated physician.
Services                       Further information regarding the regulation may be viewed at:
                               http://www.labor.ky.gov/NR/rdonlyres/E3928EB1-5A5C-45D2-A0EF-
                               3CF43F87E632/0/803KAR25096.pdf

SB199                          Provides for the adoption of the American Medical Association’s Guide to the Evaluation of            Signed by the Governor on          4/10/08
                               Permanent Impairment, Fifth Edition rather than the most recent Sixth Edition.                        4/10/08.
                               Requires that recommendations be presented to the Legislative Research Commission by
                               8/1/08 addressing the position on adopting the Sixth Edition or retaining the Fifth Edition.
                               Makes adoption of the Sixth Edition effective 1/1/09.
                               Further information regarding the new law may be viewed at:
                               http://www.lrc.ky.gov/record/08RS/SB199.htm




                                                                                                6
      Legislation                                                  Synopsis                                                   Status & Last Action Date           Effective Date
Louisiana
HB1099                 Proposed legislation would, among other things:                                                        Referred to the House Labor and      N/A
                          Authorize the Workers’ Compensation Agency Director to establish and adopt a medical                Industrial Relations Committee on
                          treatment schedule based upon the current edition of the Official Disability Guidelines –           3/31/08.
                          Treatment in Workers’ Compensation by 1/1/09, and establishes a presumption that medical
                          treatment is correct if rendered in accordance with the treatment schedule.
                          Establish a reconsideration process for medical bills that are disputed by the provider and
                          permits penalties, including attorney fees, if the decision to not pay or underpay by the
                          insurance carrier was arbitrary and capricious.
                          Modify the procedure effective 1/1/09 governing physical examinations.
                          Permit an insurance carrier to initiate return-to-work and vocational rehabilitation prior to an
                          employee reaching maximum medical improvement.
                          Provide that a vocational counselor is not required to obtain approval of the treating physician
                          with respect to specific jobs which the counselor believes the employee is capable of
                          performing.
                          Strengthen the requirements for ordering independent medical examinations and requires
                          examiners to prepare a certified report containing their analysis and determinations.
                          Further information regarding the proposed legislation may be viewed at:
                          http://www.legis.state.la.us/billdata/streamdocument.asp?did=472694

Massachusetts
Treatment Guidelines       The Massachusetts Department of Accidents’ Health Care Services Board created draft                Comment period ended on              N/A
                           treatment guidelines designed to manage knee injuries that do not require surgery.                 6/10/08.
Knee Injury                Further information regarding the draft treatment guideline may be viewed at:
                           http://www.mass.gov/?pageID=elwdterminal&L=5&L0=Home&L1=Government&L2=EOL
                           WD+Publications&L3=Healthcare+Services+Board+Publications&L4=Treatment+Guidelines
                           &sid=Elwd&b=terminalcontent&f=dia_hcsb_08_tg14_draft&csid=Elwd


Minnesota
SF3218                 Newly enacted legislation amends the Minnesota workers’ compensation law by, among other               Signed by the Governor on            Various
                       things:                                                                                                4/30/08.
                           Increasing the maximum hourly rate for qualified rehabilitation consultants and interns
                           (effective 4/30/08).
                           Extending the timeframe for injured workers to request retraining benefits (effective for
                           injuries occurring on or after 10/1/08).
                           Prohibiting reimbursement of unlicensed or unregistered complementary and alternative health
                           care practitioners (effective 4/30/08).
                           Specifying that all health care providers that provide treatment outside of Minnesota be paid at
                           the rates under the workers’ compensation law where the treatment was provided (effective
                           4/30/08).
                           Allowing for updates to the workers’ compensation relative value fee schedule, at least every 3
                           years, by incorporating and referencing updates to the Medicare relative value fee schedule
                           (effective 4/30/08).
                           Further information regarding the legislation may be viewed at:
                           https://www.revisor.leg.state.mn.us/bin/bldbill.php?bill=S3218.2.html&session=ls85



                                                                                         7
      Legislation                                                       Synopsis                                                   Status & Last Action Date             Effective Date
Nebraska
LB1082                         Proposed legislation allows compensation for mental conditions and illnesses, with or without       Died in the Legislature on 4/10/08.    N/A
                               physical injuries, for first responders and other persons who, in the course of their employment,
                               witness or are victims of a violent criminal act.

Nebraska Workers’              Amendments to Rule 26 revise the Schedule of Fees for Medical Services.                             Published on 5/14/08.                  6/1/08
Compensation Court             Further information regarding the amendments may be viewed at:
                               http://www.wcc.ne.gov/medical/fee_schedule/proposed_medical_services_fee_schedule.pdf
Rule 26

Medical Fee Schedule


Nebraska Workers’              Proposed amendment to Rule 64 modifies the timeframes that examinations by Independent              Adopted on 4/24/08. Pending            N/A
Compensation Court             Medical Examiners are required to be scheduled and reports submitted.                               approval by the Nebraska
                               Further information regarding the proposed amendment may be viewed at:                              Supreme Court.
Rule 64                        http://www.wcc.ne.gov/news/ph_amendments_20080323.pdf

Independent Medical
Examiners


Nevada
Medical Fee Schedule        Modifications to the Nevada Medical Fee Schedule Maximum Allowable Provider Payment were               Posted on 1/17/08.                     2/1/08 to 1/31/09
                            posted to the Division of Industrial Relations’ website (Workers’ Compensation Section) and
                            include:
                                Increases to track the 2007 consumer price index and reimbursement increases for home health
                                services.
                                An increase in the time factor before a no-show can be billed for a permanent disability
                                evaluation.
                                Continuing the use of CMS’ 2007 group list of ambulatory surgical codes and payment groups.
                                Further information regarding the fee schedule may be viewed at:
                                http://dirweb.state.nv.us/WCS/2008medfee.pdf

New York
NY Codes, Rules and            Re-adopted emergency regulation in place for another 90 days or until replaced by a                 Re-adopted on 4/7/08.                  4/7/08
Regulations Subchapter M       permanently adopted rule, which implements the pharmacy network and durable medical
                               equipment provisions contained in New York’s 2007 workers’ compensation reforms.
Emergency Rule                 Further information regarding the re-adopted rule may be viewed at:
                               http://www.wcb.state.ny.us/content/main/wclaws/SubchapterM_1-7-08.jsp
Pharmacy, Durable
Medical Goods, and Dental
Fee Schedules




                                                                                              8
      Legislation                                                        Synopsis                                                  Status & Last Action Date         Effective Date
NY Codes, Rules and          Proposed permanent regulation implementing the pharmacy network and durable medical                   Comment period ended on 4/7/08.    N/A
Regulations Subchapter M     equipment provisions contained in New York’s 2007 workers’ compensation reforms, which,
                             among other things:
Permanent Rule                  Provides definitions for brand name drugs, controlled substances, generic drugs, rural areas,
                                independent pharmacy, pharmacy chain, remote pharmacy, and third party payor.
Pharmacy and Durable            Sets forth the requirements, which a carrier must follow to notify the Board with regard to
Medical Goods                   filing a listing of designated pharmacies and pharmacy chains, as well as providing notice of
                                modifications to such designations.
                                Lists the requirements applicable to pharmacies that are designated as part of a pharmacy
                                network at which an injured worker must fill prescriptions including inventory requirements.
                                Provides for exclusions under which an injured worker is not required to use a designated
                                pharmacy or pharmacy network.
                                Details the employee/injured worker notification requirements which must be satisfied before a
                                carrier is permitted to steer into the network including the identity of the pharmacy chains and
                                independent pharmacies in the network (or an entity that can provide such information), time
                                frames for notice and method of delivery, as well as notifications of changes in a pharmacy
                                network and the methods of providing notice.
                                Requires the carrier to provide a document, such as a pharmacy benefits card, to injured
                                workers which lists the carrier and other contact information regarding the injured worker's
                                coverage as well as the pharmacy information, such as contact information and website
                                address.
                                Ties the pharmacy fee schedule in uncontroverted cases to the New York State Medicaid fee
                                schedule plus a dispensing fee of $5 for generic drugs and $4 for brand name drugs.
                                Establishes a pharmacy fee schedule in controverted cases at 25% above the New York State
                                Medicaid fee schedule plus a dispensing fee of $7.50 for generic drugs and $6 for brand name
                                drugs, and permits adjustments by the Board in circumstances where the reimbursement
                                amount is grossly inadequate to meet pharmacy costs.
                                Sets forth a transition period for injured workers to transfer prescriptions to a designated
                                pharmacy or pharmacy network depending on the type of drug (controlled substances or non-
                                controlled substances.)
                                Outlines the procedure for payment and reimbursement of prescription bills.
                                Indexes the DME fee schedule to the New York State Medicaid fee schedule.
                                Provides for a rate of reimbursement when Medicaid has not established a fee payable for a
                                specific DME item, and allows for adjustments to the fee schedule by the Board in situations
                                when the reimbursement amount is grossly inadequate to meet a pharmacy’s or provider's
                                costs.
                                Further information regarding the proposed permanent rule may be viewed at:
                                http://www.wcb.state.ny.us/content/main/wclaws/proposed_2-20-08.jsp

NY Codes, Rules and             Proposed grammatical, typographical and other non-substantive amendments.                          Comment period ended on            N/A
Regulations Subchapters C,      Proposed substantive amendment increasing the threshold amount from $500 to $1000 for              5/27/08.
D, and E                        medical services which require authorization.
                                Further information regarding the proposed amendments may be viewed at:
Medical Treatment and           http://www.wcb.state.ny.us/content/main/wclaws/Proposed/Proposed_4-9-08_SecC.jsp
Care




                                                                                               9
        Legislation                                                   Synopsis                                                   Status & Last Action Date           Effective Date
Pharmacy Fee Schedule        The New York State Workers’ Compensation Board issued a list of corrected drug prices for           Subject Number issued on 5/27/08.    5/27/08
                             certain brand name drugs after it was discovered that the pharmacy fee schedule contained
                             price disparities between the drug acquisition price and the reimbursement price.
                             The corrected drug prices list may be viewed at:
                             http://www.wcb.state.ny.us/content/main/hcpp/NYS_WCB_Corrected_Brand_Drug_Fees.pdf

A05112 (See also A05417      Authorizes the care and treatment of injured employees by a licensed social worker upon the         Referred to the House Labor          N/A
and S1623)                   referral of a physician.                                                                            Committee on 1/9/08.
                             Directs the Chair of the Workers’ Compensation Board to establish a fee schedule for charges
                             and fees for social work treatment and care.

S587 (See also A01587)       Proposed legislation requires chiropractors that treat workers’ compensation claimants to be        Referred to the Senate Labor         N/A
                             reimbursed for each individual diagnostic, treatment service, and modalities performed.             Committee on 1/9/08.

A02130 (See also S4217)   Proposed legislation dealing with chiropractic care, which, among other things:                        Referred to the House Labor          N/A
                             Requires the chiropractic fee schedule to provide for payments that are equivalent to the care      Committee on 1/9/08.
                             or treatment provided by physicians for similar conditions.
                             Provides that chiropractic care and treatment would be subject to reasonable utilization review
                             but such review would not be more restrictive than the UR applicable to physicians.
                             Provides that each Preferred Provider Organization (PPO) shall offer coverage for care and
                             treatment provided by chiropractors.
                             Provides that an injured employee may seek care from a chiropractor outside the PPO 30 days
                             after a visit with an authorized PPO physician.

A06297 (See also S549)       Proposed legislation amends the workers’ compensation laws to specifically include massage          Held for consideration in the        N/A
                             therapy services; directs the Chair to set a massage therapy fee schedule; and addresses the        House Labor Committee on
                             arbitration of disputes involving the value of massage therapy services provided.                   5/20/08.

S1631 (See also A05847)      Authorizes a pilot program (effective until 12/31/12) to allow certified nurse practitioners to     Referred to the Senate Labor         N/A
                             provide care and treatment to injured workers, establishes a nurse practitioner committee to        Committee on 1/9/08.
                             regulate their practice, and directs the Chair to prepare and establish a nurse practitioner fee
                             schedule.
                             Provides that the report or testimony of a nurse practitioner concerning the condition and
                             treatment of an injured employee shall be deemed competent but not controlling evidence.

S4386                     Proposed legislation:                                                                                  Referred to the Senate Labor         N/A
                             Authorizes the care and treatment by a licensed or certified acupuncturist upon the referral of a   Committee on 1/9/08.
                             physician.
                             Directs the Chair of the Workers’ Compensation Board to establish an acupuncture fee
                             schedule.
                             Specifies reporting requirements by the acupuncturist to interested parties and establishes an
                             acupuncture practice committee to investigate, hear, and make findings on all charges of
                             professional or other misconduct of any authorized acupuncturist.




                                                                                            10
       Legislation                                                     Synopsis                                                   Status & Last Action Date          Effective Date
North Carolina
A Summary for Injured          The North Carolina Industrial Commission (NCIC) revised its Summary for Injured Workers of         Issued on 4/14/08.                  4/14/08
Workers of the Rules           the Rules Governing the Use of Rehabilitation Professionals in Workers’ Compensation Cases,
Governing the Use of           which instructs rehabilitation professionals to provide a copy of the document, or copy of the
Rehabilitation                 NCIC Rules for Utilization of Rehabilitation Professionals in Workers’ Compensation Claims,
Professionals in Workers’      at their first meeting with the injured worker.
Compensation Cases             Further information regarding the revised Summary may be viewed at:
                               http://www.comp.state.nc.us/ncic/pages/rehabsum.htm


HB1623                         Proposed legislation would place authority with the injured worker’s attending physician to        Passed in the House. Referred to    N/A
                               select the health care provider and the diagnostic services center to administer and analyze any   the Senate Committee on
                               diagnostic tests authorized by a physician under the workers’ compensation law.                    Commerce, Small Business and
                                                                                                                                  Entrepreneurship on 5/24/07.


Oklahoma
HB2605                      Proposed legislation that would reform the Oklahoma Workers’ Compensation system by, among            Died in the House.                  NA
                            other things:
                               Establishing a strict definition of a compensable injury.
                               Incorporating well-defined carpal tunnel syndrome guidelines.
                               Requiring medical findings to be “objective and measurable.”
                               Excluding pain and range of motion tests as objective medical findings.
                               Creating a health and safety division to track employers with high injury rates and to promote
                               safety.
                               Providing for mandatory vocational assessment of out-of-work injured employees for more
                               than one month.
                               Providing for managed care networks.
                               Providing for review of temporary total disability claims after 20 weeks.
                               Reducing total weeks of disability payments to 260 weeks.
                               Providing for fee schedules established by the Workers’ Compensation Commission.

Oregon
Oregon Administrative       Various proposed amendments are pending before the Department of Consumer and Business                Public hearing held on 5/19/08.     N/A
Rules                       Services (Workers’ Compensation Division), which include changes to:                                  Comment period ended on
                               Oregon Medical Fee and Payment Rules                                                               5/22/08.
Chapter 436                    Medical Service Rules
                               Managed Care Organization Rules
                               Preferred Worker Program Rules
                               Further information including the text of the proposed amendments may be viewed at:
                               http://www.cbs.state.or.us/external/wcd/policy/rules/rules.html#proprules

Hospital Fee Schedule          The Workers’ Compensation Board issued a new hospital fee schedule that adjusts Oregon             Bulletin issued on 3/31/08.         4/1/08
                               hospital cost/charge ratios for inpatient and outpatient services.
                               Further information may be viewed at:
                               http://www.cbs.state.or.us/external/wcd/policy/bulletins/bul_290.doc



                                                                                             11
      Legislation                                                      Synopsis                                                   Status & Last Action Date   Effective Date
South Dakota
HB1037                     New legislation regarding prompt payment of workers’ compensation claims and release of                Signed by the Governor on    7/1/08
                           medical information, which:                                                                            3/17/08.
                             Adds a new section requiring that all or a portion of a claim for medical payment that is not
                             denied, be paid within 30 days of receipt, or that a request for additional information to
                             determine whether the claim for payment is excessive, medically necessary, or the injury is
                             compensable be issued within the same time frame.
                             Imposes civil penalties of up to $500 for failing to comply.
                             Requires an injured employee to sign an authorization for the release of medical records which
                             are relevant to the claim for workers’ compensation benefits.
                             Further information regarding the new legislation may be viewed at:
                             http://legis.state.sd.us/sessions/2008/Bills/HB1037ENR.pdf

Tennessee
SB3886 (See also HB3848)   Proposed legislation:                                                                                  Died in the Senate.          N/A
                              Requires a contract negotiated and signed directly between the provider and the employer,
                              trust, pool, insurer, or PPO network for any fees paid below the medical fee schedule for
                              medical services furnished on or after 1/1/09.
                              Prohibits negotiated rates for workers' compensation services from being assigned to or
                              accessible to any other party than the employer, trust, pool, or insurer who signed the contract.
                              Requires the medical fee schedule rates to apply if a company marketing itself as a workers'
                              compensation PPO cannot produce a signed contract between the PPO and the provider.

SB2650 (See also HB2571)   Newly enacted legislation:                                                                             Signed by the Governor on    5/28/08
                             Designates the American Medical Association’s (AMA) Guides to the Evaluation of                      5/28/08.
                             Permanent Impairment, Sixth Edition as the current edition until a new edition is adopted by
                             the Tennessee General Assembly.
                             Directs the Commissioner of Labor and Workforce Development to evaluate any future new
                             editions and report the findings to the Tennessee General Assembly.
                             Further information about the new law may be found at:
                             http://www.legislature.state.tn.us/bills/currentga/Chapter/PC1025.pdf

HB1569 (See also SB1805)   Proposed legislation:                                                                                  Died in the House.           N/A
                              Limits authorization for workers’ compensation specialists to order benefits, including medical
                              benefits, to situations where an order is first issued determining the compensability of the
                              injury, or that the employee is entitled to the benefits pursuant to a final court order or
                              settlement agreement.
                              Revises the law governing how and when an independent medical examination can be obtained
                              to determine the degree of medical impairment.

SB2975 (See also HB3807)      Proposed legislation would require utilization review of medical services to be completed by a      Died in the Senate.          N/A
                              Tennessee licensed physician who is board certified in the same specialty as the physician
                              providing the medical services.




                                                                                             12
       Legislation                                                      Synopsis                                                  Status & Last Action Date         Effective Date
SB3890 (See also HB3841)       Proposed legislation would authorize psychologists to provide impairment ratings for injured       Died in the Senate.                N/A
                               workers by any appropriate method used and accepted by the medical or psychological
                               community.




Texas
28 Texas Administrative     Recently adopted regulatory amendments implementing HB 724, HB 1003, and HB 2004, which,              Adopted on 5/5/08.                 5/25/08
Code §§ 133.305, 133.307,   among other things:
and 133.308                    Provide that a doctor performing an independent review of health care services, including a
                               retrospective review, hold a Texas license and professional certification in a health care
Dispute of Medical Bills       specialty appropriate to the type of health care that the injured employee is receiving.
                               Incorporate administrative-level hearings into the Divisions’ MDR process as a step between
                               MDR or IRO review and judicial review in the resolution of certain medical fee and medical
                               necessity disputes.
                               Clarify that carriers shall notify the Department of Insurance within one working day from the
                               date the request for an independent review is received by the carrier or its URA.
                               Define evidentiary limits at a Division contested hearing, procedural requirements, and the
                               circumstances when a judicial review may be sought.
                               Add definitions and clarifies that healthcare provided through a voluntary or informal network
                               is considered non-network care.
                               Further information about the final regulations may be viewed at:
                               http://www.tdi.state.tx.us/wc/rules/adopted/documents/aordermdr0508.pdf

28 Texas Administrative        Proposed repeal of the Acute Care Inpatient Hospital Fee Guideline, which currently provides       Comment period ended on            N/A
Code §134.401                  for per-diem reimbursement and a “stop-loss” provision, as a result of the new Hospital            3/24/08. A public hearing was
                               Facility Fee Guidelines which became effective on 3/1/08.                                          held on 4/22/08.
Acute Care Inpatient
Hospital Fee Guideline



28 Texas Administrative     Proposed amendments to the Ambulatory Surgical Center (ASC) fee schedule which, among other           Comment period ends on 7/14/08.    N/A
Code §134.402               things:                                                                                               Public hearing scheduled for
                                Provide an effective date of 9/1/08 for all facility services provided in an ASC.                 7/1/08.
Ambulatory Surgical             Excludes professional medical services and treatment under a certified Health Care Network.
Center Fee Guidelines           Provides specific definitions for ASC device portion, ASC service portion, device intensive
                                procedures, implantables, and surgical implant provider.
                                Requires the application of Medicare payment policies in effect on the date a service is
                                provided, and also provides for the inclusion of specific Texas Labor Code provisions that take
                                precedence over conflicting CMS rules.
                                Sets a maximum allowable reimbursement (MAR) methodology, which is calculated using the
                                Medicare ASC reimbursement amount.
                                Establishes differing payment structures depending on whether the request for reimbursement
                                is for a non-device intensive procedure or a device intensive procedure.
                                Further information regarding the proposed rule may be found at:
                                http://www.tdi.state.tx.us/wc/rules/proposedrules/documents/prasc0608.pdf


                                                                                             13
      Legislation                                                       Synopsis                                                 Status & Last Action Date            Effective Date
28 Texas Administrative      Proposed rules implementing HB 473 (Informal Networks and Voluntary Networks) which,                Comment period ended on 4/7/08.       N/A
Code §§133.2, 133.4, and     among other things:
133.5                           Requires notification to health care providers of any person with access to the informal or
                                voluntary network fee arrangement.
Informal and Voluntary          Lists the specific items required to be included in the notice.
Networks                        Sets timeframes for the notice and penalties for noncompliance.
                                Establishes reporting requirements to the DWC.

28 Texas Administrative      Proposed informal draft rules implement provisions of HB 7, HB 34, HB 1003, HB 1006 and HB          Informal stakeholder comment          N/A
Code §§180.1 through         2004 by:                                                                                            period ended on 6/13/08.
180.28                          Deleting the Approved Doctors List.
                                Establishing licensing and certification requirements for doctors performing Designated Doctor
Medical Benefit Regulation      Exams, Required Medical Exams, Utilization Review, and Peer Reviews.
                                Deeming specific acts of improper inducement, influence, or threats as administrative
General Rules for               violations
Enforcement                     Further information regarding the proposed informal rules may be viewed at:
                                http://www.tdi.state.tx.us/wc/rules/planning/drafts.html


28 Texas Administrative         Proposed regulations implementing HB 724 establish rules authorizing health care insurers to     Comment period ended on               N/A
Code §§140.6, 140.7, and        seek reimbursement from a workers’ compensation carrier for health care paid by the health       5/28/08.
140.8                           care insurer for work-related, compensable injuries.
                                Further information regarding the proposed regulations may be viewed at:
Dispute Resolution –            http://www.tdi.state.tx.us/wc/rules/proposedrules/documents/prsubclprbl0408.pdf
General Provisions


Official Disability             The Texas Department of Insurance, Division of Workers’ Compensation, and the Work Loss          Memorandum issued on 6/4/08.          6/4/08
Guidelines – Treatment in       Data Institute have partnered to produce a monthly update that will inform system participants
Workers’ Compensation           of changes that have occurred in the online version of the ODG during the preceding month.
                                The memorandum may be viewed at:
                                http://www.tdi.state.tx.us/wc/dm/documents/odgmemo0608.pdf

Vermont
SB345                           Proposed legislation, in pertinent part, would retain the use of the American Medical            Passed in the House and the Senate    N/A
                                Association’s Guides to the Evaluation of Permanent Impairment, Fifth Edition until the          on 5/2/08. Awaiting further action
                                Commissioner of Labor can analyze and ensure that the adoption of the new Sixth Edition          by the Governor.
                                would not have a significantly detrimental impact on injured workers.
                                Further information on the proposed legislation may be viewed at:
                                http://www.leg.state.vt.us/docs/legdoc.cfm?URL=/docs/2008/bills/senate/S-345.HTM




                                                                                             14
         Legislation                                                          Synopsis                                                       Status & Last Action Date                Effective Date
 West Virginia
 Privatization and Managed          West Virginia’s workers’ compensation system will be moving from a monopolistic                         N/A                                         7/1/08
 Health Care Plans                  environment to a competitive market beginning 7/1/08. As a result, private carriers, TPAs and
                                    other authorized participants will be able to take advantage of the managed health care
                                    provisions of the workers’ compensation law, and establish and/or contract with Managed
                                    Health Care Plans (MHCP) as a vehicle to provide effective medical care, including directing
                                    care to health care providers authorized by the MHCP for the care and treatment of injured
                                    workers' compensable injuries.
                                    Further information may be found at the Offices of the Insurance Commissioner’s website:
                                    http://www.wvinsurance.gov/wc/index.htm

 HB2471                             Proposed legislation creates a rebuttable presumption when certain requirements are satisfied           Died in the House.                          N/A
                                    that a cardiovascular injury or disease or pulmonary disease suffered by a professional
                                    firefighter arose out of and in the course of employment.


 SB571                              New law creates a rebuttable presumption that cardiovascular injury, disease, death, pulmonary          Signed by the Governor on 4/1/08.           7/1/08
                                    disease or death of a professional firefighter is an occupational injury if certain criteria are met
                                    and sufficient notice of injury has been given provided the injury was not self-inflicted.
                                    Further information about the new law may be viewed at:
                                    http://www.legis.state.wv.us/Bill_Text_HTML/2008_SESSIONS/RS/BILLS/SB571%20SUB1
                                    %20enr.htm


 Wisconsin
 SB430                          New legislation modifies the workers’ compensation pharmacy provisions by:                                  Signed by the Governor on                   4/1/08
                                  Deleting the American Druggist Blue Book as a reference for determining outpatient pharmacy               3/26/08.
                                  reimbursement rates, and limits a carrier’s liability for the cost of such prescription drugs to the
                                  average wholesale price quoted in the Drug Topics Red Book.
                                  Creating a process for resolving disputes involving the pharmacy fee schedule.
                                  Further information about the new law may be viewed at:
                                  http://www.legis.state.wi.us/2007/data/acts/07Act185.pdf



This document is presented for informational purposes only. The information contained herein highlights several legislative and regulatory developments and is not intended to represent these
developments in their entirety or the entirety of legislative and regulatory developments in the area of workers’ compensation law throughout the fifty states. Neither the document nor the
information contained herein is intended to be construed as legal advice and should not be considered legal advice. Readers should refer to the full text of the legislation or regulation for additional
information and consult with their legal professional(s) regarding the applicability of these laws and regulations to their business operations. This report may not be reproduced, distributed, or
copied without the prior written consent of American International Group, Inc.




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