At the 2016 WCI360 Conference, “Common Pitfalls of a Multi-State Practice” prompted some interesting discussion. The breakout session took place on Aug. 24th in the Grand Ballroom 7A from 8:45 – 10:45. Briggs Peery and Kyle Kinney, attorneys who practice in Georgia and Alabama respectively, moderated.
This breakout topic inspired us to create our own list of “pitfalls” to watch out for. Here’s a summary of some of the more thorny issues we encounter doing utilization review in various states.
PORTIONS OF CA MTUS ARE OUT OF DATE
A significant portion of California MTUS is… old. There’s no other way to say it. As some background, from 2004 to 2007, the Medical Treatment Utilization Schedule (MTUS) was simply The American College of Occupational and Environmental Medicine (ACOEM) guidelines. In 2007, the Administrative Director changed MTUS to be ACOEM plus the Colorado acupuncture guidelines. In 2009, MTUS was changed again to add post-surgical guidelines and chronic pain guidelines that came from the Official Disability Guidelines (ODG).
MTUS continues to be revised, and in fact, was recently revised again when the CA DWC set forth new opioid and chronic pain guidelines. But the sections for neck, upper back, low back, shoulder, forearm, wrist, knee, ankle, eyes and stress-related conditions are all from AEOEM Practice Guidelines, 2nd edition (2004). Yep, they are from guidelines that are 12 years old. Needless to say, much has changed in the past 12 years, including major medical advancements that are not reflected in the 2004 edition.
TEXAS HAS NETWORK AND NON-NETWORK CLAIMS
The great state of Texas has a list of treatments that require preauthorization. These procedures are set out in 28 Texas Administrative Code (TAC) Section 134.600 et seq. But there’s a catch. In Texas, insurance carriers are allowed to create their own networks. Granted, the networks have to go through a rigorous approval process. For example, an insurance company cannot just create a bare bones workers’ comp network that pays little or nothing in benefits.
For each Texas claim, the UR practitioner has to ask, “Is this a network or non-network claim?” If it’s non-network then you process it according to 28 TAC Sec. 134.600. If it’s a network claim, then you must process according to the network. For example, if the claimant is in the Coventry Network, you must refer to Coventry’s web page, which lists the items requiring preauthorization. Watch out, because some networks, such as Aetna, actually use the list for non-networks. In this instance you’d refer back to 28 TAC Sec. 134.600. Simply put, the duality can be confusing.
MASSACHUSETTS WANTS TO SEE WHERE YOU DO UR – LITERALLY
When you apply for a license to do UR in Massachusetts the MA Office of Health Policy will need to physically examine where you do UR. For example, if you have a UR nurse who does your Massachusetts UR in Texas, the MA Office of Health Policy will want to fly to your office to meet with her and see where she’s doing UR. You can expect them to literally look around your office. The visit will be in addition to going over other requirements, such as the specifics of your UR plan. And you will be required to pay for the MA Office of Health Policy inspector to fly out and stay in town. That may seem strange, but it’s required.
IN LOUISIANA, WATCH OUT FOR AGGRESSIVE RULINGS FROM THE BENCH
Louisiana has what is called the “Form 1009” medical review process. If an injured worker disagrees with a UR decision, the injured worker can have the Louisiana Office of Workers’ Comp review the decision by filling out Form 1009 Disputed Claim for Medical Treatment. The Office of Workers’ Comp Medical Director will retain a physician to examine whether or not the UR decision was correct.
In 2015, Judge Donald Johnson, by way of a preliminary injunction, ruled that this process was unconstitutional. His ruling was later overturned as such a ruling is not appropriate in the context of an injunction hearing. However, for almost a year the Louisiana Office of Workers’ Comp, as well as all system participants, were completely baffled as to what to do. And for those who practice UR in Louisiana these types of rulings seem all too common.
SOME STATES, LIKE TENNESSEE, HAVE OVERLAPPING OR CONFLICTING UR REQUIREMENTS AMONG REGULATORS
Tennessee has the Dept. of Insurance statutes and the TN Division of Workers’ Comp rules. So if you need to know the turnaround time, for example, for a prospective UR, you’ll notice that the statutes and the rules have timeframes… but they differ. Yes, you read that correctly. For the Dept. of Insurance statues (T.C.A. Sec. 56-6-705(a)) the turnaround time is two business days after you have all the information necessary to complete the review. In the DWC rules (Chapter 0800-02-06), the timeframe is seven business days after receipt of the case from the employer. In this instance we would generally adhere to the stricter timeframe – two business days. But as you might guess, it’s challenging to perform UR in states with conflicting regulations.
GET HELP FROM THE EXPERTS
We could provide countless more examples, but you get the idea. When practicing UR in multiple states look out… each state has its own rules, nuances and local knowledge. Partnering with a company like UniMed Direct can make multi-state claims seamless for carriers, employers and TPAs. And this may sound crazy, but it’s something the experts at UniMed Direct enjoy. In fact, it’s the main reason we created UR Nation in the first place.
Kara Larson, Regulatory Manager at UniMed Direct