FEE SCHEDULE NEWS:

• The DWC has adopted the Medi-Cal rates effective November 15, 2018. The next update is expected December 15, 2018.

REGULATORY ACTIVITY:

• The Workers’ Compensation Information System (WCIS) advisory committee meeting was held on October 30, 2018.  The agenda of the meeting included First and Subsequent Reports of Injury (FROI/SROI).  To view a copy of the agenda and the presentations, go to https://www.dir.ca.gov/dwc/WCIS/AdvisoryCommiteeMeetings.htm.
• The California Division of Workers’ Compensation (DWC) is pleased to announce that registration for its 26th Annual Educational Conference is now open. The conference will take place February 11-12, 2019 at the Los Angeles Airport Marriott and February 28-March 1, 2019 at the Oakland Marriott City Center Hotel. Attendee, exhibitor and sponsor registration forms may be downloaded from the conference website : https://www.dir.ca.gov/dwc/educonf26/DWC_EducationalConference.html.
  Registration flyers were recently mailed to the names on the conference mailing list. These forms are also available at DWC district offices. This annual event is the largest workers’ compensation training in the state and allows claims administrators, attorneys, medical providers, return-to-work specialists, employers, human resources and others to learn firsthand about the most recent developments in the system. Attendees will be interested in learning about current topics from a variety of workers’ compensation experts (e.g. the DWC, other state and public agencies, and the private sector).  The DWC has applied for continuing educational credits by attorney, rehabilitation counselor, case manager, disability management, human resource and qualified medical examiner certifying organizations among others. Organizations who would like to become sponsors of the DWC conference can do so by going to the website.  The 2018 conference had 1,772 attendees and 128 exhibitors, so early registration is encouraged.
• The Division of Workers’ Compensation (DWC) Eureka office has moved to the following address:  State of California Office Building 409 K Street, Room 201 Eureka, CA 95501.  The office phone numbers remain the same from the former location on H Street. The Eureka office is a satellite of DWC’s Santa Rosa district office, with a workers’ compensation judge and support staff. Information and Assistance and Disability Evaluation services are provided through coordination with the Santa Rosa and Redding office.

LEGISLATIVE ACTIONS:

• Assembly Bill 2046

California’s existing law makes it a misdemeanor or a felony to engage in specified acts of fraud or material misrepresentation for the purpose of obtaining or denying workers' compensation, as specified. Existing law, the Workers' Compensation Insurance Fraud Reporting Act (the act), requires insurers and licensed rating organizations to release upon request to an authorized governmental agency, as defined, relevant information deemed important to the authorized governmental agency that the insurer or licensed rating organization may possess relating to any specific workers' compensation insurance fraud investigation. The act requires, under specified circumstances, an insurer or licensed rating organization to notify the local district attorney’s office and the Fraud Division of the Department of Insurance and authorizes that entity to notify any other authorized governmental agency, of suspected fraud, as specified. The act also requires the Employment Development Department to release, upon written request, to an authorized governmental agency, relevant information that the Employment Development Department may possess relating to any specific workers' compensation insurance fraud investigation. The act authorizes the governmental agency that is provided with information pursuant to those provisions to release or provide that information in a confidential manner to any other authorized governmental agency for purposes of investigation, prosecution, or prevention of insurance fraud or workers' compensation fraud.  This bill would require an authorized governmental agency that is provided with information pursuant to those provisions to release or provide that information, upon request, as described above, unless it would violate federal law or otherwise compromise an investigation. The bill would also require an authorized governmental agency that seeks to disclose this information to any other governmental agency that is not authorized to receive that information to obtain Employment Development Department approval prior to disclosure, as specified. Effective Date January 1, 2019.

• Assembly Bill 2705

Existing law establishes a workers’ compensation system to compensate an employee for injuries sustained in the course of employment. Existing law generally requires an employer to secure the payment of compensation, as specified, and makes it a misdemeanor to fail to secure the payment of compensation by one who knew, or should be reasonably expected to have known, of the obligation to secure the payment of compensation, punishable by imprisonment in the county jail for up to one year, a specified fine of not less than $10,000, or both. Existing law, except as specified, generally requires that prosecution for an offense not punishable by death or imprisonment in the state prison, as specified, be commenced within one year after commission of the offense.  Existing law, the Contractor’s State License Law, provides for the licensure and regulation of contractors by the Contractors’ State License Board in the Department of Consumer Affairs and requires an applicant for a contractor’s license, or a licensee, to have on file a current and valid Certificate of Workers’ Compensation Insurance or Certification of Self-Insurance. Existing law makes a violation of the provisions governing these certificates a misdemeanor. Existing law requires that prosecution for a violation of these provisions be commenced within 2 years after commission of the offense. This bill additionally would make it a misdemeanor violation not to secure the payment of compensation, as specified, by any licensee or agent or officer thereof, or by any person licensed in accordance with these provisions acting as a contractor and would make that violation subject to the 2-year statute of limitations. By expanding the scope of an existing crime and by creating a new crime, this bill would impose a state-mandated local program.  The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.  This bill would provide that no reimbursement is required by this act for a specified reason. Effective Date January 1, 1019.

• Senate Bill 1086

California’s current law specifies the time period within which various proceedings may be commenced under provisions of law relating to workers’ compensation. With certain exceptions, a proceeding to collect death benefits is required to be commenced within one year from several circumstances, including, but not limited to, from the date of death if it occurs within one year from the date of injury. Existing law prohibits proceedings from being commenced more than one year after the date of death, and generally not more than 240 weeks from the date of injury. Existing law, for specified deceased members, including peace officers and active firefighting members, extends until January 1, 2019, the time period to commence proceedings to collect death benefits, if the proceedings are brought by, or on behalf of, a person who was a dependent on the date of death, from 240 weeks from the date of injury to no later than 420 weeks from the date of injury, not to exceed one year after the date of death for certain injuries, as specified. The enacted legislation deletes the January 1, 2019, date of repeal operation of the above-referenced extension.  Effective Date January 1, 2019.

FEE SCHEDULE NEWS:

• The DWC has adopted the Medi-Cal rates effective October 15, 2018. The next update is expected November 15, 2018.
• The DWC adopted a new Inpatient Fee Schedule effective December 1, 2018.  The next update is expected December 1, 2019.

REGULATORY ACTIVITY:

• The Division of Workers’ Compensation (DWC) posted proposed amendments to the Pharmaceutical Fee Schedule to its online forum where members of the public could review and comment on the proposal. The comment period closed on October 8, 2018.  Comment submitted by the public can be viewed at https://www.dir.ca.gov/dwc/DWCWCABForum/Pharmaceutical-Fee-Schedule.htm.

• The Division of Workers' Compensation (DWC) has posted a revised version of the Workers’ Compensation Information System (WCIS) California Electronic Data Interchange Implementation Guide for First and Subsequent Reports of Injury (FROI/SROI) on its rulemaking forum. Members of the public are encouraged to review the proposed regulatory revisions in the guide and submit written comments. The comment period is open until 5 p.m. on Tuesday, October 30.  California's WCIS uses electronic data interchange to collect comprehensive information from claims administrators to help the Department of Industrial Relations oversee the state's workers' compensation system. This information helps facilitate evaluation of the system and measure adequacy of benefits for injured workers and their dependents and provides statistical data for research. The revised implementation guide contains updates and corrections to the first reports of injury and subsequent reports of injury (FROI/SROI) reporting rules of the current version that took effect in March 2018. The proposed changes address the manner of transmitting data to WCIS, the filing of SROI, requirements for specific data elements and data edits.  Written comments can be emailed to DWCRules@dir.ca.gov or mailed to: Division of Workers’ Compensation P.O. Box 420603 San Francisco, CA 94142 Attn: WCIS Rulemaking Forum The forum can be found on the DWC forums web page under “current forums.”
• The Division of Workers’ Compensation (DWC) has posted an adjustment to the inpatient hospital section of the Official Medical Fee Schedule (OMFS) to conform to changes in the 2019 Medicare payment system as required by Labor Code section 5307.1. The effective date of the changes is December 1, 2018.   Further information and adjustments to the inpatient hospital section of the Official Medical Fee Schedule can be found at https://www.dir.ca.gov/dwc/OMFS9904.htm#4.

FEE SCHEDULE NEWS:

• The DWC has adopted the Medi-Cal rates effective September 15, 2018. The next update is expected October 15, 2018.
• The DWC has adopted new changes to the Physician Fee Schedule effective October 1, 2018. The next update is expected January 1, 2019.
• The DWC adopted changes to the Outpatient and ASC Fee Schedule effective October 1, 2018. The next update is expected January 1, 2019.

REGULATORY ACTIVITY:

• The Division of Workers’ Compensation (DWC) has posted the 2017 ethics advisory committee's annual report on its website. The workers' compensation ethics advisory committee is a state committee independent from the DWC, that is charged with reviewing and monitoring complaints of misconduct filed against workers' compensation administrative law judges.  The ethics advisory committee is required to make a public report each year summarizing activities in the previous calendar year. To view the report, go to https://www.dir.ca.gov/dwc/ethrpt17.pdf
• The Division of Workers’ Compensation’s (DWC) Administrative Director George Parisotto has issued an Order updating the Medical Treatment Utilization Schedule (MTUS) Drug List effective October 1, 2018 pursuant to Labor Code section 5307.29. The Administrative Director’s update Order adopts changes to the MTUS Drug List, based on the American College of Occupational and Environmental Medicine (ACOEM) Practice Guidelines, including the following:
  • Addition of drugs addressed in the Chronic Pain Guideline and Opioids Guideline
  • New, Revised, and Deleted Drug Recommendations (related primarily to the Chronic Pain Guideline, and the Opioids Guideline)

  The updated MTUS Drug List v. 3, the Administrative Director’s Order and the formulary regulations can be accessed on the DWC MTUS drug formulary web page. Further updates to the MTUS Drug List will be made on a quarterly or more frequent basis.  To view the updated drug list, go to https://www.dir.ca.gov/dwc/MTUS/MTUS-Formulary-Orders.html.

• The Department of Industrial Relations (DIR) and its Division of Workers’ Compensation (DWC) posted a progress report on the department’s Independent Medical Review (IMR) program.

IMR is the medical dispute resolution process that uses medical expertise to obtain consistent, evidence-based decisions and is one of the most important components of Senate Bill 863, Governor Edmund G. Brown Jr.’s landmark 2012 workers’ compensation reform.  “This shows that Independent Medical Review – which replaced a system where injured workers had to wait for medical treatment while disputes were litigated – continues to provide a timely, efficient process for resolving treatment disputes and supporting appropriate care,” said George Parisotto, DWC Administrative Director. “For the last few years, DIR and DWC have worked to reduce the average number of days to complete IMR decisions. We continue with the ongoing efforts to enhance the program, including Medical Treatment Utilization Schedule updates, adopting the drug formulary and posting public copies of more than 660,000 IMR final determinations.”  Highlights of the report include:

• • The monthly average length of time to issue an IMR determination after the receipt of all medical records ranged from 10 days to 14 days, as compared to a high of 24 days in 2016.
  • An average of 14,350 IMR decisions were issued each month in 2017.
  • The number of eligible applications increased for the fifth consecutive year.
  • Case decisions continue to be similar when comparing several demographic categories, including the injured workers’ date of injury, their representation status, and the geographic region of their residence.
  • Similar to prior years, over 40 percent of treatment requests sent for IMR are for pharmaceuticals, with three of every ten pharmaceutical requests for opioids.
  • Guidelines contained in the Medical Treatment Utilization Schedule continue to be the primary resource for the determination of medical necessity.

To view the report, go to https://www.dir.ca.gov/dwc/IMR.htm.

• The Division of Workers’ Compensation (DWC) normally posts the weekly updated Medi-Cal pharmaceutical fee data file each Wednesday.  On Wednesday, September 5, 2018, DWC posted the weekly pharmaceutical fee data file received from the Department of Health Care Services (DHCS).  On Thursday, September 6, 2018, DHCS notified DWC that a corrected file had been issued and DWC posted the corrected file to the website and to the FTP server. While there appear to be relatively few changes to less than 100 out of over 700,000 records, DWC advises anyone who downloaded the weekly pharmaceutical data file posted on September 5th to download the corrected file from the website or collect the file from the FTP server.  In addition, anyone who used the online pharmaceutical calculator on September 5 or 6 should run the calculation again to ensure the result received is consistent with the updated file.
• The Division of Workers’ Compensation (DWC) had the first Pharmacy and Therapeutics Committee meeting on Wednesday, September 26 from 12:30 to 3:30 p.m. in the Elihu M. Harris State Building, conference room #1 on the second floor, 1515 Clay Street in Oakland. The Pharmacy and Therapeutics Committee was established by Assembly Bill No. 1124 (2015) as an advisory body that will consult with the DWC Administrative Director on updates to the Medical Treatment Utilization Schedule (MTUS) drug formulary.

• The Division of Workers’ Compensation (DWC) will hold a public meeting on Wednesday, October 17 to discuss the structure of a new medical-legal fee schedule for the workers’ compensation system. This fee schedule is used to compensate physicians for examinations and reports that decide issues of compensability for work-related injuries. DWC posted a notice of pre-rulemaking proposed amendments to the current medical-legal fee schedule in an open forum on May 3 and received an overwhelming response by the workers’ compensation community, with most respondents requesting an overhaul of the entire medical-legal fee schedule.  The October meeting is intended to respond to this input and develop next steps for revising the fee schedule.  DWC seeks input from stakeholders who will be affected by the final version of the medical-legal fee schedule. The Division is particularly interested in:

• • Determining the best format for the new fee schedule to offer optimum benefit for QMEs, AMEs, Injured Workers, Employers, Medical Management Organizations and Carriers;
  • Identifying any possible obstacles to that process; and
  • Identifying representatives to participate in small pre-rulemaking meetings to further develop the best format for the new medical-legal fee schedule.

The public meeting is scheduled for Wednesday, October 17 at 10 a.m. in the auditorium of the Elihu Harris Building, 1515 Clay Street, Oakland.  Meeting attendees will be allowed up to three minutes to express their ideas on changes to the fee schedule. Written comments can also be submitted at the public meeting, emailed to DWCRules@dir.ca.gov, or mailed to:

Division of Workers’ Compensation

P.O. Box 420603

San Francisco, CA 94142

Attn: Medical-Legal Fee Schedule Forum

To view the notice and additional information, go to https://www.dir.ca.gov/dwc/DWCWCABForum/1.asp

• The Division of Workers’ Compensation (DWC) has posted proposed amendments to the Pharmaceutical Fee Schedule to its online forum where members of the public may review and comment on the proposal. Under the California Labor Code, the fee schedule for pharmaceuticals is based primarily upon the Medi-Cal pharmacy payment system. Medi-Cal is now implementing a revised payment methodology approved by the Centers for Medicare and Medicaid Services (CMS). Background information on the Medi-Cal changes can be reviewed on the Department of Health Care Services (DHCS) Pharmacy Reimbursement Project web page. Due to requirements of federal law, the DHCS will implement Medi-Cal pharmacy fee schedule changes retroactively to April 1, 2017. For workers’ compensation, fee schedule changes will not be retroactive; the draft regulations propose that the new methodology become effective for pharmaceuticals dispensed on or after January 1, 2019. The following regulation changes are proposed to implement Labor Code section 5307.1 and to align the fee schedule with the new Medi-Cal system:

• • Elimination of the Average Wholesale Price (AWP) minus 17 percent as a benchmark for the drug ingredient;
  • Revised methodology for payment of the drug ingredient, which sets the maximum at the lower of the following:
    • National Drug Acquisition Cost (NADAC) or Wholesale Acquisition Cost (WAC) for drugs lacking a NADAC price;
    • Federal Upper Limit;
    • Maximum Allowable Ingredient Cost (MAIC);
    • Usual and Customary Charge;
  • Adoption of the revised two-tier Medi-Cal dispensing fee structure for pharmacies (which increases the dispensing fee from the current $7.25 to $10.05, or to $13.20 for those pharmacies listed by Medi-Cal as eligible for the higher fee);
  • Rules addressing fees for compounded drugs and repackaged drugs.

The forum can be found on the DWC forums web page under “current forums.”  Comments will be accepted on the forum until Monday, October 8.

• The Division of Workers’ Compensation (DWC) has adopted amendments to the Official Medical Fee Schedule (OMFS) for Physician and Non-Physician Practitioner Services (California Code of Regulations, title 8, section 9789.12.1 through 9789.19.1) to replace the average statewide geographic adjustment factor with local geographic adjustment factors as of January 1.  The locality-specific geographic adjustment factors, known as the Geographic Practice Cost Index (GPCI), was implemented by Medicare in January 2017 as part of its Metropolitan Statistical Area (MSA) program. Adoption of the Medicare MSA-based locality GPCIs will improve payment allowance accuracy by reflecting the resources required to provide a service according to specific regions. The amendments also make minor clarifying revisions to the regulations. DWC submitted a request to the California Office of Administrative Law to file the amended regulations with the Secretary of State and have them published in the California Code of Regulations. The regulations can be found on the DWC  Further information and adjustments to the Physician section of the OMFS can be found on the DWC’s OMFS web page.

LEGISLATIVE ACTIONS:

• Assembly Bill 1749

This bill would provide that whenever any peace officer is injured, dies, or is disabled from performing his duties as a peace officer by reason of engaging in the apprehension or attempted apprehension of law violators or suspected law violators within or out of the state, or protection or preservation of life or property within or out of the state, or the preservation of the peace anywhere in this state, but is not at the time acting under the immediate direction of his employer, he or his dependents shall be accorded by his employer all of the same benefits the peace officer or his dependents would have received had that peace officer been acting under the immediate direction of his employer. The bill would provide that this provision is declaratory of existing law. Effective Date January 1, 2019.

• Senate Bill 880

Existing law prohibits a person or entity, other than physicians or attorneys, from advertising, printing, displaying, publishing, distributing, or broadcasting in any manner a statement concerning services or benefits to be provided to an injured worker, which is paid for by that person or entity that is false, misleading, or deceptive. Violation of these provisions is a misdemeanor punishable by incarceration in the county jail for not more than one year, or by a fine not exceeding $10,000, or by both that imprisonment and fine. This bill would make technical, non-substantive changes to the above provision and would delete an obsolete provision. Effective Date January 1, 2019.

FEE SCHEDULE NEWS:

• The DWC has adopted the Medi-Cal rates effective August 15, 2018.  The next update is expected September 15, 2018.

REGULATORY ACTIVITY:

• On June 26, the Division of Workers’ Compensation (DWC) adopted an order adjusting the Official Medical Fee Schedule (OMFS) to conform to changes in the Medicare Physician Fee Schedule payment system’s July 1, 2018 quarterly update.  The June 26 Order included adoption of updates to the National Correct Coding Initiative “Medically Unlikely Edits” (MUE). The MUE edits file sets forth the maximum number of units of service related to a specific procedure that are medically likely to be reported by a treating physician. It serves as a useful screening tool to identify possible billing errors for many procedure codes. However, evaluation of the July 1, 2018 MUE file reveals that many codes are listed as zero value due to Medicare coverage rules that do not apply to the scope of workers’ compensation medical care. For example, acupuncture codes and hearing aid examination codes were added to the file with a value of “zero” because they are not Medicare benefits; however, they are covered services for workers’ compensation patients when medically necessary. The fee schedule regulation provides that the correct coding edits, including the MUE, do not apply where workers’ compensation payment rules differ from Medicare rules. (Title 8, Cal. Code of Regs. § 9789.12.13, subd. (a).) In order to avoid possible confusion and inappropriate denials of bills for medically necessary care, DWC has determined that the codes listed in the MUE with a value of zero should not be included in the MUE file adopted for workers’ compensation. Therefore, the DWC has adopted a revised Physician and Non-Physician Practitioner fee schedule update Order for services rendered on or after July 1, 2018. The revised Order adopts an Excerpt of the MUE file, which deletes codes listed with a zero value.   The exclusion of the zero value codes from the MUE file does not mean that all of the deleted codes are payable. It should be noted that some of the MUE zero value codes would not be payable in workers’ compensation, in particular the codes that are identified as Status Code B (bundled) in the Relative Value Unit File and codes specifically identified in the fee schedule regulation as not payable. (Title 8, Cal. Code of Regs. § 9789.19.) Although the Status Code B bundled codes, and the workers’ compensation “not payable” codes, will not be identified by the MUE, the payer may apply other edits to identify those non-payable codes.  In addition, the Order adopts revisions to conform to current Medicare terminology, as the “Physician CCI Edits” are now entitled “Practitioner PTP Edits.”
  If a medical provider believes a medical bill has been inappropriately denied based upon the application of the MUE, he or she may submit a request for second bill review to the claims administrator.
  The order, revised regulation text and the MUE Excerpt file are effective for services rendered on or after July 1, 2018 and can be found on the DWC website.
• Posted notice in the state register regarding possible actions of the state pharmacy board.  The board proposes to clarify and make specific the standards for pharmacies and pharmacists compounding drug preparations.  The broad objective of this proposal is to ensure that compounding is performed in a manner and under conditions that ensure the compounded drug preparations dispensed to the public by a pharmacy and pharmacist are safe and effective.  The specific benefits anticipated by the proposed amendments are to protect the public from risks of unsafe and or ineffective compounding of drug preparations. Unsafe compounded drug preparations pose risks to patients, including a risk of death. In effect, compounded drug preparations can pose a risk to patients if the patient does not receive the prescribed dose of a medicine. A pharmacist’s expanded ability to extend the BUD for non−sterile compounded drug preparations makes such preparations more accessible, and therefore makes patients healthier by increasing the compliance with a doctor’s directions. It also includes benefits such as the protection of public health and safety, worker safety, the environment, and the increase in openness and transparency in business and government. To view the announcement, go to https://oal.ca.gov/august-2018-notice-registers/.

FEE SCHEDULE NEWS:

• The DWC has amended the Physician fee schedule effective July 1, 2018. The update is relevant to the Medicare quarterly update of the MUE file dated July 1, 2018 where many codes are listed as zero due to Medicare coverage rules.  These rules are not applicable to the workers’ compensation medical care.  The new fee schedule order states: “Except where payment ground rules differ from the Medicare ground rules, claims administrators shall apply the NCCI physician coding edits” (title 8, Cal. Code Regs. §9789.12.13(a).) To lessen possible confusion and to avoid inappropriate denial of bills, the Administrative Director issues this order which replaces the full CMS July 2018 MUE update file adopted by the June 26, 2018 order, with an excerpt of the CMS July 2018 MUE update file, where all procedures assigned a value of “0” units are removed from file, for services rendered on or after July 1, 2018.”
• The DWC has adopted the Clinical Lab fee schedule effective July 1, 2018. The next update is expected in January 2019.
• The DWC has adopted the Medi-Cal rates effective July 15, 2018. No changes were found in the newly posted data.  The next update is expected August 15, 2018.

REGULATORY ACTIVITY:

• The Division of Workers’ Compensation (DWC) is pleased to announce the formation of the Pharmacy and Therapeutics (P&T) Committee. The P&T Committee is established pursuant to Assembly Bill No. 1124 (2015) as an advisory body that will consult with the DWC Administrative Director on updates to the Medical Treatment Utilization Schedule Drug Formulary.   The committee’s first meeting will be held on Wednesday, September 26 from 12:30 p.m. to 3:30 p.m. in the Elihu M. Harris State Building, conference room #1 on the second floor, located at 1515 Clay Street in Oakland.  The P&T Committee will be chaired by DWC Executive Medical Director Raymond Meister, M.D. The six appointees are California-licensed medical doctors and pharmacists.   “We were fortunate to receive applications from many distinguished physicians and pharmacists for this committee and selected a very well qualified team for this important work,” said Dr. Meister. “DWC appreciates the commitment of these volunteer committee members and looks forward to a productive collaboration that will improve the therapeutic outcomes for the many injured workers that rely on the MTUS Drug Formulary.” Each member of the P&T Committee will serve a term of two years and remain in the position until the selection of a successor. The current committee members are:
  • Lori A. Reisner, Pharm.D.
  • Todd Shinohara, Pharm.D.
  • Raymond Tan, Pharm.D.
  • Basil R. Besh, M.D.
  • Rajiv P. Das, M.D.
  • Steven Feinberg, M.D.

The agenda and further information regarding the P&T Committee meeting will be posted on the DWC MTUS Drug Formulary web page at least 10 days prior to the meeting and will also be distributed to the DWC Newsline mailing list. The public may submit questions or comments about the formulary to the DWC MTUS Drug Formulary email inbox: formulary@dir.ca.gov.

• The Workers’ Compensation Appeals Board (WCAB) has approved new and updated subpoena forms for use in the district offices of the Division of Workers’ Compensation (DWC).   The fillable forms are posted on the DWC website and will also be made available at the district offices: Subpoena (DWC WCAB 30), Subpoena Duces Tecum (DWC WCAB 32).  Parties should start using the updated forms as soon as possible. To view the forms, go to https://www.dir.ca.gov/dwc/forms.html#Court. 
• The Division of Workers’ Compensation (DWC) has received questions from the public regarding the July 1 update to the Physician Fee Schedule and its impact on acupuncture treatment. It is important for the public to know that acupuncture continues to fall within the definition of “medical treatment” as defined in Labor Code section 4600 and is available to the injured worker when it is medically necessary to cure or relieve the effects of the injury.    The July 1 update to the Physician and Non-Physician Practitioner Fee Schedule includes updates to the National Correct Coding Initiative “Medically Unlikely Edits” (MUE). The MUE edits file sets forth the number of units of service related to a specific procedure that are medically likely to be reported by a treating physician and serves as a useful screening tool to identify possible billing errors for many procedure codes.  However, in the July MUE file which was adopted by DWC, the acupuncture codes were included for the first time, and were listed with a value of zero. The Division is reviewing the July MUE file to determine what action is necessary to alleviate confusion caused by the July update. DWC expects to issue a modified July 2018 Physician Fee Schedule update shortly to address this issue. In the meantime, the public is advised that acupuncture treatment continues to be available to the injured workers when medically necessary. Maximum reimbursement for acupuncture continues to be subject to the Physician Fee Schedule without application of the MUE edit.
• The Division of Workers’ Compensation (DWC) is now accepting applications for the Qualified Medical Evaluator (QME) examination on Saturday, October 20, 2018. QMEs are independent physicians certified by the DWC Medical Unit to conduct medical evaluations of injured workers. Applications for the QME exam may be downloaded from the DWC website.  Applicants may also contact the Medical Unit at 510-286-3700 to request an application via U.S. mail, email or fax.  The deadline for filing the exam applications is September 6. For more information please contact the Medical Unit at 510-286-3700 or by email at QMETest@dir.ca.gov.

FEE SCHEDULE NEWS:

• The DWC has adopted a new Physician fee schedule and CCI edits with an effective date of July 1, 2018.  The next update is expected in October 2018.
• The DWC has adopted a new Outpatient and ASC fee schedule with an effective date of July 1, 2018.  The next update is expected in October 2018.
• The DWC has updated the DMEPOS fee schedule effective July 1, 2018. This update includes both the Medicare Interim Final Rule changes (CMS-1687-IFC) and the July 2018 DMEPOS rates. The next update is expected in October 2018.

REGULATORY ACTIVITY:

• The Division of Workers’ Compensation (DWC) has issued a notice of public hearing for proposed evidence-based updates to the Medical Treatment Utilization Schedule (MTUS), which can be found at California Code of Regulations, title 8, sections 9792.22 and 9792.24.5.  The public hearing is scheduled for Wednesday, July 18 at 10 a.m. in the auditorium of the Elihu Harris Building, 1515 Clay Street, Oakland. Members of the public may review and comment on the proposed updates no later than July 18.  The proposed evidence-based updates to the MTUS incorporate by reference the latest published guidelines from American College of Occupational and Environmental Medicine (ACOEM) for the following:  Traumatic Brain Injury (ACOEM November 15, 2017); General Approaches section of the MTUS: Prevention (ACOEM May 1, 2011); General Approach to Initial Assessment and Documentation (ACOEM July 25, 2016); Cornerstones of Disability Prevention and Management (ACOEM May 1, 2011). Although proposed evidence-based updates to the MTUS regulations are exempt from Labor Code sections 5307.3 and 5307.4 and the rulemaking provisions of the Administrative Procedure Act, DWC is required under Labor Code section 5307.27 to have a 30-day public comment period, hold a public hearing, respond to all the comments received during the public comment period and publish the order adopting the updates online.
• The Division of Workers’ Compensation (DWC) announces that the 2019 minimum and maximum temporary total disability (TTD) rates will increase on January 1, 2019. The minimum TTD rate will increase from $182.29 to $187.71 and the maximum TTD rate will increase from $1,215.27 to $1,251.38 per week.  Labor Code section 4453(a) (10) requires the rate for TTD be increased by an amount equal to percentage increase in the State Average Weekly Wage (SAWW) as compared to the prior year. The SAWW is defined as the average weekly wage paid to employees covered by unemployment insurance as reported by the U.S. Department of Labor for California for the 12 months ending March 31 in the year preceding the injury. In the 12 months ending March 31, 2018, the SAWW increased from $1,206.92 to $1,242.78—an increase of 2.971 percent.  Under Labor Code section 4659(c), workers with a date of injury on or after January 1, 2003 who are receiving life pension (LP) or permanent total disability (PTD) benefits are also entitled to have their weekly LP or PTD rate adjusted based on the SAWW.

FEE SCHEDULE NEWS:

• Medi-Cal rates have been released with an effective date of May 15, 2018. The next update is scheduled for June 15, 2018.

REGULATORY ACTIVITY:

• The Division of Workers’ Compensation (DWC) has posted proposed amendments to the Medical-Legal Fee Schedule to its online forum where members of the public may review and comment on the proposals. The draft regulations include:
  • Objective standards for the application of complexity factors in the fee schedule;
  • Provisions that align the Medical-Legal Fee Schedule with the statutory scheme for reimbursement of medical-legal expenses;
  • Elimination of provisions that refer to medical-legal evaluations no longer being performed; and
  • Clarification of when billing under the Official Medical Fee Schedule can be accomplished in conjunction with billing under the Medical-Legal Fee Schedule.

There are no changes to the amount of fee schedule payments. The proposals clarify the use of the complexity factors relating to causation, medical research, record review and apportionment. The factors that indicate the presence of extraordinary circumstances in a medical-legal evaluation are more clearly defined. The language required in a report to define extraordinary circumstances is explained. Realistic limits on certain areas of billing are implemented. The forum can be found on the DWC forums webpage under “current forums.” To view the text of the regulation being proposed, go to  http://www.dir.ca.gov/dwc/DWCWCABForum/Reimbursement-of-Medical-Legal-Expenses.htm.

FEE SCHEDULE NEWS:

• Medi-Cal rates have been released with an effective date of April 15, 2018. The next update is scheduled for May 15, 2018.
• DWC has posted an order to adjust the pathology and clinical laboratory section of the Official Medical Fee Schedule to conform with changes to the Medicare payment system. The order is effective for services rendered on and after April 1, 2018.

REGULATORY ACTIVITY:

• The Division of Workers’ Compensation (DWC) has posted proposed interpreter fee schedule regulations to its online forum where members of the public may review and comment on the proposals. The draft regulations include:
  • An objective, uniform fee structure based on the federal court system. Higher rates are paid for certified interpreters over provisionally certified, to encourage use of certified interpreters.
  • Reduction in double billing fees for multiple interpretations during the same time slot.
  • Detailed invoice information and billing codes. The independent bill review procedure will be required to quickly resolve disputes over bill amounts.
  • An emphasis on the use of qualified interpreters. Specific documentation of efforts to obtain a certified interpreter is required to ensure that the injured worker is provided with a qualified interpreter.
  • Requirements clarifying the selection and arrangement of interpreters.
  • New credentialing identification requirements. The organizations approved to certify interpreters remains unchanged from the current regulations. For hearings and depositions, an interpreter must be listed as a certified interpreter on either the State Personnel Board or California Courts websites. For medical treatment or medical-legal evaluations, the interpreter must be either certified for hearings and depositions, certified as a medical interpreter by the California Department of Human Resources, or has a current certification or credential in specific languages by either the Certification Commission for Healthcare Interpreters or the National Board of Certification for Medical Interpreters.
• The forum can be found on the DWC forums web page under “current forums.” To view a copy of the regulations, go to http://www.dir.ca.gov/dwc/DWCWCABForum/Interpreter.htm.
• The Division of Workers’ Compensation (DWC) has posted an order adjusting the Hospital Outpatient Departments and Ambulatory Surgical Centers section of the Official Medical Fee Schedule (OMFS) to conform to the quarterly changes in the Medicare payment system as required by Labor Code section 5307.1.  The order, dated April 10, is the second Administrative Director order for the April 2018 quarterly update to the Hospital Outpatient Departments and Ambulatory Surgical Centers Fee Schedule. It adopts column A of the April 2 update to CMS’ ASC addendum AA and column A of the April 2 update to CMS’ ASC addendum EE for services rendered on or after April 1, 2018. CMS replaced the March 21 files with April 2 updates.  There are no changes to the HCPCS codes listed in column A of ASC addendum AA and column A of ASC addendum EE from the March 21 files and the April 2 replacement. The Administrative Director update order adopting the OMFS adjustment is effective for services rendered on or after April 1, 2018 and can be found at http://www.dir.ca.gov/dwc/OMFS9904.htm.
• DWC Administrative Director George Parisotto has issued an Order updating the Medical Treatment Utilization Schedule (MTUS) Drug Formulary effective May 15, 2018 pursuant to Labor Code section 5307.29. The Administrative Director’s update Order adopts changes to the MTUS Drug List including the following:
  • Addition and deletion of drugs for treatment of Eye Disorders to coordinate with the updated ACOEM Eye Disorders Guideline which was adopted into the MTUS
  • Designation of “Exempt/Non-Exempt” status for drugs added for treatment of Eye Disorders
  • Designation of “Special Fill” status for drugs added for treatment of Eye Disorders
  • Update of guideline reference symbols for Ankle and Foot Disorders and Eye Disorders
  • Designation of an additional corticosteroid as eligible for the “Special Fill”.
• The updated MTUS Drug List and the Administrative Director Order is posted on the DWC MTUS drug formulary web page. Further updates to the MTUS Drug List will be made on a quarterly, or more frequent, basis.
• The Department of Industrial Relations (DIR) has posted on its Fraud Prevention webpage public documents on which DIR relied in flagging lien claimants as potentially subject to Labor Code section 4615. Labor Code section 4615 places an automatic stay on liens filed by or on behalf of physicians and providers who are criminally charged with certain types of fraud. The automatic stay prevents those liens from being litigated or paid while the prosecution is pending.  DIR flags liens in its Division of Workers’ Compensation’s (DWC’s) Electronic Adjudication Management System (EAMS) as potentially subject to section 4615. A full list of lien claimants with flagged liens is posted online.  The Department of Industrial Relation’s (DIR’s) fraud prevention efforts are posted online, including information on lien consolidations and the Special Adjudication Unit, frequently updated lists for physicians, practitioners, and providers who have been issued notices of suspension and those who have been suspended pursuant to Labor Code §139.21(a)(1).

FEE SCHEDULE NEWS:

• Medi-Cal rates have been released with an effective date of March 15, 2018. The next update is scheduled for April 15, 2018.
• The Division of Workers’ Compensation (DWC) has posted an order adjusting the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) section of the Official Medical Fee Schedule to conform to the 2018 changes in the Medicare payment system as required by Labor Code section 5307.1.   The order, which is effective for services on or after April 1, 2018, adopts the Medicare DMEPOS fee schedule second release for calendar year 2018. The next update is expected July 2018.
• The Division of Workers’ Compensation has posted a new update to the Physician and NCCI Edits data effective April 1, 2018. The next update is scheduled for July 2018.
• The state has also adopted a new Outpatient and ASC fee schedule with an effective date of April 1, 2018. The next scheduled update is for July 2018.

REGULATORY ACTIVITY:

• The Division of Workers’ Compensation (DWC) has posted an order adjusting the Ambulance Services section of the Official Medical Fee Schedule (OMFS) to conform to relevant 2018 changes in the Medicare payment system as required by Labor Code section 5307.1.  The order is the second Administrative Director order for the 2018 update to the Ambulance Services Fee Schedule. It adopts an updated public use file for 2018, which was issued on February 14, 2018, by the Centers for Medicare and Medicaid Services. The updated public use file implements legislative provisions of the Bipartisan Budget Act of 2018. The new legislation extends three temporary add-on provisions that would have expired on December 31, 2017. The Administrative Director Order dated February 28, 2018, adopts the updated public use file for services rendered on or after January 1, 2018, and can be found on http://www.dir.ca.gov/DWC/OMFS9904.htm
• The Division of Workers’ Compensation (DWC) has posted adjustments to the hospital outpatient departments and ambulatory surgical centers section of the official medical fee schedule (OMFS) to conform to changes in the Medicare payment system as required by Labor Code section 5307.1. The changes took effect March 15, 2018.   The public should take note of the following:
  • Recently added 42 C.F.R. section 419.71, Payment reduction for certain X-ray imaging services, became effective January 1, 2018. The OMFS adopts and incorporates by reference section 419.71, and related payment rules, addressing payment reduction for film X-ray imaging services and computed radiography imaging services.
  • Subdivision (a)(1) of section 9789.32 is corrected by deleting status indicator “Q4” from the table, for services rendered on or after December 15, 2016. Services assigned status indicator “Q4,” clinical laboratory services, are not considered a “supply, drug, device, blood product, or biological.” Thus, subdivision (a)(1) is not applicable to codes assigned status indicator “Q4.”
  • Composite APCs and comprehensive APCs payment rules are added and incorporated by reference by date of service. The adopted clarifying composite APCs and comprehensive APCs payment rules are declaratory of existing regulations.   More information and the adjustments to the hospital outpatient departments and ambulatory surgical centers section of the OMFS can be found at  http://www.dir.ca.gov/DWC/OMFS9904.htm.
• The Division of Workers’ Compensation (DWC) has posted a correction to the Hospital Outpatient Departments/Ambulatory Surgical Centers portion of the Official Medical Fee Schedule. The correction, reflected in an Administrative Director order, replaces Table A found at Title 8, California Code of Regulations, section 9789.34, with a revised Table A. The order applies to services rendered on or after March 15, 2018.   The Table A replaced by the order inadvertently listed Los Angeles County twice with different county-specific wage indexes and wage-adjusted conversion factors. The correct county-specific wage index for Los Angeles County is 1.2778 and the correct wage-adjusted conversion factor is $94.04. This table is now superseded with a revised table that deletes the incorrect duplicate entry.   The March 15, 2018 effective date remains the same. The order can be found at the http://www.dir.ca.gov/dwc/OMFS9904.htm#6
• The Division of Workers’ Compensation (DWC) has issued a notice of public hearing to revise the Official Medical Fee Schedule for Physician and Non-Physician Practitioner Services (Physician Fee Schedule), which can be found at California Code of Regulations, title 8, section 9789.12.1 through 9789.19.  The public hearing is scheduled at 10 a.m. on Tuesday, April 17 in the Auditorium of the Elihu Harris State Building, 1515 Clay Street, Oakland 94612. Members of the public may also submit written comments on the proposed amendments until 5 p.m. that day.  The proposed amendments to the physician fee schedule regulations would eliminate the use of the average statewide geographic adjustment factor and adopt Medicare’s MSA based locality-specific geographic adjustment factors, known as the Geographic Practice Cost Indices (GPCIs), which Medicare implemented effective January 1, 2017. Adoption of the new Medicare MSA based locality GPCIs will improve payment allowance accuracy by reflecting the resources required to provide a service according to specific geographic areas. The proposed amendments also make minor clarifying revisions to the regulations.  To view a copy of the proposed regulation, go to http://www.dir.ca.gov/dwc/DWCPropRegs/OMFS-Table-A/OMFS-Table-A.htm.
• The Division of Workers’ Compensation (DWC) has posted an order adjusting the Official Medical Fee Schedule (OMFS) to conform to changes in the Medicare payment system as required by Labor Code section 5307.1.   The Physician and Non-Physician Practitioner Fee Schedule update Order adopts the following Medicare changes: • CMS’ Medicare National Physician Fee Schedule Relative Value File RVU18B April 1, 2018 quarterly update • National Correct Coding Initiative Physician/Practitioner Services CCI Edits April 1, 2018 quarterly update • National Correct Coding Initiative Medically Unlikely Edits April 1, 2018 quarterly update  The order adopting the OMFS adjustments is effective for services rendered on or after April 1, 2018 and can be found on the DWC website.
• The Department of Industrial Relations (DIR) today issued a progress report on its anti-fraud efforts, including updates on the suspension of 227 medical providers from treating California’s injured workers and the dismissal of 292,000 illegitimate liens with claims valued at over $2.5 billion.   To view a copy of the notice, go to http://www.dir.ca.gov/DIRNews/2018/2018-22.pdf.  To view a copy of the report, go to http://www.dir.ca.gov/Fraud_Prevention/Reports/Anti-Fraud-Report2018.pdf.
• The Division of Workers’ Compensation (DWC) has posted an order adjusting the Hospital Outpatient Departments and Ambulatory Surgical Centers section of the Official Medical Fee Schedule (OMFS) to conform to changes in the Medicare payment system as required by Labor Code section 5307.1.   The Hospital Outpatient Departments and Ambulatory Surgical Centers fee schedule update Order adopts the following Centers for Medicare & Medicaid Services (CMS) Medicare changes:  • The CMS Medicare Hospital Outpatient Prospective Payment System (OPPS) April 2018 Addendum A [Zip] quarterly update • The CMS Medicare OPPS April 2018 Addendum B [Zip] quarterly update • The CMS Ambulatory Surgical Center Payment System, April 2018 ASC Approved HCPCS Code and Payment Rates [zip], Column A entitled “HCPCS Code” of “Apr 2018 ASC AA” and Column A entitled “HCPCS Code” of “Apr 2018 ASC EE” • Certain sections of the CMS Medicare OPPS April 2018 Integrated Outpatient Code Editor (I/OCE), IntegOCEspecsV19.1 quarterly update. • Section 6 of the CMS April 2018 Update of the Hospital Outpatient Prospective Payment System (OPPS), Change Request (CR) 10515 (revised March 22, 2018), Transmittal R4005CP.  To view the revised fee schedule, go to http://www.dir.ca.gov/dwc/OMFS9904.htm#6

FEE SCHEDULE NEWS:

• Medi-Cal rates have been released with an effective date of February 15, 2018. The next update is scheduled for March 15, 2018.
• The Outpatient and ASC fee schedule was updated with an effective date of March 15, 2018. The state has adopted the Medicare 2018 OPPS APC Addenda, ASC Addendum AA and updated wage-adjusted conversion factors.