Healthcare Financial Management Association

Transcription

1 Healthcare Financial Management Association Workers Compensation Update Kimberlee Barriere Deputy Director Maine Workers Compensation Board

2 Nationwide The State of the Economy: Weak but Gaining Strength Health services is an area of job creation nationally and in Maine Claim frequency down/claim severity up (modestly) Medical cost-containment initiatives, focusing on: physician and facility fee schedule updates, physician-dispensed repackaged drugs, and controlling opioid drug abuse Medical Marijuana and Employer Drug Testing Mobile/Remote Workers

3 Nationwide Affordable Care Act Immigration Reform Misclassification of Employee/Independent Contractors Exclusive Remedy Challenges and Opt- Out/Alternative Coverage Options The Terrorism Risk Insurance Act (TRIA) Medicare Set-Asides Longshore and Harbor Workers Compensation General Reforms and Recreational Vessel Clarification

4 State of Maine While growing, the economy in Maine is likely to continue to lag the United States as a whole Claim frequency declining at slower rate/claim severity increasing Older workforce High percentage of self-insured employers High percentage of hospital-based physicians

5 Balancing Act In order to ensure appropriate limitations on the cost of health care services while maintaining broad access for employees to health care providers in the State, the board shall adopt rules that establish a medical fee schedule setting the fees for medical and ancillary services and products rendered by individual health care practitioners and health care facilities in accordance with the following

6 Balancing Act The medical fee schedule for services rendered by individual health care practitioners must reflect the methodology underlying the federal Centers for Medicare and Medicaid Services resourcebased relative value scale; Weights adopted from CMS Base rates set by Board Anesthesia All Other Professional

7 Balancing Act The medical fee schedule for services rendered by health care facilities must reflect the methodology and categories set forth in the federal Centers for Medicare and Medicaid Services severity-diagnosis related group system for inpatient services Weights adopted from CMS Base rates set by Board Acute Care Hospitals Critical Access Hospitals

8 Balancing Act The medical fee schedule for services rendered by health care facilities must reflect the methodologies and categories set forth in the federal Centers for Medicare and Medicaid Services ambulatory payment classification system for outpatient services; Weights adopted from CMS Base rates set by Board Acute Care Hospitals Critical Access Hospitals Ambulatory Surgery

9 Periodic Updates The board shall undertake a comprehensive review of the medical fee schedule once every 3 years beginning in The board shall consider the following factors in setting or revising the medical fee schedule as required by this section: A. The private 3rd-party payor average payment rates obtained from the Maine Health Data Organization; B. Any material administrative burden imposed on providers by the nature of the workers' compensation system; and C. The goal of maintaining broad access for employees to all individual health care practitioners and health care facilities in the State.

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11 ACH IP Base Rates ACUTE CARE HOSPITALS The base rate for inpatient services at acute care hospitals shall be as follows: 1. On the effective date of this chapter, the base rate shall be $9, On April 1, 2016, the base rate shall be $9, On April 1, 2017, the base rate shall be $9,

12 CAH IP Base Rates CRITICAL ACCESS HOSPITALS The base rate for inpatient services at critical access hospitals shall be as follows: 1. On the effective date of this chapter, the base rate shall be $10, On April 1, 2016, the base rate shall be $10, On April 1, 2017, the base rate shall be $9,

13 ACH OP Base Rates ACUTE CARE HOSPITALS The base rate for outpatient services at acute care hospitals shall be as follows: 1. On the effective date of this chapter, the base rate shall be $ On April 1, 2016, the base rate shall be $ On April 1, 2017, the base rate shall be $

14 CAH OP Base Rates CRITICAL ACCESS HOSPITALS The base rate for outpatient services at critical access hospitals shall be as follows: 1. On the effective date of this chapter, the base rate shall be $ On April 1, 2016, the base rate shall be $ On April 1, 2017, the base rate shall be $

15 ASC Surgical Services Base Rates AMBULATORY SURGICAL CENTERS The base rate for surgical services at ambulatory surgical centers shall be: 1. On the effective date of this chapter, the base rate shall be $ On April 1, 2016, the base rate shall be $ On April 1, 2017, the base rate shall be $78.53.

16 Registration Process 70% of a claim form is generated during the registration process meaning that if everything is not done exactly right in the beginning, there could be a big mess later. Kramer Technologies

17 Registration Process Employer of Injury Date of Injury/Illness Claim Administrator Claim Number (if available) Claim Handler (if available) Consider giving patient a copy of Form WCB-90 (available online)

18 M-1 Forms

19 M-1 Forms Must use prescribed form Initial must be sent within 5 days If Regular Duty is indicated on the form, the section regarding restrictions should be left blank by the provider. Conversely, if any restrictions are identified on the form, then Regular Duty should not be checked off.

20 Bills Bills must specify: the billing entity s tax identification number, the license number, registration number, certificate number, or National Provider Identifier of the health care provider, the employer, the date of injury/occurrence, the date of service, the work-related injury or disease treated, the appropriate procedure code(s) for the work-related injury or disease treated, and the charges for each procedure code.

21 Billing Process Bills must be accompanied by health care records to substantiate the services rendered. Professional services are no longer required to be billed separately by facilities. Outpatient hospital facility services performed on the same day for the same patient must be reported on a single UB-04 form.

22 Billing Process Confirm Coverage BEFORE sending the bill Insurer v. claim administrator Insurer that wrote the policy is ultimately responsible for the claim Claim administrator v. medical bill review company Confirm address where bills are to be sent

23 Reimbursement The employer/insurer must pay the health care provider's usual and customary charge or the maximum allowable payment under this chapter, whichever is less, within 30 days of receipt of a properly coded bill unless the bill or previous bills from the same health care provider have been controverted or denied. Are you getting what you bargained for, i.e. lower base rates in exchange for fewer disputes? In other words, are your clean claims being paid timely and accurately?

24 Medicare Set-Asides If a health care provider is treating an employee for a work injury and that employee has a Workers Compensation Medicare Set-Aside (WCMSA) based on the Maine Workers Compensation Medical Fee Schedule, the provider must bill the employee directly using the billing procedures outlined in Board Rules Chapter 5. A WCMSA allocates a portion of a workers compensation settlement for all future work-injuryrelated medical expenses that are covered and otherwise reimbursable by Medicare. Employees with a WCMSA based on the Maine Workers Compensation Fee Schedule are required to pay for treatment related to the work injury pursuant to the Maine Workers Compensation Medical Fee Schedule.

25 Medicare Set-Asides Health care providers may wish to establish a separate financial class for employees with a WCMSA to facilitate the billing process. If a health care provider mistakenly bills Medicare or other insurer for treatment related to the work injury, the provider is responsible for refunding any payments received for that treatment.

26 PPO Agreements A written payment agreement directly between a health care provider and an employer/insurer supersedes the maximum allowable payment otherwise available under this chapter. A written payment agreement between a health care provider and an entity other than the employer/insurer seeking to invoke its terms supersedes the maximum allowable payment otherwise available under this chapter only if the employer/insurer was a named beneficiary of the payment agreement at the time the health care provider signed the payment agreement. An employee retains the right to select health care providers for the treatment of an injury or disease for which compensation is claimed regardless of any such payment agreement.

27 Bureau of Insurance The National Council on Compensation Insurance (NCCI), the state s designated statistical agent, files annual advisory loss costs on behalf of insurers for approval with the Superintendent. Advisory loss costs represent the portion of the rates that accounts for losses and loss adjustment expenses. Each insurer files factors called loss cost multipliers for the Superintendent s approval. These multipliers account for company experience, overhead expenses, taxes, contingencies, investment income and profit. Each insurer reaches its rates by multiplying the advisory loss costs by the loss cost multipliers. Other rating rules, such as experience rating, schedule rating, and premium discounts, also affect the ultimate premium amount paid by an individual employer.

28 Bureau of Insurance 4/1/2014 4/1/2015 Industry/Class Description Loss Cost Loss Cost Diff Physicians & Clerical $0.44 $0.48 $0.04 Hospital Professional Employees $1.10 $1.13 $0.03 Convalescent or nursing home-all employees $2.84 $3.12 $0.28 Home, Public, and Traveling Healthcare-all employees $2.81 $2.79 -$0.02 Analytical laboratories or assaying $0.61 $0.60 -$0.01 Hospital-Veterinary & Drivers $1.36 $1.28 -$0.08 Drug, Medicine or Pharmaceutical Preparation $0.85 $1.07 $0.22 Retirement Living Centers: health Care Emplyees $4.09 $3.58 -$0.51 Hospital: All Other Employees $4.95 $4.66 -$0.29 Store: Drug- Retail $0.53 $0.63 $0.10

29 Bureau of Labor Standards At no cost, The Bureau of Labor Standards can provide: An easy-to-use Occupational Injury and Illness data profile of your workers compensation claims for the past 10 years. The profile provides details such as types and causes of injuries involving cases that involve one or more days away from work. State and National injury profile for your industry. Special profiles of different types of injuries and fatalities. To request an injury profile, call or The profile will be sent to you within seven working days. Your only obligation is to complete a short confidential survey after you receive the data. The results of the survey are used to increase the usefulness of the profiles and to help improve the service.

30 Occupational Injury and Illness Data Profiles You can use the data to: Analyze injury trends Analyze work injury losses Identify common causes of injuries Develop accident prevention activities Develop training programs and materials Conduct safety and health research Support grant applications Support contract bids Conduct company and community health needs assessments Evaluate effectiveness of safety and health programs Conduct safety and health walkthroughs Advocate for safety and health policy and legislation

31 Lost Time Claims for the Healthcare/Social Assistance Industry, Year of Claim Total # of Claims Total Medical Costs Total Costs $9,109, $18,647, $7,138, $13,400, $5,643, $8,993, TOTAL 8309 $21,891, $41,041,116.89

32 Top 5 Industry Subsections Description of Industry Subsector # of Claims % of Total # of Claims General Medical & Surgical Hospitals % Nursing Care Facilities % Services for the Elderly & Persons w/ Disabilities % Assisted Living Facilities for the Elderly % Residential Intellectual & Developmental Disability Facilities %

33 Top 5 Occupations Occupation # of Claims % of Total # of Claims C.N.A % Personal Care Aides % Registered Nurses % Maids & Housekeeping Cleaners % Medical Assistants %

34 Top 5 Events Description of Event # of Claims % of Total # of Claims Fall on same level due to slipping % Overexertion in lifting, single episode % Other exertions or bodily reactions, unspecified % Overexertion in pushing, pulling, or turning single episode % Overexertion involving outside sources, unspecified %

35 Top 5 Injuries (# of Claims) Description of Injury # of Claims % of Total # of Claims Strains % Sprains, strains, tears, unspecified % Soreness, pain, hurt nonspecified injury % Bruises, contusions % Traumatic injuries and disorders, unspecified %

36 Top 5 Injuries (Total Medical Cost) Description of Injury Total Medical Cost of Claims % of Total Medical Costs Sprains, strains, tears, unspecified $5,402, % Strains $5,180, % Soreness, pain, hurt nonspecified injury $2,569, % Fractures $2,565, % Traumatic injuries and disorders, unspecified $1,316, %

37 Top 5 Sources of Injury Description of Source # of Claims % of Total # of Claims Patient % Bodily motion or position of injured, ill worker % Bodily conditions of injured, ill worker % Floor, unspecified % Floors, walkways, ground surfaces, unspecified %

38 Questions or Concerns? Kimberlee Barriere (preferred): Phone: