While it seems the members of our state legislature have been busy doing nothing but arguing about the budget for the past year – one young state rep has proposed a bill that may have a positive effect on employers seeking review of medical care for Workers’ Comp claimants. The passage of this bill will also affect any medical care provider who treats injured workers whose bills are being paid by an employer or insurance carrier. “House Bill 1800,” that is set for a vote later this month, is geared toward establishing a standard set of guidelines for medical care for injured workers. Its impact will not be immediate, but in the long run it will likely be beneficial for employers dealing with the medical management of Workers’ Comp claims.
Other states have gone in this direction in Workers’ Comp – and PA is catching up. For Workers’ Comp litigation purposes, the Utilization Review process will be affected because, once the guidelines are established, the measuring stick for whether medical care is reasonable/necessary becomes more black and white. These new medical standards will most likely be set by “panels” of doctors, or for some types of care, simply adopted through current AMA Guidelines. Right now, the process of a UR is a bit gray – with attorneys relying on opinions of doctors who disagree on medical standards for duration/frequency of care that is appropriate for an injury.
Through the proposed bill, once the set standards are in place – – the duration/frequency/type of care will be held to these standards. For example, if the treatment “standard” for a sprained ankle is 6-8 weeks of physical therapy at 3x/wk., and the injured worker’s treatment exceeds that “standard” in duration or frequency, the employer/carrier can formally challenge the care via UR, and have a much clearer idea of what is “the standard.” Under the current system, the employer/carrier would be forced to litigate the UR, and hope to convince a Judge that their medical expert’s opinion regarding the reasonableness or necessity of the care should be taken as gospel.
Adopting a set of standards for medical care for an injured worker will also have an effect on medical care providers whose treatment will be held to the standards now more than ever. The proposed bill is limited on its face – as it is intended only to apply to Workers’ Comp UR litigation – – but, the undercurrent is of course, cost-containment, and review of the efficacy of care in general. This will undoubtedly have a ripple effect on medical care providers who treat injured workers because their care will be measured by the established standards. For example, if House Bill 1800 passes, it is likely that employers/carriers will be much quicker to seek review of care that perhaps has dragged on unnecessarily or appears to have reached the point of diminishing returns.
The “good” news for care providers is…once the standards are established, there will likely be considerable leeway. My sprained ankle example above would likely be subject to some sort of “extended” period of care if/when the patient’s condition has not improved after undergoing the “standard” form of care…perhaps allowing another 4-6 week window of treatment.
As we await the vote in Harrisburg, the memo drafted by the state rep, attached to the proposed bill, is somewhat helpful to read:
Stay tuned for updates on the outcome of the vote.
For additional information contact Ken Scholtz at email@example.com
March 10, 2016
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