Preathorization of Medical Treatment

At the recent Vermont Workers' Compensation Adjusters' Continuing Education Conference a number of participants had questions regarding pre-authorization under Vermont law.  The statute sets forth time lines and other obligations that are placed on a carrier/employer that receives a written pre-authorization request and supporting documentation.

 

The statute requires that a pre-authorization request must be submitted to the insurer with supporting medical documentation. Within 14 days of receipt of the request the carrier/employer shall either (1) authorize the treatment; (2) deny the treatment with appropriate documentation; or (3) notify the health care provider, the injured worker, and the department that the insurer has scheduled an examination of the employee or ordered a medical record review.  In that event the carrier/employer must notify the department, health care provider and the injured worker within 45 days of the request for pre-authorization of the decision to pre-authorize or not.  21 VSA §640b.

 

The statute is located here:

 

http://www.leg.state.vt.us/statutes/fullsection.cfm?Title=21&Chapter=009&Section=00640b

 

The Director of Workers' Compensation has issued guidance regarding the pre-authorization statute.  Those memorandum are located here:

http://www.labor.vermont.gov/Portals/0/WC/preauthmemo.pdf

http://www.labor.vermont.gov/Portals/0/WC/preauthclarify.pdf

A form providers may choose to use for a pre-authorization request is located at: 

 

http://www.labor.vermont.gov/Portals/0/WC/preauthform.pdf. 

Department of Labor Creates "Health Care Provider Report" Form

The Vermont Department of Labor has created a new form to assist physicians in providing the employer/carrier with information regarding the treatment of an injured worker.  The form is called the “Health Care Provider Report” and is also known as the HCP1. The form is not required to be filed.  The Department describes this as a tool to assist in obtaining relevant medical information regarding workers’ compensation injuries/illnesses. 

The form is a one page document that provides basic information such as: The employee’s name, address, date of birth and phone number; Information regarding the injury itself, such as, the date of the injury, the body part injured, the date of the examination, the diagnosis and whether the injury was work related; A line is provided for documenting test results, interpretation of the results, what medications are prescribed and what the treatment plan is; and there is a section for a brief comment on return to work.

This form is not required.  It does not change the law that requires that any provider seeking reimbursement for services must provide legible, supporting documentation. Vermont Workers’ Compensation Rules, Rule 40.021(C).  That supporting documentation is described as, “documentation for each service provided which is sufficiently detailed to allow for the review of the medical necessity of the service and the appropriateness of the fee charged.” Vermont Workers’ Compensation Rules, Rule 40.021(E).

The link to the new form is:

http://www.labor.vermont.gov/Portals/0/WC/healthcareprovidersrpt.pdf

It’s Almost July 1st, Remind Me Again: What Do I Have to Do?

As July 1st approaches, licensed Vermont workers' compensation adjusters need to:

Adjust the COLA

Any worker who has been receiving temporary total or temporary partial disability compensation for 26 or more weeks is entitled to a COLA. The new maximum for those injuries arising after June 30, 1986 is $1,166.00.  The new maximum for injuries prior to that date is $777.00.  The minimum in all cases is $389.00. The new Form 28(FY14) and the Form 28A(FY14) are now available and may be downloaded from the Vermont Department of Labor website located at: http://labor.vermont.gov/Default.aspx?tabid=170. 

Determine If Medicaid Has Paid Bills

Insurers must take reasonable steps to discover whether the Department of Vermont Health Access has paid medical bills associated with workers’ compensation claims. 33 V.S.A. §1910 (b)(2). The State of Vermont Human Service Agency has a lien against the insurer for monies paid for medical expenses on behalf of a person who has an injury, illness or disease and the person initiates a claim against an insurer for that injury, illness or disease. The Department has noted that “the claim file should contain documentation (electronic, recorded language, typed or handwritten) to support the insurer's actions.”  The procedure sets forth that reasonable steps to determine the existence of such a lien include: (1) Asking the claimant or claimant’s representative at the beginning of the process by telephone, letter or electronic mail if he or she was a Medicaid recipient at the time of the injury.  If the answer is yes then the insurer should contact the Department of Vermont Health Access and refrain from payment until the lien is determined.  If the answer is no then the insurer must continue to review bills to determine if there is evidence that the Department of Vermont Health Access has paid bills on the claimant’s behalf and if so the insurer should determine the amount of the lien.  If not the insurer may proceed to resolve the claim; (2) An insurer may contact the Department of Vermont Health Access at any time to determine if a lien exists by contacting  the Department at: DVHATPLTeam@state.vt.us; by telephone at 802-879-5646; or by fax at 802-879-5959. The outreach document prepared by the Department of Vermont Health Access is located here: http://dvha.vermont.gov/budget-legislative/insurer-procedure-medicaid-liens.pdf

Agency of Administration Submits Report on Integration of Workers’ Compensation With Health Care Reforms

 

The Agency of Administration Health Care Reform has submitted a report to the Vermont legislature on the Integration or Alignment of Vermont Workers’ Compensation System with Green Mountain Care. 

The report recommended that “Vermont should pursue greater administrative alignment of the workers’ compensation system with cost-reduction measures posed under the Vermont’s health care reform efforts and the Affordable Care Act. The research on the amount of potential savings through integration is conflicting, so integration should be considered only after a thorough analysis that is Vermont specific. Furthermore, integration would require Vermont to develop a monopolistic publicly funded workers’ compensation system, which it is not well-positioned to do at this time. Consideration of alignment is more appropriate after the new system is in place. In the meantime, administrative reform will preserve workers’ rights and the current workers’ compensation insurance market while potentially increasing savings for employers.” 

The text of the full report is here: http://hcr.vermont.gov/sites/hcr/files/2013/Act%2048%20Integration%20of%20Workers%27%20Compensation%201%2015%202013%20FINAL.pdf

Vermont Insurers Must Determine Existence of Medicaid Liens Starting July 1, 2013

 

Effective July 1, 2013, insurers shall take reasonable steps to discover whether the Department of Vermont Health Access has paid medical bills associated with workers’ compensation claims. 33 V.S.A. §1910 (b)(2). The legislation provides that the State of Vermont Human Service Agency has a lien against the insurer for monies paid for medical expenses on behalf of a person who has an injury, illness or disease and the person initiates a claim against an insurer for that injury, illness or disease. Additionally the legislation provides that “Payment to the recipient instead of the agency does not discharge the insurer from payment of the agency’s claim.” 33 V.S.A. §1910 (b)(2).  The statute is: http://www.leg.state.vt.us/statutes/fullsection.cfm?Title=33&Chapter=019&Section=01910

 

The Department of Vermont Health Access has written a memorandum on the insurer procedure for determining the existence of Medicaid Liens.  Most importantly the Department has noted that “the claim file should contain documentation (electronic, recorded language, typed or handwritten) to support the insurer's actions.”  The procedure sets forth that reasonable steps to determine the existence of such a lien include: (1) Asking the claimant or claimant’s representative at the beginning of the process by telephone, letter or electronic mail if he or she was a Medicaid recipient at the time of the injury.  If the answer is yes then the insurer should contact the Department of Vermont Health Access and refrain from payment until the lien is determined.  If the answer is no then the insurer must continue to review bills to determine if there is evidence that the Department of Vermont Health Access has paid bills on the claimant’s behalf and if so the insurer should determine the amount of the lien.  If not the insurer may proceed to resolve the claim; (2) An insurer may contact the Department of Vermont Health Access at any time to determine if a lien exists by contacting  the Department at: DVHATPLTeam@state.vt.us; by telephone at 802-879-5646; or by fax at 802-879-5959. The memorandum indicates that the insurer should document the claim files as to when and who was contacted at DVHA.  The memorandum concludes that if a lien exists the insurer must ensure reimbursement out of settlement proceeds by the claimant, the claimant’s representative, the insurer, or by naming Department of Vermont Health Access on monies paid to the claimant.  Then the claim may be closed and documentation of these actions protects the insurer from claims of bad faith or duplicate payment to the Department or the claimant.

The outreach document prepared by the Department of Vermont Health Access is located here: http://dvha.vermont.gov/budget-legislative/insurer-procedure-medicaid-liens.pdf