HB1820: Workers' compensation; pecuniary liability of the employer for medical services, report.


VIRGINIA ACTS OF ASSEMBLY -- CHAPTER
An Act to amend and reenact § 65.2-605 of the Code of Virginia, relating to workers' compensation; pecuniary liability for medical services.
[H 1820]
Approved

 

Be it enacted by the General Assembly of Virginia:

1. That § 65.2-605 of the Code of Virginia is amended and reenacted as follows:

§ 65.2-605. Liability of employer for medical services ordered by Commission; malpractice; assistants-at-surgery; coding.

A. The pecuniary liability of the employer for medical, surgical, and hospital service herein required when ordered by the Commission shall be limited to such charges as prevail in the same community for similar treatment when such treatment is paid for by the injured person and the employer shall not be liable in damages for malpractice by a physician or surgeon furnished by him pursuant to the provisions of § 65.2-603, but the consequences of any such malpractice shall be deemed part of the injury resulting from the accident and shall be compensated for as such.

B. The Commission shall determine the number and geographic area of communities across the Commonwealth. In establishing the communities, the Commission shall consider the ability to obtain relevant charge data based on geographic area and such other criteria as are consistent with the purposes of this title.

C. The pecuniary liability of the employer for treatment pursuant to subsection A that is rendered on or after July 1, 2014, by:

1. A nurse practitioner or physician assistant serving as an assistant-at-surgery shall be limited to no more than 20 percent of the reimbursement due under subsection A to the physician performing the surgery; and

2. An assistant surgeon in the same specialty as the primary surgeon shall be limited to no more than 50 percent of the reimbursement due under subsection A to the primary physician performing the surgery.

C. D. Multiple procedures completed on a single surgical site associated with medical, surgical, and hospital services pursuant to subsection A and rendered on or after July 1, 2014, shall be coded and billed with appropriate Current Procedural Terminology (CPT) modifiers and paid according to the National Correct Coding Initiative (NCCI) rules and the CPT as in effect at the time the health care was provided to the claimant. The CPT and NCCI, as in effect at the time such health care was provided to the claimant, shall serve as the basis for processing a health care provider's billing form or itemization for such items as global and comprehensive billing and the unbundling of health care services. Hospital in-patient health care services shall be coded and billed through the International Statistical Classification of Diseases and Related Health Problems (ICD) as in effect at the time the health care was provided to the claimant.

2. That the Workers' Compensation Commission shall promulgate regulations to implement the provisions of this act to be effective within 280 days of its enactment and shall provide an opportunity for public comment on the regulations prior to adoption.

3. That the Workers' Compensation Commission shall convene a work group of stakeholder representatives of employers, health care service providers, claimants, and insurers to advise and assist the Commission in (i) reviewing, analyzing, and comparing information contained within and reports on all possible databases containing workers compensation or healthcare data for medical services rendered in Virginia, (ii) reviewing, analyzing, and comparing information contained within and reports on how similar databases are used for the establishment of the pecuniary liability of the employer in other states, and (iii) making findings or recommendations as to how the databases reviewed and the contents thereof may serve to enhance or replace Virginia's current mechanisms for establishing the pecuniary liability of the employer. The Workers' Compensation Commission shall report its findings and recommendations to the Chairmen of the House and Senate Commerce and Labor Committees by December 15, 2015.


HOUSE BILL NO. 1820
AMENDMENT IN THE NATURE OF A SUBSTITUTE
(Proposed by the Senate Committee on Commerce and Labor
on February 23, 2015)
(Patron Prior to Substitute--Delegate Farrell)
A BILL to amend and reenact § 65.2-605 of the Code of Virginia, relating to workers' compensation; pecuniary liability for medical services.

Be it enacted by the General Assembly of Virginia:

1. That § 65.2-605 of the Code of Virginia is amended and reenacted as follows:

§ 65.2-605. Liability of employer for medical services ordered by Commission; malpractice; assistants-at-surgery; coding.

A. The pecuniary liability of the employer for medical, surgical, and hospital service herein required when ordered by the Commission shall be limited to such charges as prevail in the same community for similar treatment when such treatment is paid for by the injured person and the employer shall not be liable in damages for malpractice by a physician or surgeon furnished by him pursuant to the provisions of § 65.2-603, but the consequences of any such malpractice shall be deemed part of the injury resulting from the accident and shall be compensated for as such.

B. The Commission shall determine the number and geographic area of communities across the Commonwealth. In establishing the communities, the Commission shall consider the ability to obtain relevant charge data based on geographic area and such other criteria as are consistent with the purposes of this title.

C. The pecuniary liability of the employer for treatment pursuant to subsection A that is rendered on or after July 1, 2014, by:

1. A nurse practitioner or physician assistant serving as an assistant-at-surgery shall be limited to no more than 20 percent of the reimbursement due under subsection A to the physician performing the surgery; and

2. An assistant surgeon in the same specialty as the primary surgeon shall be limited to no more than 50 percent of the reimbursement due under subsection A to the primary physician performing the surgery.

C. D. Multiple procedures completed on a single surgical site associated with medical, surgical, and hospital services pursuant to subsection A and rendered on or after July 1, 2014, shall be coded and billed with appropriate Current Procedural Terminology (CPT) modifiers and paid according to the National Correct Coding Initiative (NCCI) rules and the CPT as in effect at the time the health care was provided to the claimant. The CPT and NCCI, as in effect at the time such health care was provided to the claimant, shall serve as the basis for processing a health care provider's billing form or itemization for such items as global and comprehensive billing and the unbundling of health care services. Hospital in-patient health care services shall be coded and billed through the International Statistical Classification of Diseases and Related Health Problems (ICD) as in effect at the time the health care was provided to the claimant.

2. That the Workers' Compensation Commission shall promulgate regulations to implement the provisions of this act to be effective within 280 days of its enactment and shall provide an opportunity for public comment on the regulations prior to adoption.

3. That the Workers' Compensation Commission shall convene a work group of stakeholder representatives of employers, health care service providers, claimants, and insurers to advise and assist the Commission in (i) reviewing, analyzing, and comparing information contained within and reports on all possible databases containing workers compensation or healthcare data for medical services rendered in Virginia, (ii) reviewing, analyzing, and comparing information contained within and reports on how similar databases are used for the establishment of the pecuniary liability of the employer in other states, and (iii) making findings or recommendations as to how the databases reviewed and the contents thereof may serve to enhance or replace Virginia's current mechanisms for establishing the pecuniary liability of the employer. The Workers' Compensation Commission shall report its findings and recommendations to the Chairmen of the House and Senate Commerce and Labor Committees by December 15, 2015.


HOUSE BILL NO. 1820
AMENDMENT IN THE NATURE OF A SUBSTITUTE
(Proposed by the House Committee on Commerce and Labor
on February 5, 2015)
(Patron Prior to Substitute--Delegate Farrell)
A BILL to amend and reenact § 65.2-605 of the Code of Virginia, relating to workers' compensation; pecuniary liability for medical services.

Be it enacted by the General Assembly of Virginia:

1. That § 65.2-605 of the Code of Virginia is amended and reenacted as follows:

§ 65.2-605. Liability of employer for medical services ordered by Commission; malpractice; assistants-at-surgery; coding.

A. The pecuniary liability of the employer for medical, surgical, and hospital service herein required when ordered by the Commission shall be limited to such charges as prevail in the same community for similar treatment when such treatment is paid for by the charged to an injured person and the not ordered by the Commission, such charges being referred to in this section as the prevailing community rate. However, if an employer is a party to a contractual agreement with a workers' compensation health care provider, his professional entity, or his employer, for medical, surgical, or hospital services under which the provider has agreed to accept a specified amount of payment for his charges, the pecuniary liability of the employer for medical, surgical, and hospital services shall be governed by the provisions of that specific agreement and not by the prevailing community rate. In absence of a contract as referenced above, no employer shall reimburse the provider for an amount less than the prevailing community rate.

B. The Commission, by regulation, shall establish the prevailing community rate for medical, surgical, or hospital services in communities in the Commonwealth, as follows:

1. The prevailing community rate for medical, surgical, and hospital services shall be established by the Commission at an amount that is representative of the charge for the same services charged by providers in the community where the services are provided in the Commonwealth;

2. The Commission shall determine the number and geographic area of communities across the Commonwealth. In establishing the communities, the Commission shall consider the ability to obtain relevant charge data based on geographic area and such other criteria as are consistent with the purposes of this title;

3. In determining an amount that is representative of the charge of the same services charged by the same providers in a community, the Commission shall collect such charge data, by purchasing data from aggregators of such data or by other means that the Commission finds appropriate, it deems is necessary to obtain a representative sample of charges for such services by providers in the community. The data included in such samples shall not be based on charges developed by the provider for the sole or primary purpose of billing for services provided pursuant to this title. The data included in such samples shall be coded and billed with appropriate Current Procedural Terminology (CPT) codes and modifiers, Healthcare Common Procedure Coding System (HCPCS) codes and modifiers, International Classification of Diseases (ICD) codes, or Diagnosis Related Groups (DRG) codes, in the versions current as of the date of treatment, and for the initial base year the Commission shall use such charge data for services provided during the period January 1, 2014, through December 31, 2014. The initial prevailing community rate established by the Commission pursuant to this subsection shall be the prevailing community rate determined for calendar year 2014 as adjusted to reflect changes in the appropriate Index for 2015 as referenced in subsection C;

4. If the sample size of data of charges for such services by providers in a community is sufficient to serve as the basis for statistically significant results, as determined by the Commission, the Commission shall determine the mean, median, and mode of the charges for the same services. The Commission shall establish the prevailing community rate for the same service at the middle value of such mean, median, and mode of the charges for the same services;

5. If the sample size of data of charges for such services by providers in a community is not sufficient to serve as the basis for statistically significant results, as determined by the Commission, the Commission may consider additional data from communities adjacent to the community in the Commonwealth where the services were rendered in establishing the prevailing community rate; and

6. If the Commission is not able to determine a prevailing community rate for a newly issued CPT, HCPCS, ICD, or DRG billing codes, the prevailing community rate shall be the charge of the health care provider rendering the health care service until such time as a prevailing community rate can be calculated.

C. The Commission shall adjust each prevailing community rate initially established pursuant to subsection B to an amount that reflects the rate of increase, if any, over the previous 12 months in the medical care component of the Consumer Price Index for All Urban Consumers (CPI-U) for the South as published by the Bureau of Labor Statistics of the U.S. Department of Labor (the "Index"). The Commission's first such adjustment shall cover the 12 months that follow the effective date of the regulations establishing the prevailing community rate, and subsequent adjustments shall be made annually thereafter. The Commission may make further adjustments to each prevailing community rate over and above the Index and in doing so may consider access to health care, the need to control costs, or factors deemed relevant by the Commission.

D. The Commission shall provide public access to information regarding the prevailing community rate for services by code, including any adjustments made pursuant to subsection C, through the Commission's website. No information provided on the website shall be provider-specific or disclose or release the identity of any provider.

E. The employer shall not be liable in damages for malpractice by a physician or surgeon furnished by him pursuant to the provisions of § 65.2-603, but the consequences of any such malpractice shall be deemed part of the injury resulting from the accident and shall be compensated for as such.

B. F. The pecuniary liability of the employer for treatment pursuant to subsection A that is rendered on or after July 1, 2014, by:

1. A nurse practitioner or physician assistant serving as an assistant-at-surgery shall be limited to no more than 20 percent of the reimbursement due under subsection A to the physician performing the surgery; and

2. An assistant surgeon in the same specialty as the primary surgeon shall be limited to no more than 50 percent of the reimbursement due under subsection A to the primary physician performing the surgery.

C. G. Multiple procedures completed on a single surgical site associated with medical, surgical, and hospital services pursuant to subsection A and rendered on or after July 1, 2014, shall be coded and billed with appropriate Current Procedural Terminology (CPT) modifiers and paid according to the National Correct Coding Initiative (NCCI) rules and the CPT as in effect at the time the health care was provided to the claimant. The CPT and NCCI, as in effect at the time such health care was provided to the claimant, shall serve as the basis for processing a health care provider's billing form or itemization for such items as global and comprehensive billing and the unbundling of health care services. Hospital in-patient health care services shall be coded and billed through the International Statistical Classification of Diseases and Related Health Problems (ICD) as in effect at the time the health care was provided to the claimant.

2. That any prevailing community rate established pursuant to this act shall apply only to medical, surgical, and hospital services provided on or after the date the Workers' Compensation Commission establishes the prevailing community rate for the medical, surgical, or hospital service.

3. That the Workers' Compensation Commission shall convene a work group of stakeholders to review information and reports from the Virginia All-Payer Claims Database and make recommendations as to whether such information and reports may be a benchmark or of use in establishing the prevailing community rate. The Workers' Compensation Commission shall report its findings and recommendations to the Chairmen of the House and Senate Commerce and Labor Committees by December 15, 2015.

4. That the Workers' Compensation Commission shall promulgate regulations to implement the provisions of this act to be effective within 280 days of its enactment. The Workers' Compensation Commission shall utilize a group of stakeholders, including providers, claimants, insurance carriers, employers, to assist in the development of necessary regulations and shall provide an opportunity for public comment on the regulations prior to adoption.

5. That the Workers' Compensation Commission shall consult an advisory panel of providers, claimants, insurance carriers, employers, and other persons determined by the Workers' Compensation Commission, regarding the collection or purchase of data under subdivision B 3 of § 65.2-605 of the Code of Virginia as added by this act.

6. That the provisions of this act shall expire on July 1, 2018.

HOUSE BILL NO. 1820

Offered January 14, 2015
Prefiled January 13, 2015
A BILL to amend and reenact §§ 65.2-605 and 65.2-605.1 of the Code of Virginia, relating to workers' compensation; pecuniary liability for medical services.
Patron-- Farrell

Committee Referral Pending

Be it enacted by the General Assembly of Virginia:

1. That §§ 65.2-605 and 65.2-605.1 of the Code of Virginia are amended and reenacted as follows:

§ 65.2-605. Liability of employer for medical services ordered by Commission; malpractice; assistants-at-surgery; coding.

A. The pecuniary liability of the employer for medical, surgical, and hospital service herein required when ordered by the Commission shall be limited to such charges as prevail in the same community the amount that is generally paid to the provider for similar treatment when the provider is paid for such treatment is paid for by the injured person and the or on behalf of an individual receiving such treatment when not ordered by the Commission. The amount that is generally paid to a provider for a treatment when the provider is paid for the treatment by or on behalf of an individual receiving the treatment when not ordered by the Commission shall (i) equal 120 percent of the average amount reported to have been paid for the treatment to all providers of the treatment statewide, based on paid claims data for covered benefits collected by the Virginia All-Payer Claims Database pursuant to § 32.1-276.7:1, in the most recent year for which such paid claims data is available or (ii) if paid claims data is not available through the Virginia All-Payer Claims Database for the treatment, be established by the Commission based on evidence produced by the provider or other interested party of the average amount that the provider is paid for the treatment by or on behalf of individuals receiving the treatment when not ordered by the Commission, including payments made to the provider by health carriers as defined in § 38.2-3438, governmental agencies, employers providing health benefits under a self-insurance program, and other third-party payors.

B. The employer shall not be liable in damages for malpractice by a physician or surgeon furnished by him pursuant to the provisions of § 65.2-603, but the consequences of any such malpractice shall be deemed part of the injury resulting from the accident and shall be compensated for as such.

B. C. The pecuniary liability of the employer for treatment pursuant to subsection A that is rendered on or after July 1, 2014, by:

1. A nurse practitioner or physician assistant serving as an assistant-at-surgery shall be limited to no more than 20 percent of the reimbursement due under subsection A to the physician performing the surgery; and

2. An assistant surgeon in the same specialty as the primary surgeon shall be limited to no more than 50 percent of the reimbursement due under subsection A to the primary physician performing the surgery.

C. D. Multiple procedures completed on a single surgical site associated with medical, surgical, and hospital services pursuant to subsection A and rendered on or after July 1, 2014, shall be coded and billed with appropriate Current Procedural Terminology (CPT) modifiers and paid according to the National Correct Coding Initiative (NCCI) rules and the CPT as in effect at the time the health care was provided to the claimant. The CPT and NCCI, as in effect at the time such health care was provided to the claimant, shall serve as the basis for processing a health care provider's billing form or itemization for such items as global and comprehensive billing and the unbundling of health care services. Hospital in-patient health care services shall be coded and billed through the International Statistical Classification of Diseases and Related Health Problems (ICD) as in effect at the time the health care was provided to the claimant.

§ 65.2-605.1. Prompt payment; limitation on claims.

A. Payment for health care services that the employer does not contest, deny, or consider incomplete shall be made to the health care provider within 60 days after receipt of each separate itemization of the health care services provided.

B. If the itemization or a portion thereof is contested, denied, or considered incomplete, the employer or the employer's workers' compensation insurance carrier shall notify the health care provider within 45 days after receipt of the itemization that the itemization is contested, denied, or considered incomplete. The notification shall include the following information:

1. The reasons for contesting or denying the itemization, or the reasons the itemization is considered incomplete;

2. If the itemization is considered incomplete, all additional information required to make a decision; and

3. The remedies available to the health care provider if the health care provider disagrees.

Payment or denial shall be made within 60 days after receipt from the health care provider of the information requested by the employer or employer's workers' compensation carrier for an incomplete claim under this subsection.

C. Payment due for any properly documented health care services that are neither contested within the 45-day period nor paid within the 60-day period, as required by this section, shall be increased by interest at the judgment rate of interest as provided in § 6.2-302 retroactive to the date payment was due under this section.

D. An employer's liability to a health care provider under this section shall not affect its liability to an employee.

E. No employer or workers' compensation carrier may seek recovery of a payment made to a health care provider for health care services rendered after July 1, 2014, to a claimant, unless such recovery is sought less than one year from the date payment was made to the health care provider, except in cases of fraud. The Commission shall have jurisdiction over any disputes over recoveries.

F. No health care provider shall submit a claim to the Commission contesting the sufficiency of payment for health care services rendered to a claimant after July 1, 2014, unless (i) such claim is filed within one year of the date the last payment is received by the health care provider pursuant to this section or (ii) if the employer denied or contested payment for any portion of the health care services, then, as to that service or portion thereof, such claim is filed within one year of the date the medical award covering such date of service for a specific item or treatment in question becomes final.

G. Any health care provider located outside of the Commonwealth who provides health care services under the Act to a claimant shall be reimbursed as provided in this section, and the "same community," as used in subsection A of § 65.2-605, shall be deemed to be the principal place of business of the employer if located in the Commonwealth or, if no such location exists, then the location where the Commission hearing regarding the dispute is conducted.